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Patho Hesi 2017 Practice Questions
Get Quizlet's official HESI A2 - 1 term, 1 practice question, 1 full practice test
Terms in this set (50)
The nurse hears short, high-pitched sounds just before the end of inspiration in the right and left lower lobes when auscultating a client's lungs. How should this finding be recorded?
A. Inspiratory wheezes in both lungs
B. Crackles in the right and left lower lobes
C. Abdominal lung sounds in the bases of both lungs
D. Pleural friction rub in the right and left lower lobes
Fine crackles are short, high pitched sounds heard just before the end of inspiration that are the result of rapid equalization of pressure when collapsed alveoli or terminal bronchioles suddenly snap open. Wheezing (A) is a continuous high pitched squeaking or musical sound caused by rapid vibration of bronchial walls that are first evident on expiration and may be audible. Although (C) describes an adventitious lung sound, the documentation is vague. (D) is a creaking or grating sound from roughened, inflamed surfaces of the pleura rubbing together heard during inspiration, expiration, and with no change during coughing.
The nurse is assessing an older client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the nurse use to document this finding?
A. Ptosis on the left eyelid
B. A nystagmus on the left
C. Astigmatism on the right
D. Exophthalmos on the right
Ptosis is the term used to describe an eyelid droop that covers a large portion of the iris, which may result from oculomotor nerve or eyelid muscle disorder. (B) is characterized by rapid, rhythmic movement of both eyes. (C) is a distortion of the lens of the eye, causing decreased visual acuity. (D) is a term used to describe a protrusion of the eyeballs that occurs with hyperthyroidism
A client's family asks why their mother with heart failure needs a pulmonary artery catheter now that she is in the ICU. What information should the nurse include in the explanation to the family?
A. A central monitoring system reduces the risk of complications undetected by observation
B. A pulmonary artery catheter measures central pressure for monitoring fluid replacement
C. Pulmonary artery catheters allow for early detection of lung problems
D. The healthcare provider should explain the many reasons for its use.
Pulmonary artery catheters are used to measure central pressures and fluid balance. Even though all clients in the ICU require close monitoring, they do not all need a PA catheter (A). PA lines do not detect pulmonary problems (C). (D) avoids the family's question.
Several hours after surgical repair of an abdominal aortic aneurysm, the client develops left flank pain. The nurse determines the client's urinary output is 20 mL/hr for the past 2 hours. The nurse should conclude that these findings support which complication?
C. Intestinal ischemia
D. Renal artery embolization
Postoperative complications of surgical repair of AAA are related to the location of resection, graft, or stent placement along the abdominal aorta. Embolization of a fragment of thrombus or plaque from the aorta into a renal artery can compromise blood flow in one of the renal arteries, resulting in renal ischemia that precipitates unilateral flank pain. Intraoperative blood loss or rupture of the aorta anastomosis can cause acute renal failure related to hypovolemia (B), which involves both kidneys and causing bilateral flank pain. (A) and (C) are not associated with these symptoms
The nurse is assessing a postmenopausal woman who is complaining of urinary urgency and frequency and stress incontinence. She also reports difficulty emptying her bladder. These complaints are most likely due to which condition?
B. Bladder infection
D. Irritable bladder
This constellation of signs in a postmenopausal woman are characteristic of cystocele. These symptoms are not characteristic of (B), (C), or (D)
A male client who has never smoked by has had COPD is now being assessed for cancer of the lung. The nurse knows that he is most likely to develop which type of lung cancer?
B. Oat-cell carcinoma
C. Malignant melanoma
D. Squamous cell carcinoma
Adenocarcinoma is the only lung cancer not related to cigarette smoking. It has been found to be directly related to lung scarring and fibrosis from preexisting pulmonary disease such as TB or COPD. Both (B) and (D) are malignant lung cancers related to cigarette smoking. (C) is a skin cancer and is related to sunlight, not to lung problems
Muscular Dystrophy is characterized by which pathophysiological condition?
