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Patho Quiz 3- Multiple Choice with rationale
Terms in this set (75)
A 52-year-old female is admitted to the cardiac unit with a diagnosis of pericarditis. She asks the nurse to explain where the infection is. In providing an accurate description, the nurse states that the pericardium is:
The outer muscular layer of the heart
A membranous sac that encloses the heart
The heart's fibrous skeleton
The innermost layer of the heart chambers
Answer: A membranous sac that encloses the heart
Rationale: The pericardium is the membranous sac that surrounds the heart.
The outer layer of the heart is the myocardium.
The innermost layer of the heart is the endocardium.
The heart's fibrous skeleton is attached to the myocardium.
A 50-year-old female received trauma to the chest that caused severe impairment of the primary pacemaker cells of the heart. Which of the following areas received the greatest damage?
Sinoatrial (SA) node
Atrioventricular (AV) node
Bundle of His
Answer: SA node
Rationale: The SA node is considered the pacemaker of the heart.
The SA node, not the AV node, is considered the pacemaker of the heart.
The SA node is considered the pacemaker of the heart; the bundle of His is not involved.
The SA node is considered the pacemaker of the heart; the ventricles are not involved.
A cardiologist is teaching about the period that follows depolarization of the myocardium and represents a period during which no new cardiac potential can be propagated. What is the cardiologist describing?
Answer: absolute refractory
Rationale: A refractory period is the time during which no new cardiac action potential can be initiated by a stimulus. It follows depolarization.
The _____ represents the sum of all ventricular muscle cell depolarization.
Answer: QRS complex
Rationale: The QRS complex represents the sum of all ventricular muscle cell depolarizations.
The PR interval represents the onset of atrial activation to the onset of ventricular activity.
The QT interval represents "electrical systole" of the ventricles.
The P wave represents atrial depolarization.
A 65-year-old male develops blockage in the pulmonary artery. As a result of the blockage, blood would first back up into the:
Answer: Right ventricle
Rationale: Blockage in the pulmonary artery would cause blood to back up into the right ventricle.
Which principle should the nurse remember when planning nursing care for a patient with heart problems? As stated by the Frank-Starling law, there is a direct relationship between the _____ of the blood in the heart at the end of diastole and the _____ of contraction during the next systole.
Answer: volume, force
Rationale: The Frank-Starling law of the heart describes the length-tension relationship of ventricular end-diastolic volume (VEDV) (preload) to myocardial contractility (as measured by stroke volume).
While planning care for a heart patient, which principle should the nurse recall? Right ventricular afterload is affected by:
Vascular resistance in the systemic vessels
Right end-diastolic pressure
Pulmonary vascular resistance
Pressures in the vena cava
Answer: pulmonary vascular resistance
Rationale: Right ventricular afterload is affected by pulmonary vascular resistance because this is the pressure the ventricle must pump against.
Systemic resistance affects left-sided afterload.
A nurse observes a cardiologist multiplying the heart rate by stroke volume. What is the cardiologist measuring?
Answer: cardiac output
Rationale: Cardiac output is found by multiplying the heart rate times stroke volume.
Vascular resistance is not a factor in the calculation of cardiac output; it does play a role in blood pressure.
Preload affects cardiac output but is not the result of heart rate times stroke volume.
Ejection fraction is the amount ejected per beat.
A nurse is teaching about the heart. Which information should the nurse include? The chamber of the heart that generates the highest pressure is the:
Answer: Left ventricle
Rationale: The left ventricle generates the highest pressure due to pushing blood into systemic circulation.
A patient researches baroreceptors online. Which information indicates a good understanding? Baroreceptors are located in the:
Circle of Willis
Superior vena cava
Answer: Carotid sinus
A nurse is evaluating the direct end effect of the renin-angiotensin-aldosterone system. Which principle should the nurse remember?
Aldosterone increases renal retention of water only.
Angiotensin I promotes sodium and water reabsorption by the kidneys.
Renin promotes the excretion of sodium and water in the renal tubules.
Angiotensin II causes systemic vasoconstriction.
Answer: Angiotensin II causes systemic vasoconstriction
Rationale: Angiotensin II is a potent vasoconstrictor.
Renin promotes the retention of sodium and water.
Aldosterone increases retention of water and sodium.
Angiotensin I does not have an effect on the kidneys.
