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Advanced Patho HESI
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Terms in this set (57)
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?
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.
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?
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.
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?
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
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.
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.
The nurse should conclude that these findings support which complication?
Intraoperative blood loss or rupture of the aorta anastomosis can cause acute renal failure related to hypovolemia.
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?
This constellation of signs in a postmenopausal woman are characteristic of cystocele.
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?
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.
Muscular Dystrophy is characterized by which pathophysiological condition?
Skeletal muscle degeneration is a classic symptom of 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?
Atropine may be prescribed to increase the automaticity of the SA node and prevent a dangerous reduction in HR during surgical anesthesia.
What information should the nurse include in a teaching plan about the onset of menopause?
Smoking, Oophorectomy and hysterotomy, Early menarche, Genetic influence and Chemotherapy exposure.
A patient with aortic valve stenosis develops heart failure.
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.
Which pathophysiological finding occurs in the myocardial cells as a result of the increased cardiac workload?
Myocardial hypertrophy results because the cells increase in surface area or size by increasing the amount of contractile proteins, but the quantity.
Physical examination of a comatose patient reveals decorticate posturing. Which statement is accurate regarding this client's status based upon this finding?
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.
Which client is at highest risk for chronic kidney disease secondary to diabetes mellitus?
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 neuropathy and chronic kidney disease.
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?
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 spasticity and to stay calmly near the child. The mother's presence with the child provides security and support,
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?
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.
What histologic finding in an affected area of the body would suggest the presence of chronic inflammation?
A predominance of monocytes and macrophages in an inflamed area indicates the start of a chronic infection.
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?
PSA is a glycoprotein found in prostatic epithelial cells, and elevations are used as a specific tumor marker. Elevations in PSA are related to gland volume, i.e. benign prostatic hypertrophy, prostatitis, and cancer of the prostate, indicating (tumor) cell load.
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?
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.
A client is admitted to the ER with a tension pneumothorax. Which assessment should the nurse expect to identify?
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.
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?
Symptoms of a febrile transfusion reaction includes: sudden chills, fever, headache, flushing and muscle pain. An allergic reaction
The nurse is analyzing the waveforms of a client's electrocardiogram. What finding indicates a disturbance in electrical conduction of the ventricles?
The normal duration of QRS is 0.04-0.12 seconds, so a prolonged QRS indicates an electrical anomaly in the ventricles.
A client with a marked distended bladder is diagnosed with hydro-nephrosis and left hydroureter after an IV pyelogram. The nurse catheterizes the client and obtains a residual urine volume of 1650 mL.
Hydroureter (dilation of the renal pelvis), vesicoureteral reflux (backward movement of urine from the lower to upper urinary tracts), and hydro-nephrosis (dilation or enlargement of the renal pelvis and calyces) result from post-renal obstruction which can consequently result in chronic pyelonephritis and renal atrophy.
This finding supports which pathophysiological cause of the client's urinary tract obstruction?
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
The nurse is planning care for a patient who has right a hemispheric stroke.
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).
Which nursing diagnosis should the nurse include in the plan of care?
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.
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?
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. MSUD is not an x-linked
A client reports unprotected sexual intercourse one week ago and is worried about HIV exposure. An initial HIV antibody screen (ELISA) is obtained.
Although the HIV antigen is detectable approximately 2 weeks after exposure, seroconversion to HIV positive may take up to 6-12 weeks after exposure,
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?
The client should return to repeat the serum screen for the presence of HIV antibodies during that time frame.
A nurse is planning to teach self-care measures to a female client about prevention of yeast infections.
A common genital tract infection in females is candidiasis, 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.
Which instructions should the nurse provide?
The client should wear clothing that is loose fitting and absorbent, such as cotton underwear, and avoid using bubble bath or bath salts.
Which reaction should the nurse identify in a client who is responding to stimulation of the sympathetic nervous system?
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.
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?
The best antihypertensive agent for clients with asthma is Metoprolol (Lopressor) (C), a beta2 blocking agent which is also cardio-selective and less likely to cause bronchoconstriction and increase asthmatic symptoms.
A deficiency of intrinsic factor should alert the nurse to assess a client's history for which condition?
Pernicious anemia is a type of anemia due to failure of absorption of cobalamin (Vit B12). The most 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?
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?
Oxidative damage to cells is thought to be a causative factor in disease and aging. If free radicals bind to polyunsaturated fatty acids found in the lysosome membrane, the lysosome, nicknamed "suicide bags", leaks its protein catalytic enzymes intracellularly and the cell is destroyed. Inadequate ATP production
Which clinical finding should the nurse identify in a client who is admitted with cardiac cirrhosis?
Four types of cirrhosis include: alcoholic, post-necrotic, biliary and cardiac cirrhosis, which is associated with severe right sided heart failure, so peripheral edema (C) is most consisted with right sided heart failure.
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.
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 should provide additional information about the secretions or lactation.
The nurse is assessing the laboratory results for a client who is admitted with renal failure and osteodystrophy.
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.
Which findings are consistent with this client's clinical picture?
A decreased tubular excretion and a decreased glomerular filtration rate results in hypocalcemia, hyperphosphatemia, and hyperkalemia.
Which healthcare practice is most important for the nurse to teach a postmenopausal client?
Bone density loss associated with 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 to help maintain bone density and prevent osteoporosis.
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?
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. Although PSA levels are prescribed for routine screening, the findings suggestive of BPH.
Which condition is associated with an over secretion of renin?
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 angiotensinogen into angiotensin I, which causes the secretion of aldosterone, resulting in renal absorption of sodium, water, and subsequently increases BP.
A client is brought to the ER after a snow-skiing accident. What intervention is most important for the nurse to implement.
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 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
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?
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.
The nurse is caring for a client who has had an excision of a malignant pituitary tumor. Which findings should the nurse document that indicate the client is developing signs of inappropriate antidiuretic hormone (SIADH)?
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.
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?
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.
Which rationale best supports an older client's risk of complications related to dysrhythmia?
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.
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?
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.
What signs and symptoms are associated with arterial insufficiency?
Pallor and intermittent claudication are signs related to stage II of peripheral vascular disease, which causes arterial insufficiency.
The severity of diabetic retinopathy is directly related to which condition?
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?
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?
Among findings of a large bowel obstruction is the distension of the lower abdomen.
The nurse is caring for a patient with syndrome of inappropriate antidiuretic hormone (SIADH), which is manifested in which symptoms?
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.
The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH). This condition is most often related to which predisposing condition?
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.
Which pathophysiologic response supports a client's vomiting experience?
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).
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