A. Stressed induced tremor and trembling
B. Cardiac damage
C. Seizure activity
D. Skeletal muscle degeneration
Skeletal muscle degeneration is a classic symptom of muscular dystrophy. Tremors and trembling (A) of hands, particularly when stressed are symptoms of Parkinson's. Cardiac damage (B) and seizures (C) are not exclusive to muscular dystrophy
The nurse is preparing to administer atropine, an anticholinergic, to a client who is scheduled for a cholecystectomy. The client asks the nurse to explain the reason for the prescribed medication. What is the best response for the nurse to provide?
A. Provide a more rapid induction of anesthesia
B. Decrease the risk of bradycardia during surgery
C. Induce relaxation before induction of anesthesia
D. Minimize the amount of analgesia needed postoperatively
Atropine may be prescribed to increase the automaticity of the SA node and prevent a dangerous reduction in HR during surgical anesthesia. (A), (C), and (D) do not address the therapeutic action of atropine use perioperatively
What information should the nurse include in a teaching plan about the onset of menopause?
B. Oophorectomy and histerectomy
C. Early menarche
D. Cardiac disease
E. Genetic influence
F. Chemotherapy exposure
A, B, C, E, and F
Menopausal symptoms are related to the cessation of ovarian function. Factors influencing the onset of menopause include smoking, genetic influences, early menarche, surgical removal, and exposure to chemotherapy agents and radiation. Cardiovascular disease (D) is unrelated
A patient with aortic valve stenosis develops heart failure. Which pathophysiological finding occurs in the myocardial cells as a result of the increased cardiac workload?
A. Increase in size
B. Decrease in length
C. Increase in number
D. Decrease in excitability
Hypertension and incompetent or stenotic heart valves cause an increase in the workload of the heart by increasing the afterload which requires an increase in the force of contraction to pump blood out of the heart. Myocardial hypertrophy results because the cells increase in surface area or size by increasing the amount of contractile proteins, but the quantitiy (C) of fibers remain constant. As myocardial hypertrophy progresses, the heart becomes ineffective as a pump because the ventricular wall cannot develop enough tension to cause effective contraction (B) which causes myocardial irritability (D) due to hypoxia
Physical examination of a comatose patient reveals decorticate posturing. Which statement is accurate regarding this client's status based upon this finding?
A. A cerebral infectious process is causing the posturing
B. Severe dysfunction of the cerebral cortex has occurred
C. There is a probably dysfunction of the midbrain
D. The client is exhibiting signs of a brain tumor
Decorticate posturing (adduction of arms and shoulders, flexion of arms on chest with wrists flexed and hands fisted and extension and adduction of extremities) is seen with severe dysfunction of the cerebral cortex. (A) is a characteristic of meningitis. (C) is characterized by decerebrate posturing (rigid extension and pronation of arms and legs). A client with (D) may exhibit decorticate posturing, depending on the position of the tumor and the condition of the client.
Which client is at highest risk for chronic kidney disease secondary to diabetes mellitus?
A. Type 1 DM and a serum hemoglobin-A1 of 3.5%
B. Type 2 DM and retinopathy and mild vision loss
C. Type 2 DM and hypertension controlled by metoprolol
D. Type 2 DM and a history of morbid obesity for 5 years
Diabetic retinopathy and nephropathy are related to prolonged hyperglycemia and hypertension which damage the microvasculature of the eyes and kidneys, so a client with Type 1 DM and retinopathy is most likely to develop neuropothy and chronic kidney disease. (A) is demonstrating compliance with therapy (H-A1c target level is no greater than 7%), which indicates tight glucose control and reduces the risk for microvascular complications. The client with controlled hypertension (C) is less likely to develop CKD, although metoprolol, a beta adrenergic receptor antagonist, can mask the signs of hypoglycemia. A client with Type 2 DM is more likely at risk for complications associated with chronic obesity (D)
A mother is crying as she holds and rocks her child with tetanus who is having muscular spasms and crying. After administering diazepam (Valium) to the child, what action should the nurse implement?
A. Lay the child down and ask the mother to stay near the child in the crib
B. Encourage the mother to take a break and leave the room to stop crying
C. Keep all light sources off and close the window blinds to the room
D. Use clam, reassurance and understanding to comfort the mother
Controlling environmental stimulation such as noise, light, or tactile stimuli helps reduce CNS irritability related to acute tetanus. The mother should be instructed to minimize handling of the child during episodes of muscle spasicity and to stay calmly near the child. The mother's presence with the child provides security and support, so (B) is not indicated. Reducing external stimuli (C) may have some effect in reducing the child's distress but light tends to be less irritating than vibratory or auditory stimuli and is essential for careful observation. Although a calm, reassuring manner and sympathetic understanding (D) can help reduce the mother's anxiety, the most comforting measure for the child is the presence of the mother
A female client tells the nurse that she does not know which day of the month is best to do self breast examinations. Which instruction should the nurse provide?