When a patient wants to know about the renin-angiotensin-aldosterone system, what is the nurse's best response? Conversion of angiotensin I to angiotensin II happens in the:
Rationale: Angiotensin I is converted to angiotensin II by angiotensin converting enzyme in the lungs.
The liver synthesizes angiotensinogen.
The kidneys release renin.
The heart is not involved in this conversion.
Which statement indicates the nurse understands blood flow? Oxygenated blood flows through the:
Superior vena cava
Answer: pulmonary veins
Rationale: The pulmonary artery carries deoxygenated blood to receive oxygen in the lungs. It flows back into the heart through the pulmonary veins- it will now travel through left side of the heart to systemic circulation.
Superior vena cava and cardiac veins carry deoxygenated blood.
A 60-year-old male presents to his primary care provider reporting chest pain. He is diagnosed with atherosclerosis. This disease is caused by:
Abnormal thickening and hardening of vessel walls
Abnormally dilated arteries and veins
Autonomic nervous system imbalances
Arterial wall thinning and weakening
Answer: Abnormal thickening and hardening of vessel walls
Rationale: Atherosclerosis is a form of arteriosclerosis characterized by thickening and hardening of the vessel wall. It is not related to autonomic nervous system changes which would lead to changes in rate and rhythm.
When a nurse checks the patient for orthostatic hypotension, what did the nurse have the patient do?
Answer: stand up
Rationale: Orthostatic hypotension refers to a drop in blood pressure when standing up.
What term should the nurse document for a detached blood clot?
A detached thrombus is a thromboembolus.
A thrombus is a clot that remains attached to a vessel wall.
An embolus is any bolus of material floating in the blood stream.
An infarction is death of tissue.
A 32-year-old female presents with lower leg pain, with swelling and redness. While obtaining the patient's history, which finding could have caused her condition?
Heart valve damage
Answer: venous thrombus
Rationale: A thrombus formation in the vein leads to inflammation that may cause pain and redness with obstruction. Increased pressure in the vein behind the clot may lead to edema of the extremity.
A 28-year-old female presents with severe chest pain and shortness of breath. She is diagnosed with pulmonary embolism, which most likely originated from the:
Deep veins of the leg
Superficial veins of the arm
Answer: deep veins of the leg
Rationale: The most likely origin of the embolism is from the deep veins of the legs.
Individuals with Raynaud disease need to be counseled to avoid which of the following conditions to prevent severe symptoms?
Hot water immersion
Answer: cold exposure
Rationale: Raynaud disease consists of vasospastic attacks triggered by brief exposure to cold.
Raynaud disease demonstrates symptoms when extremities are exposed to cold.
A 75-year-old obese female presents to her primary care provider reporting edema in the lower extremities. Physical exam reveals that she has varicose veins. Upon performing the history, which of the following is a possible cause for the varicose veins?
Trauma to the deep veins
Long periods of standing
Answer: long periods of standing
Rationale: Varicose veins are most likely due to long periods of standing leading to the action of gravity promoting venous distention. Exercise would help prevent this.
Trauma can occur, but usually this affects the more superficial veins.
Ischemia affects arteries not veins.
While planning care for a patient with superior vena cava syndrome (SVCS), which principle should the nurse remember? SVCS is a progressive _____ of the superior vena cava (SVC) that leads to venous distention of the upper extremities and head.
Rationale: SVCS is a progressive occlusion of the SVC that leads to venous distention in the upper extremities and head.
A 56-year-old male is diagnosed with coronary artery disease. Which of the following modifiable risk factors would the nurse suggest the patient change?
Drinking tomato juice
Answer: smoking cigarettes
Rationale: Cigarette smoking leads to vasoconstriction and should be the first behavior the patient changes.
Eating meat alone would not lead to the development of coronary artery disease; cigarette smoking leads to vasoconstriction and should be the first behavior the patient changes.
When a patient asks the nurse what is the most common cause of myocardial ischemia, which statement is the correct response? The most common cause of myocardial ischemia is:
Arterial emboli from heart valve
Rationale: The most common cause of myocardial ischemia is atherosclerosis. Arterial emboli may cause ischemia, but atherosclerosis is the major cause of myocardial ischemia. Venous emboli would not lead to myocardial ischemia
A 51-year-old male presents with recurrent chest pain on exertion. He is diagnosed with angina pectoris. When he asks what causes the pain, how should the nurse respond? The pain occurs when:
The vagus nerve is stimulated.