A. Midway between menstrual cycles
B. One week before your period
C. The first day of your period
D. Five to seven days after menses cease
Due to the effect of cyclic ovarian changes on the breast, the best time to do a BSE is 5-7 days after menstruation stops (D) because physiologic alterations in breast size and activity reach their minimal level after menses. (A) and (B) can vary from month to month and do not provide a consistent day of the month for the client to remember to do a BSE. (C) is commonly the day of the menstrual cycle that the breasts are most affected by hormonal influence.
What histologic finding in an affected area of the body would suggest the presence of chronic inflammation?
A. Predominance of neutrophils
B. Absence of fibroblasts and proteases
C. Decrease in degradation products
D. Increase in monocytes and macrophages
A predominance of monocytes and macrophages in an inflamed area indicates the start of a chronic infection (D). Macrophages are responsible for cleaning up the healing wound through phagocytic and debridement actions, and monocytes assist in the healing of the wound after neutrophils have entered the area. (A) arrives during the acute stage of inflammation rather than at the later, chronic stage. (B) accumulates at the scene of a chronic infection. (C) increases due to the accumulation of dead neutrophils at the site
After talking with the healthcare provider, a male client continues to have questions about the results of a prostatic surface antigen (PSA) screening test and asks the nurse how the PSA levels become elevated. The nurse should explain which pathophysiological mechanism?
A. A the prostate gland enlarges, its cells contribute more PSA in the circulating blood
B. The PSA levels normally rise and fall, so multiple testings over time are necessary
C. Low PSA levels indicate that the prostate gland is not functioning properly
D. The PSA blood test is used to determine dosage for Viagra prescriptions
PSA is a glycoprotein found in prostatic epithelial cells, and elevations are used as a specific tumor marker. Elevations in PSA are related togland volume, i.e. benign prostatic hypertrophy, prostatitis, and cancer of the prostate, indicating (tumor) cell load (A). PSA levels are also used to monitor response to therapy. (B), (C), and (D) provide incorrect information
A 27 year old male client with Hodgkin's disease is scheduled to undergo radiation therapy. The client expresses concern about the effect of radiation on his ability to have children. What information should the nurse provide?
A. The radiation therapy causes the inability to have an erection
B. Radiation therapy with chemo causes temporary infertility
C. Permanent sterility occurs in male clients who receive radiation
D. The client should restrict sexual activity during radiotherapy
Low sperm count and loss of motility are seen in males with Hodgkin's disease before any therapy. Radiotherapy often results in permanent aspermia, or sterility (C). (A), (B), and (D) are inaccurate
A client is admitted to the ER with a tension pneumothorax. Which assessment should the nurse expect to identify?
A. An absence of lung sounds on the affected side
B. An inability to auscultate tracheal breath sounds
C. A deviation of the trachea toward the side opposite the pneumothorax
D. A shift of the point of maximal impulse to the left, with bounding pulses
Tension pneumothorax is caused by rapid accumulation of air in the pleural space, causing severely high intrapleural pressure. This results in collapse of the lung, and the mediastinum shifts toward the unaffected side, which is subsequently compressed (C). (A), (B), and (D) are not demonstrated with a tension pneumothorax
A client who is receiving a whole blood transfusion develops chills, fever, and a headache 30 minutes after the transfusion started. The nurse should recognize these symptoms as characteristic of what reaction?
A. A mild allergic reaction
B. A febrile transfusion reaction
C. An anaphylactic transfusion reaction
D. An acute hemolytic transfusion reaction
Symptoms of a febrile transfusion reaction (B) include sudden chills, fever, headache, flushing and muscle pain. An allergic reaction (A) is the response of histamine release which is characterized by flushing, itching and urticaria. An anaphylactic reaction (C) exhibits an exaggerated allergic response that progresses to shock and possible cardiac arrest. An acute hemolytic reaction (D) presents with fever and chills, but is hallmarked by the onset of low back pain, tachycardia, tachypnea, vascular collapse, hemoglobinuria, dark urine, acute renal failure, shock, cardiac arrest, and death
The nurse is analyzing the waveforms of a client's electrocardiogram. What finding indicates a disturbance in electrical conduction of the ventricles?
A. T wave of 0.16 second
B. PR interval of 0.18 second
C. QT interval of 0.34 second
D. QRS interval of 0.14 second
The normal duration of QRS is 0.04-0.12 second, so a prolonged QRS (D) indicates an electrical anomaly in the ventricles. The T wave is normally 0.16 second (A). The PR interval range is 0.12-0.2 second (B). The QT interval should be 0.31-0.38 second (C).
A client with a marked distended bladder is diagnosed with hydronephrosis and left hydroureter after an IV pyelogram. The nurse catheterizes the client and obtains a residual urine volume of 1650 mL. This finding supports which pathophysiological cause of the client's urinary tract obstruction?
A. Obstruction at the urinary bladder neck
B. Urethral calculi obstruction
C. Ureteropelvic junction stricture
D. Partial post-renal obstruction due to ureteral stricture
Hydroureter (dilation of the renal pelvis), vesicoureteral reflux (backward movement of urine from the lower to upper urinary tracts), and hydronephrosis (dilation or enlargement of the renal pelvis and calyces) result from post-renal obstruction which can consequently result in chronic pyelonephritis and renal atrophy. Ascending urinary reflux occurs when normal ureteral peristaltic pressure is met with an increase in urinary pressure occurring during bladder filling if the urinary bladder neck is obstructed (A). A large residual urine does not occur with (B), (C), and (D) because the urine cannot get to the bladder
The nurse is planning care for a patient who has right a hemispheric stroke. Which nursing diagnosis should the nurse include in the plan of care
A. Impaired physical mobility related to right sided hemiplegia
B. Risk for injury related to denial of deficits and impulsiveness
C. Impaired verbal communication related to speech language deficits
D. Ineffective coping related to depression and distress about disability
With right brain damage, a client experiences difficulty in judgement and spatial perception and is more likely to be impulsive and move quickly, which is why the nurse should note the client is at risk for falls (B). Although clients with right and left hemisphere damage may experience impaired physical mobility, the client with right brain damage will manifest physical impairments on the contralateral side of the body, not the same side (A). The client with a left brain injury may manifest right sided hemiplegia with speech or language deficits (C). A client with left sided brain damage is more likely to be aware of the deficits and experience grief related to physical impairment and depression (D)
The nurse is teaching a client with maple syrup urine disease (MSUD), an autosomal recessive disorder, about the inheritance pattern. Which information must the nurse provide?
A. This recessive disorder is only carried on the X chromosome
B. Occurrences mainly affect males and heterozygous females
C. Both genes of a pair must be abnormal for the disorder to occur
D. One copy of the abnormal gene is required for this disorder
Maple syrup uterine disease (MSUD) is a type of autosomal recessive inheritance disorder in which both genes of a pair must be abnormal for the disorder to be expressed (C). MSUD is not an x-linked (A) and (B) dominant or recessive disorder or an autosomal dominant inheritance disorder. Both genes of a pair, not (D) must be present.
A client reports unprotected sexual intercourse one week ago and is worried about HIV exposure. An initial HIV antibody screen (ELISA) is obtained. The nurse teaches the client that seroconversion to HIV positive relies on antibody production by B lymphocytes after exposure to the virus. Which should the nurse recommend the client return for repeat blood testing?
A. 6-8 months
B. 1-12 months
C. 1-18 weeks
D. 6-12 weeks
Although the HIV antigen is detectable approximately 2 weeks after exposure, seroconversion to HIV positive may take up to 6-12 weeks (D) after exposure, so the client should return to repeat the serum screen for the presence of HIV antibodies during that time frame. (A) will delay treatment if the client tests positive. (B) and (C) may provide inaccurate results because the time frame may be too early to reevaluate the client
A nurse is planning to teach self-care measures to a female client about prevention of yeast infections. Which instructions should the nurse provide?