Cardiac output has fallen below normal levels.
The myocardial oxygen supply has fallen below demand.
Myocardial stretch has exceeded the upper limits.
Answer: The myocardial oxygen supply has fallen below demand.
Rationale: Angina is chest pain caused by myocardial ischemia, which develops if the flow or oxygen content of coronary blood is insufficient to meet the metabolic demands of myocardial cells.
A decrease in cardiac output would lead to general systemic symptoms, not just chest pain, which is due to a decrease in myocardial oxygenation.
Myocardial stretch does not affect angina symptoms.
When the vagus nerve is stimulated, a change in rate occurs; it does not precipitate chest pain.
A 51-year-old male is at the health clinic for an annual physical exam. After walking from the car to the clinic, he developed substernal pain. He also reported discomfort in his left shoulder and his jaw, lasting 2 to 3 minutes and then subsiding with rest. He indicates that this has occurred frequently over the past few months with similar exertion. The nurse suspects he is most likely experiencing:
Myocardial infarction (MI)
Answer: stable angina
Stable angina is associated with activity and subsides with rest.
Unstable angina is a form of acute coronary syndrome that results from reversible myocardial ischemia and occurs at rest.
Chest pain that occurs at rest and at night is descriptive of Prinzmetal angina.
MI pain does not subside with rest.
A 49-year-old male presents to his primary care provider reporting chest pain. EKG reveals ST elevation. He is diagnosed with myocardial ischemia. Which of the following interventions would be most beneficial?
Apply oxygen to increase myocardial oxygen supply.
Administer a diuretic to decrease volume.
Give an antibiotic to decrease infection.
Encourage exercise to increase heart rate.
Answer: Apply oxygen to increase myocardial oxygen supply.
Rationale: Increase myocardial oxygen supply is indicated to treat ischemia.
Oxygen is indicated, not a decrease in volume.
Heart rate should be decreased to decrease cardiac workload.
Antibiotics are not the most beneficial; oxygen is.
A 60-year-old female had a myocardial infarction. She was brought to the hospital 30 minutes later. She survived, but now the nurse is providing care for impaired ventricular function because:
There is too much stress on the heart.
There is a temporary alteration in electrolyte balance.
The cells become hypertrophic.
The resulting ischemia leads to hypoxic injury and myocardial cell death.
Answer: The resulting ischemia leads to hypoxic injury and myocardial cell death.
Rationale: The patient has impaired ventricular functioning because a portion of the myocardium has died due to ischemia.
Impaired ventricular function is due to damage to the myocardium; it is not due to electrolyte imbalance.
There was stress on the heart, but the impaired functioning is due to myocardial damage secondary to ischemia.
The impaired ventricular dysfunction is due to myocardial cell death, not hypertrophy.
While planning care, the nurse remembers which principle? In valvular _____, the valve opening is constricted and narrowed because the valve leaflets, or cusps, fail to open completely.
Rationale: Valvular stenosis occurs when the valve opening is constricted and narrowed.
Valvular regurgitation occurs when blood moves backward into the chamber from which it came.
Valvular insufficiency occurs when blood regurgitates backward into the chamber from where it came.
Valvular incompetence leads to regurgitation.
A 60-year-old female was diagnosed with mitral stenosis. As a result, the nurse realizes the patient has incomplete emptying of the:
Answer: left atrium
Rationale: Mitral stenosis would result in incomplete emptying of the left atrium, as the mitral valve is located between the left atrium and left ventricle.
A 72-year-old female has a history of hypertension and atherosclerosis. An echocardiogram reveals backflow of blood into the left ventricle. Which of the following is the most likely diagnosis documented on the chart?
Answer: aortic regurgitation
Rationale: Aortic regurgitation would allow backward flow of blood into the left ventricle. Mitral regurgitation would allow backward flow of blood into the left atrium.
Mitral stenosis would impede blood flow from the right atrium into the right ventricle.
Aortic stenosis would impede blood flow into the aorta
Most cases of combined systolic and diastolic hypertension have no known cause and are documented on the chart as _____ hypertension.
Rationale: Most cases of hypertension are idiopathic so documented as primary. Secondary hypertension due to a known cause. Congenital present at birth.