A. Use a douche preparation no more than once a month
B. Increase daily intake of fiber and leafy green vegetables
C. Select nylon underwear that is loose fitting, white, and comfortable
D. Avoid tight fitting clothing and do not use bubble bath or bath salts
A common genital tract infection in females is candidasis, which is an overgrowth of the normal vaginal flora of Candida albicans that thrives in an environment that is warm and moist and is perpetuated by tight fitting clothing, underwear or pantyhose made of non-absorbent materials. The client should wear clothing that is loose fitting and absorbent, such as cotton underwear, and avoid using bubble bath or bath salts (D) which further irritate the sensitive genital tissue. Douching (A) is not recommended because it can irritate the vaginal tissue, alter pH, and contribute to fungal growth. While (B) encourages healthy, nutritional guidelines, it is not the focus of the teaching. Cotton, not nylon undergarments (C), provide absorbency and reduce moisture in the perineal area
Which reaction should the nurse identify in a client who is responding to stimulation of the sympathetic nervous system?
A. Pupil constriction
B. Increased HR
C. Bronchial constriction
D. Decreased BP
Any stressor that is perceived as threatening to homeostasis acts to stimulate the sympathetic nervous system and manifests as a fight or flight response, which includes an increase in HR (B). (A), (C), and (D) are responses of the parasympathetic NS
A client with asthma receives a prescription for high BP during a clinic visit. Which prescription should the nurse anticipate the client to receive that is least likely to exacerbate asthma?
A. Pindolol (Visken)
B. Carterolol (Ocupress)
C. Metoprolol tartrate (Lopressor)
D. Propranolol hydrochloride (Inderal)
The best antihypertensive agent for clients with asthma is Metoprolol (Lopressor) (C), a beta2 blocking agent which is also cardioselective and less likely to cause bronchoconstriction and increase asthmatic symptoms. Although carteolol (B) is a beta blocking agent and an effective anti-HTN agent used in causing angina, it can increase a client's risk for bronchoconstriction due to its nonselective beta blocker action. Propranolol (D) also blocks the beta2 receptors in the lungs, causing bronchoconstriction, an di snot indicated in clients with asthma and other obstructive pulmonary disorders
A deficiency of intrinsic factor should alert the nurse to assess a client's history for which condition?
C. Pernicious anemia
D. Oxalic acid toxicity
Pernicious anemia is a type of anemia due to failure of absorption of cobalmin (Vit B12). Th emost common cause of lack of intrinsic factor, a glycoprotein produced by the parietal cells of the gastric lining
The nurse is measuring BP on all four extremities of a child with coarctation of the aorta. Which BP finding should the nurse expect to obtain?
A. Higher on the left side
B. Higher on the right side
C. Lower in the arms than in the legs
D. Lower in the legs than in the arms
In coarctation of the aorta, a congenital constriction is found at the aorta near the ductus arteriosus region that lies past the left subclavian arteries, which perfuses the upper extremities. The child should have higher BP in the upper extremities than in the lower legs
What is the underlying pathophysiological process between free radicals and destruction of a cell membrane?
A. Inadequate mitochondrial ATP
B. Enzyme release from lysosomes
C. Defective chromosomes for protein
D. Defective integral membrane proteins
Oxidative damage to cells is thought to be a causative factor in disease and aging. If free radicals bind to polyunsaturated fatty acids found int he lysosome membrane, the lysosome, nicknamed "suicide bags", leaks its protein catalytic enzymes (B) intracellularly and the cell is destroyed. Inadequate ATP production (A) and defective protein synthesis (C) lead to cell death either as a result of defective chromosomes or productive of defective integral proteins (D)
Which clinical finding should the nurse identify in a client who is admitted with cardiac cirrhosis?