Which characteristic changes should the nurse keep in mind while caring for a patient with left heart failure? As left heart failure progresses:
Left end-diastolic volume decreases.
Pulmonary vascular resistance decreases.
Systemic vascular resistance decreases.
Left ventricular preload increases.
Answer: left ventricular preload increases
Rationale: Left ventricular preload increases in left heart failure because less blood is ejected from the left ventricle.
Left heart failure does not lead to a decrease in systemic resistance; it leads to an increase in resistance.
Left end-diastolic volume will increase.
Pulmonary vascular resistance will increase.
A 65-year-old male with a history of untreated hypertension is now experiencing left heart failure. A nurse recalls his untreated hypertension led to:
Alterations in alpha and beta receptor function
Myocardial hypertrophy and ventricular remodeling
Ventricular dilation and wall thinning
Inhibition of renin and aldosterone
Answer: Myocardial hypertrophy & ventricular remodeling
Rationale: With hypertension comes increased afterload and resistance to ventricular emptying and more workload for the ventricle, which responds with hypertrophy of the myocardium and ventricular remodeling.
Ventricular dilation can occur, but the wall will thicken, not thin.
Renin and aldosterone release are increased, not inhibited.
Alterations in alpha and beta functioning may occur, but the response to hypertension is myocardial hypertrophy and ventricular remodeling.
A 59-year-old female is diagnosed with left ventricular failure. If a decrease in kidney perfusion occurs, the nurse knows this would ultimately cause:
Decreased left ventricular preload
Increased systemic vascular resistance
Decreased cardiac oxygen demand
Increased pulmonary capillary permeability
Answer: Increased systemic vascular resistance
Rationale: With a decrease in kidney perfusion, renin is released with the ultimate outcome of increased systemic vascular resistance to raise blood pressure to increase blood flow to the kidney.
Ventricular preload will increase, not decrease.
Capillary permeability will likely decrease.
Cardiac oxygen demand will increase, not decrease.
When a patient with left heart failure starts to have a cough and dyspnea, which principle should the nurse remember? Pulmonary symptoms, common to left heart failure, are a result of:
Inflammatory pulmonary edema
Pulmonary vascular congestion
Decreased cardiac output
Answer: Pulmonary vascular congestion
Rationale: The clinical manifestations of left heart failure are the result of pulmonary vascular congestion and inadequate perfusion of the systemic circulation.
A 65-year-old male is diagnosed with chronic pulmonary disease and elevated pulmonary vascular resistance. Which of the following heart failures should the nurse assess for in this patient?
Left heart failure
Right heart failure
Answer: Right heart failure
Rationale: Right-sided failure occurs when the patient experiences chronic pulmonary disease and elevated pulmonary vascular resistance because the blood has difficulty overcoming the pressure and blood builds up in the right side of the heart.
When a person is in shock, a nurse remembers impairment in cellular metabolism is cause by:
Free radical formation
Inadequate tissue perfusion
Release of toxic substances
Lack of nervous or endocrine stimulation
Answer: Inadequate tissue perfusion
Rationale: In shock, impaired cellular metabolism is caused by inadequate tissue perfusion.
One consequence of switching from aerobic to anaerobic cellular metabolism during shock states is:
Free radical formation
Decreased adenosine triphosphate (ATP) production
Answer: Decreased ATP production
Rationale: Anaerobic metabolism leads to decreased ATP production.
A 27-year-old male is admitted to a neurologic unit with a complete C-5 spinal cord transection. On initial assessment, he is bradycardic, hypotensive, and hyperventilating. He appears to be going into shock. The most likely mechanism of his shock is:
Vasodilation caused by a decrease in sympathetic stimulation
Hypovolemia caused by blood loss
Hypovolemia caused by evaporative fluid losses
Vasodilation caused by gram-negative bacterial infection
Answer: Vasodilation caused by a decrease in sympathetic stimulation
Rationale: The patient is experiencing neurogenic shock in which blood volume has not changed, but SVR decreases drastically so that the amount of space containing the blood has increased, leading to hypotension.
In this type of shock, blood loss has not occurred.
In this type of shock, fluid loss has not occurred.
Vasodilation due to infection would be septic shock; the type of shock described in the patient is due to loss of sympathetic stimulation.