C. Peripheral edema
D. Left upper quadrant pain
Four types of cirrhosis include: alcoholic, post-necrotic, bilary and cardiac cirrhosis, which is associated with severe right sided heart failure, so peripheral edema (C) is most consisted with right sided heart failure. Although (A) and (B) can occur in all types of cirrhosis, the most defining characteristic of cardiac cirrhosis is related to heart failure. Hepatic engorgement can occur in a client with HF or cirrhosis and cause right upper quadrant pain, not (D)
While the nurse obtains a male client's history, review of systems, and physical examination, the client tells the nurse that his breast drains fluid secretions from the nipple. The nurse should seek further evaluation of which exocrine gland function
A. Posterior pituitary and testes
B. Adrenal medulla and adrenal cortex
C. Hypothalamus and anterior pituitary
D. Parathyroid and islets of Langerhans
Breast fluid and milk production are induced by the presence of prolactin secreted from the anterior pituitary gland, which is regulated by the hypothalamus' secretion of prolactin inhibiting hormone in both men and women. Further evaluation of the hypothalamus and the anterior pituitary gland (C) should provide additional information about the secretions or lactation. Evaluation of (A), (B), or (D) do not support a physiologic mechanism or pathology related to mammary discharge
The nurse is assessing the laboratory results for a client who is admitted with renal failure and osteodystrophy. Which findings are consistent with this client's clinical picture?
A. Blood urea nitrogen 40 m and creatinine 1.0
B. Cloudy, amber urine with sediment, specific gravity of 1.040
C. Serum potassium of 5.5 mEq and total calcium of 6 mg/dl
Hemoglobin of 10 g and hypophosphatemia
In renal failure, normal serum electrolyte balance is altered because the kidneys fail to activate vitamin D, calcium absorption is impaired, and serum calcium decreases, which stimulates the release of PTH causing reabsorption of calcium and phosphate from the bone. A decreased tubular excretion and a decreased glomerular filtration rate results in hypocalcemia, hyperphosphatemia, and hyperkalemia (C). (A) is reflective of a non-renal cause, such as dehydration or liver pathology. (B) is more indicative of infection. Renal failure causes anemia and hyperphosphatemia, NOT (D)
Which healthcare practice is most important for the nurse to teach a postmenopausal client?
A. Wear layers if experiencing hot flashes
B. Use a water-soluble lubricant for vaginal dryness
C. Consume adequate foods rich in calcium
D. Participate in stimulating mental exercises
Bone density loss associated woth osteoporosis increases at a more rapid rate when estrogen levels begin to fall, so the most important healthcare practice during menopause is ensuring an adequate calcium intake (C) to help maintain bone density and prevent osteoporosis. Although practices such as (A) and (B) may reduce some of the discomforts for a postmenopausal female, calcium intake is more important that comfort measures. Although social and mental exercises stimulate thought, there is no scientific evidence that mental exercises (D) prevent dementia or common forgetfulness associated with reduced hormonal levels
A middle aged male client asks the nurse what findings from his digital rectal exam (DRE) prompted the healthcare provider to prescribe a repeat serum prostatic surface antigen (PSA) level. What information should the nurse provide?
A. A uniformly enlarged prostate is benign prostatic hypertrophy that occurs with aging
B. The spongy or elastic texture of the prostate is normal and requires no additional testing
C. An infection is usually present when the prostate indents when a finger is pressed on it
D. Stony, irregular nodules palpated on the prostate should be further evaluated
PSA levels are prescribed to screen for prostatic cancer which is often detected by DRE and manifested as small, hard, or stony irregularly-shaped nodules on the surface of the prostate (D). Although PSA levels are prescribed for routine screening, the findings suggestive of BPH (A), normal texture (B), or infection (C) do not suggest cancer of the prostate, which requires further evaluation
Which condition is associated with an oversecretion of renin?
C. Diabetes insipidus
D. Alzheimer's disease
Renin is an enzyme synthesized and secreted by the juxtaglomerular cells of the kidney in response to renal artery blood volume and pressure changes. Low renal perfusion stimulates the release of renin, which is converted by antiotensinogen into angiotensin I, which causes the secretion of aldosterone, resulting in renal absorption of sodium, watr, and subsequently increases BP(A)
A client is brought to the ER after a snow-skiing accident. What intervention is most important for the nurse to implement
A. Review the EKG tracing
B. Obtain blood for coagulation studies
C. Apply a warming blanket
D. Provide heated PO fluids
Airway, breathing, and circulation are priorities in client assessment and treatment. Continuous cardiac monitoring is indicated because hypothermic clients have an increased risk for dysrhythmias. Coagulation studies and re-warming procedures can be initiated after a review of the EKG tracing
The nurse reviews the complete blood count (CBC) findings of an adolescent with acute myelogenous leukemia (AML). The hemoglobin is 13.8 g/dl, hematocrit is 36.7%, WBC is 8,200 mm3, and platelet count is 115,000 mm3. Based on these findings, what is the priority nursing diagnosis for this client's plan of care?