A 15-year-old male who is allergic to peanuts eats a peanut butter cup. He then goes into anaphylactic shock. Which assessment findings will the nurse assess for?
Bronchoconstriction, hives or edema, and hypotension
Hypertension, anxiety, and tachycardia
Fever, hypotension, and erythematous rash
Bradycardia, decreased arterial pressure, and oliguria
Answer: Bronchoconstriction, hives or edema, and hypotension
Rationale: Anaphylactic shock is characterized by bronchoconstriction, hives, and hypotension.
For an infection to progress to septic shock, which of the following factors should the nurse determine occurred?
The myocardium must be impaired.
The infection must be gram negative.
The individual must be immunosuppressed.
Bacteria must enter the bloodstream.
Answer: Bacteria must enter the bloodstream
Rationale: For septic shock to occur, bacteria must enter the bloodstream.
Septic shock can occur in individuals who are not immunosuppressed.
In septic shock, the myocardium is not impaired.
Many organisms in addition to gram-negative bacteria can cause septic shock.
Which patient is most prone to multiple organ dysfunction syndrome (MODS)? In a patient with:
Myocardial infarction (MI)
Answer: Septic shock
Rationale: Most common cause of MODS is septic shock
Which is the most common type of congenital heart defect the nurse should assess for in infants?
Atrial septal defect (ASD)
Atrioventricular canal defect
Ventricular septal defect (VSD)
Tetralogy of Fallot
Answer: ventricular septal defect (VSD)
A newborn experiences frequent periods of cyanosis, usually occurring during crying or after feeding. Which of the following is the most likely diagnosis the nurse will observe on the chart?
Ventricular septal defect (VSD)
Atrioventricular canal (AVC) defect
Tetralogy of Fallot
Atrial septal defect (ASD)
Answer: tetralogy of fallot
Rationale: Infants with tetralogy of Fallot experience cyanosis after crying or during feeding.
Infants with AVC defect may experience cyanosis, but it is not related to feeding or crying.
Infants with a VSD do not experience cyanosis.
Infants with an ASD do not experience cyanosis.
A newborn baby is severely cyanotic. An echocardiogram reveals transposition of the great arteries. A nurse assesses for which of the following, as it usually occurs with this defect?
Atrial septal defect (ASD)
The pulmonary artery leaving the right ventricle
Ventricular septal defect (VSD)
The aorta leaving the right ventricle
Answer: the aorta leaving the right ventricle
Rationale: In transposition of the great arteries, the pulmonary artery leaves the left ventricle and the aorta exits from the right ventricle.
The pulmonary artery normally leaves the right ventricle.
A VSD is not associated with transposition of the great arteries.
An ASD is not associated with transposition of the great arteries.
A newborn child is diagnosed with tetralogy of Fallot. What symptoms would the nurse expect to observe in the child?
Epistaxis and anemia
High-pitched cry and dyspnea
Leg pain and twitching
Cyanosis and hypoxia
Answer: Cyanosis & hypoxia
Rationale: Tetralogy of fallot is a shunt that decreases flow through the pulmonary system causing less than normal oxygen delivery to tissues and resultant cyanosis. It will not cause a high-pitched cry. Epistaxis is associated with coarctation of the aorta.
A 5-year-old female is found to have hypertension during three separate visits to her primary care provider. The nurse would expect tests to suggest that the hypertension is secondary to:
Answer: renal disease
Rationale: Hypertension in a 5-year-old is related to renal disease.
A 1-month-old infant visits his primary care provider for a well-baby check. Physical exam reveals decreased cardiac output, hypotension, tachycardia, and a loud murmur suggestive of aortic stenosis. Which of the following would be expected with this diagnosis?
Answer: ventricular hypertrophy
Rationale: The infant with aortic stenosis will also be experiencing ventricular hypertrophy because of the resistance of blood flow from the left ventricle into the aorta.
The nasopharynx is lined with a ciliated mucosal membrane with a highly vascular blood supply. The nurse is discussing the functions of this membrane. Which information should be included? One function of the membrane is to:
Answer: humidify air
Rationale: These structures are lined with a ciliated mucosa that warms and humidifies inspired air and removes foreign particles from it.
A 42-year-old male was involved in a motor vehicle accident during which he suffered a severe head injury. He died shortly after the accident from loss of respiration. The nurse suspects the area of the brain most likely involved is the:
Rationale: The respiratory center in the brainstem controls respiration by transmitting impulses to the respiratory muscles, causing them to contract and relax.
While planning care for a patient with respiratory difficulty and retaining too much carbon dioxide, which principle should the nurse recall? _______ would be stimulated in an attempt to maintain a normal homeostatic state.
Answer: central chemoreceptors
Rationale: Chemoreceptors monitor arterial blood indirectly by sensing changes in the pH of cerebrospinal fluid (CSF). The central chemoreceptors are sensitive to very small changes in the pH of CSF and can maintain a normal PaCO2.
A patient asks how oxygen is transported in the body. What is the nurse's best response? Most of the oxygen (O2) is transported:
Dissolved in the plasma
Bound to hemoglobin
As a free-floating molecule
In the form of carbon dioxide (CO2)
Answer: bound to hemoglobin
Which principle should the nurse remember while planning care for a patient with respiratory problems? Diffusion of respiratory gases takes place at the:
Answer: alveolocapillary membrane
Rationale: Diffusion of respiratory gases takes place across the alveolocapillary membrane.
A 10-year-old female develops pneumonia. Physical exam reveals subcostal and intercostal retractions. She reports that breathing is difficult and she feels she cannot get enough air. What term should the nurse use to document this condition?
Rationale: Dyspnea is defined as "a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity."
A nurse is teaching staff about pulmonary edema. Which information should the nurse include? The most common cause of pulmonary edema is:
Left heart failure
Right heart failure
Answer: Left heart failure
A 50-year-old male presents with hypotension, hypoxemia, and tracheal deviation to the left. Tests reveal that the air pressure in the pleural cavity exceeds barometric pressure in the atmosphere. Based upon these assessment findings, what does the nurse suspect the patient is experiencing?
Answer: Tension pneumothorax
Rationale: Tracheal deviation suggests tension pneumothorax.
A 20-year-old male presents to his primary care provider reporting difficulty breathing when lying down. What term should the nurse use to document this condition?
Rationale: Orthopnea is dyspnea that occurs when an individual lays flat
A 42-year-old female presents with dyspnea; rapid, shallow breathing; inspiratory crackles; decreased lung compliance; and hypoxemia. Tests reveal a fulminant form of respiratory failure characterized by acute lung inflammation and diffuse alveolocapillary injury. Which of the following is the most likely diagnosis the nurse will observe on the chart?
Acute respiratory distress syndrome (ARDS)
Postoperative respiratory failure
Malignant respiratory failure
A nurse is preparing to teach the staff about asthma. Which information should the nurse include? Airway obstruction contributing to increased airflow resistance and hypoventilation in asthma is caused by:
Mucus secretion, bronchoconstriction, and airway edema
Alveolar fibrosis and pulmonary edema
Type II alveolar cell injury and decreased surfactant
Collapse of the cartilaginous rings in the bronchi
Answer: mucus secretion, bronchoconstriction, airway edema
Rationale: The mediators of asthma cause vasodilation, increased capillary permeability, mucosal edema, bronchial smooth muscle contraction (bronchospasm), and mucus secretion from mucosal goblet cells with narrowing of the airways and obstruction to airflow.
A 25-year-old male presents with chronic bronchitis of 5 months' duration. When obtaining the patient's history, which of the following findings is most likely to cause this condition?
Answer: Cigarette smoke
Rationale: The most likely cause of chronic bronchitis is cigarette smoke.
The most likely cause of chronic bronchitis is cigarette smoke, not chronic asthma.
Air pollution may contribute, but smoking is the most common cause.
Recurrent infections could contribute, but smoking is the most common cause.
A 30-year-old female received a severe head injury in a motor vehicle accident. She is now experiencing respiratory abnormalities characterized by alternating periods of deep and shallow breathing with periods of apnea. What term should the nurse use when charting this condition?
Rationale: Cheyne-Stokes respirations are characterized by alternating periods of deep and shallow breathing, with periods of apnea lasting from 15 to 60 seconds.
When the nurse observes a diagnosis of nosocomial pneumonia, the patient generally acquires this pneumonia:
At day care centers
In the winter season
Answer: during hospitalization
Which of the following patients is at highest risk for developing pulmonary embolism (PE)?