A. Impaired gas exchange
B. Risk for infection
C. Risk for injury
D. Risk for activity intolerance
A client with AML is at risk for anemia, neutropenia, and thrombocytopenia. These CBC findings indicate that the platelet count is low (Normal 250,000-400,000 mm3), which places this client at an increased risk for injury (C), usually marked as bruising or bleeding. There is no evidence of impaired gas exchange (A) due to respiratory compromise, risk of infection (B) due to neurtropenia, or risk for activity intolerance (D) due to anemia and fatigue.
The parents of a child with hemophilia A ask the nurse about their probability of having another child with hemophilia A. Which information is the basis of the nurse's response?
A. Autosomal dominance occurs with this disorder
B. Sons of female carriers have a 50% chance of inheriting hemophilia
C. Men with hemophilia have sons who also manifest the disease
D. The disease occurs in daughters of men with hemophilia
E. Hemophilia is an x-linked recessive disorder
B and E
Hemophilia is an inherited disorder that manifests in male children whose mother is a carrier. With each pregnancy there is a 50% chance that a male child will inherit the defective gene and manifest hemophilia A, which is an x-linked recessive disorder.
(A) is descriptive of a rare type of hemophilia known as von Willebrand's disease. Hemophilia is inherited by male offspring of female carriers (C). Daughters (D) do not manifest the disease but have a 50% chance of being a carrier
The nurse is caring for a client who has had an excision of a malignant pituitay tumor. Which findings should the nurse document that indicate the client is developing signs of inappropriate antidiuretic hormone (SIADH)?
A. Hypernatremia and periorbital edema
B. Muscle spasticity and hypertension
C. Weight gain and low serum sodium
D. Increased urinary output and thirst
SIADH most frequently occurs when cancer cells manufacture and release ADH, which is manifested by water retention causing weight gain and hyponatremia. Other manifestations include oliguria, weakness (Not A, B, and D), anorexia, nausea, vomiting, personality changes, seizures, decrease in reflexes, coma
A man who was recently diagnosed with Huntington's disease asks the nurse if his adolescent son should be tested for the disease. What response is best for the nurse to provide?
A. Autosomal dominant disorders, such as Huntington's, cannot be inherited from the parent
B. Testing is needed because there is a 50% risk of passing the gene to each offspring.
C. Genetic counseling should be provided to ensure an informed decision by the family
D. Positive genetic testing may contribute to insurance discrimination that denies coverage
Huntington's disease, a progressively incapacitating, fatal, neuromuscular disease, is an autosomal dominant inherited disease that has a 50% risk of developing in each child of those who have the disorder. The risk of autosomal dominant inheritance should be explained and emphasized (B). (A) is inaccurate. Although the basic tenet of genetic counseling is to provide families with facts to assist them in making informed decisions (C), the basic laws of inheritance should be explained to direct the client to counseling. (D) provides information that does not address the client's question, and might be considered judgmental
Which rationale best supports an older client's risk of complications related to dysrhythmia?
A. An older client usually lives alone and cannot summon help when symptoms appear
B. An older client is more likely to eat high fat diets which predisposes to heart disease
C. Cardiac symptoms, such as confusion, are more difficult to recognize in an older client.
D. An older client is intolerant of decreased cardiac output which may cause dizziness and falls
In an older client, cardiac output is decreased and a loss of contractility and elasticity reduces systemic and cerebral blood flow, so dysrhythmias, such as bradycardia or tachycardia is poorly tolerated, and increases the client's risk for syncope falls, transient ischemic attacks, and possibly dementia. (B) and (C) are generalized statements that are not applicable to most individuals in the older population. Although many older persons do live alone, inability to summon help cannot be assumed (A)
The nurse is assessing a client with a ruptured small bowel and determines that the client has a temperature of 102.8 F. Which assessment finding provides the earliest indication that the client is experiencing septic shock?