72-year-old male who is recovering from hip replacement surgery in the hospital
36-year-old woman with a history of alcohol abuse who is recovering from a gastric ulcer
21-year-old male with a hemophilia bleeding disorder
28-year-old woman who had a baby 6 months earlier
Answer: 72-year-old male who is recovering from hip replacement surgery in the hospital
Rationale: The 72-year-old is at risk for immobility and at increased risk for PE.
When a patient has a massive pulmonary embolism (PE), what complications will the nurse monitor for?
Disseminated intravascular coagulation (DIC)
Damage to the lung microcapillaries
Chronic obstructive pulmonary disease (COPD)
Shock and death
Answer: shock and death
Rationale: A massive PE will lead to shock and death.
A massive PE will lead to shock and death; damage to lung capillaries can occur, but death is more likely.
COPD is not associated with PE.
DIC may occur, but is not as likely as shock and death.
A 1-year-old female is diagnosed with croup. When the parent asks what caused this, what is the nurse's best response? The most likely cause of this disease is:
Answer: viral infection
Rationale: The cause of croup is a viral infection
A 6-month-old female presents with rhinorrhea, cough, poor feeding, lethargy, and fever. She is diagnosed with bronchiolitis. Which of the following will the nurse most likely observe on the culture report?
Group A beta-hemolytic streptococcus
Respiratory syncytial virus
Haemophilus B influenzae
Answer: respiratory synctial virus
Rationale: The most common cause of bronchiolitis is respiratory syncytial virus.
While planning care, a nurse recalls respiratory distress and hypoxemia in laryngotracheobronchitis are caused by:
Infectious pulmonary edema
Answer: mucosal edema
Rationale: Edema leads to obstruction of the airway and respiratory distress.
While reviewing lab results, to help confirm a diagnosis of cystic fibrosis in a 1-year-old child which substance will be present in the child's sweat?
Answer: sodium chloride
Rationale: The standard method of diagnosis is the sweat test, which reveals sweat chloride concentration in excess of 60 mEq/L.
To prevent sudden infant death syndrome, the nurse should instruct parents to:
Keep the infant's room very warm.
Breast-feed their infants.
Place infants on a soft mattress for sleeping.
Always lay infants down on their backs to sleep.
Answer: Always lay infants on their backs to sleep
Rationale: Infants should be laid on their backs to sleep.
A soft mattress is a possible contributing factor to SIDS.
Feeding method does not play as great a role as positioning during sleep.
Sleeping position is the most preventable risk factor.
A newborn has respiratory distress syndrome. When obtaining the patient's history, which of the following is the most important predisposing factor for this condition?
Smoking by the mother during pregnancy
Alcohol consumption by the mother during pregnancy
Low birth weight
Answer: Premature birth
Rationale: Respiratory distress syndrome in the newborn is more often due to premature birth.
During a respiratory assessment of an infant with respiratory distress syndrome, a sinking in the supraclavicular and intercostal areas of the thorax was noted with inspiration. This observation is documented as:
Rationale: The sinking of supraclavicular and intercostal areas is termed retractions.
When a staff member asks what the patent opening between the aorta and pulmonary artery in a fetus is called, how should the nurse reply? It is the:
Answer: Ductus arteriosus
Rationale: In the fetal circulation, the ductus arteriosus is an opening between the aorta and the pulmonary artery.
A 20-year-old male is in acute pain. An arterial blood gas reveals decreased carbon dioxide (CO2) levels. Which of the following does the nurse suspect is the most likely cause?
Rationale: Individuals with hyperventilation blow off CO2.
Individuals with hypoventilation retain CO2.
Apnea is cessation of breathing.
Cyanosis is a blue color to the skin.
A 65-year-old female with emphysema presents to the ER for difficulty breathing. Physical exam reveals bluish skin and mucous membranes. How should the nurse chart this condition? Patient has:
Rationale: cyanosis is a blue color to the skin
A 28-year-old male reports to his primary care provider that he has had a cold for a week and is coughing up bloody secretions. When giving report, what term should the nurse use to describe this condition?
Rationale: Hemoptysis is the coughing up of bloody secretions. Hematemesis is bloody vomiting.
THIS SET IS OFTEN IN FOLDERS WITH...
Patho Quiz #1
Patho Quiz 2
Patho Quiz 4
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