A. Bilateral crackles
C. Mucus production
D. Weak peripheral pulses
The interrelated pathophysiologic changes associated with the hypermetabolic state of sepsis and septic shock produce a pathogenic imbalance between cellular oxygen demand, supply, and consumption. Hyperpnea (B), an increased depth of respirations, is an early manifestation of sepsis. (A, C, and D) are signs of advanced shock
What signs and symptoms are associated with arterial insufficiency?
A. Pallor, intermittent claudication
B. Pedal edema, brown pigmentation
C. Blanched skin, lower extremity ulcers
D. Peripheral neuropathy, cold extremities
Pallor and intermittent claudication are signs related to stage II of peripheral vascular disease, which causes arterial insufficiency. (B) are signs related to venous insufficiency. (C) are not specific to arterial insufficiency. Although (D) may be related to complications of diabetes mellitus resulting in poor circulation, arterial insufficiency causes impaired perfusion resulting in hypoxic pain or intermittent claudication
The severity of diabetic retinopathy is directly related to which condition?
A. Poor blood glucose control
B. Neurological effects of diabetes
C. Susceptibility to infection
D. Uncontrolled hypertension
Poor glucose control worsens diabetic retinopathy, where as tight glucose control can lessen the severity
A client with a fractured right radius reports severe, diffuse pain that has not responded to the prescribed analgesics. The pain is greater with the passive movement of the limb than with the active movement of the client. The nurse recognizes that the client is most likely exhibiting symptoms of which condition?
A. Acute compartment syndrome
B. Fat embolism syndrome
C. Venous thromboembolism
D. Aseptic ischemic necrosis
These signs are specific indications of Acute Compartment Syndrome and should be treated as an emergency situation
While observing a patient with a large bowel obstruction, the nurse should assess for which finding?
A. Distension of the lower abdomen
B. Nausea with profuse vomiting
C. Upper abdominal discomfort
D. Fluid and electrolyte imbalances
Among findings of a large bowel obstruction is the distension of the lower abdomen. (B, C, and D) are findings associated with large bowel obstruction
The nurse is caring for a patient with syndrome of inappropriate antidiuretic hormone (SIADH), which is manifested in which symptoms?
A. Loss of thirst, weight gain
B. Dependent edema, fever
C. Polydipsia, polyuria
D. Hypernatremia, tachypnea
SIADH occurs when the posterior pituitary gland releases too much ADH, causing water retention, a urine output of less than 20 ml/hour, and dilutional hyponatremia. Other indicators of SIADH are loss of thirst, weight gain (A), irritability, muscle weakness, and decreased level of consciousness. (B) is not associated with SIADH. (C) is a finding associated with diabetes insipidus (a water metabolism problem caused by ADH defieciency), not SIADH. The increase in plasma volume causes an increase in the glomerular filtration rate that inhibits the release of rennin and aldosterone, which results in an increased sodium loss in urine, leading to greater hyponatremia, not (D)
The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH). This condition is most often related to which predisposing condition?
A. Small cell lung cancer
B. Active TB infection
C. Hodgkin's lymphoma
D. Tricyclic antidepressant therapy
Cancer is the most common cause of the syndrome of inappropriate antidiuretic hormone (SIADH), with small cell lung cancer being the most common cancer that increases ADH, which causes dilutional hyponatremia and fluid retention. (B, C, and D) are also possible causes but secondary to CNS trauma or disease
Which pathophysiologic response supports a client's vomiting exprience?
A. Sensory input of noxious stimuli relayed to the cognitive centers is associated with disgust and illicits vomiting
B. Response of stimulation of the posterior oropharynx results in reverse peristalsis of the GI
C. Spasmodic reflex of respiratory and gastric movements results from stimulation of the chemoreceptor trigger zone
D. Increased gastric and colonic pressures move GI contents tothe orifice of last resistance
Vomiting is a reflex of spasmodic respiratory movements against the glottis causing the forceful expulsion of the contents of the stomach through the mouth. Stimulation of the emetic center results from afferent vagal and sympathetic nerve pathways that activate the chemoreceptor trigger zone (CTZ) (C). (A) is a learned response and influences nausea, but does not explain the mechanical physiology. Although self-induced vomiting responds to tactile stimulation of the posterior oropharynx (B), the physiological mechanism of vomiting coordinates actions required to empty the gastric contents. (D) may occur, but does not explain reflex vomiting
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