patho HESI
Clotting factor deficiency
A client is receiving fresh frozen plasma (FFP). The nurse would expect to see improvement in which condition?
Bacterial meningitis
A client reports neck stiffness, severe headache, and a decreased level of consciousness. What condition does the nurse suspect?
Cardiac irregularities for congenital heart disease
A newborn is found to have Down syndrome. The nurse knows that Down syndrome is usually accompanied by several problems. Which assessment should the nurse perform during the physical examination?
Headache, drowsiness, and vomiting
A nurse who is caring for a 7-year-old child with acute glomerulonephritis assesses the child for cerebral complications. What signs and symptoms indicate cerebral involvement?
Magnesium sulfate
A pregnant woman is administered medication to treat preterm labor that requires a prescription for calcium gluconate to counter the effects of the drug. Which drug was administered?
An olive-sized mass in the right upper quadrant
An infant with hypertrophic pyloric stenosis is admitted to the pediatric unit. What does the nurse expect to find when palpating the infant's abdomen?
Administering the TPN while working around the client's normal activities
What should the nurse include in the discharge instructions for a client who will be receiving total parenteral nutrition (TPN) at home?
Allowing the child to guide the examiner's hand to the area that hurts
A 4-year-old child is brought to the emergency department after falling on the handlebars of a tricycle. The child is guarding the abdomen, crying, and not allowing any physical contact with the staff. What is the best action by the nurse?
Pinpoint red spots on the chest
A client has a compound fracture of the femur. The nurse should assess the client for the typical signs and symptoms of a fat embolus. In comparison to thromboembolism, which unique clinical indicator can help the nurse identify a fat embolus?
Individuals who are obese are more prone to this condition than those who are thin.
A client has been diagnosed with cholelithiasis. Which fact about cholelithiasis should the nurse recall when assessing this client for risk factors?
Respiratory and urinary
A client is admitted with metabolic acidosis. The nurse considers that two body systems interact with the bicarbonate buffer system to preserve healthy body fluid pH. What two body systems should the nurse assess for compensatory changes?
Antirejection medications
A client who had a kidney transplant develops leukopenia 3 weeks after surgery. What does the nurse conclude is the most probable cause of the leukopenia?
Yersinia pestis
A client with bubonic plague has a body temperature of 103° F associated with chills, swollen glands, headache, and weakness. Which microorganism is most likely responsible for the client's condition?
Daily weight, slide/lying bed rest, deep tendon reflexes
A client with mild preeclampsia is admitted to the high-risk prenatal unit because of a progressive increase in her blood pressure. The nurse reviews the primary healthcare provider's prescriptions. Which prescriptions does the nurse expect to receive for this client? Select all that apply.
"Your glucose level will be hard to control as you reach term."
A client with poorly controlled type 1 diabetes is now in her thirty-fourth week of pregnancy. The primary healthcare provider tells her that she should have an amniocentesis at 37 weeks to assess fetal lung maturity and that induction of labor will be initiated if the fetus's lungs are mature. The client asks the nurse why an early birth may be necessary. How should the nurse reply?
I need to have my blood work checked periodically."
A client with rheumatoid arthritis is to begin taking ibuprofen 800 mg by mouth three times a day. The nurse provides education about the medication's side effects. The nurse concludes that the teaching was effective when the client makes which statement?
10:00 AM to 1:00 PM (insulin peak 2-5 hrs)
A client with type 1 diabetes receives regular insulin every morning at 8:00 AM. During what period of time does the nurse recognize the risk of hypoglycemia is greatest?
Amiodarone bolus
A client's cardiac monitor indicates ventricular tachycardia. The nurse assesses the client and identifies an increase in apical pulse rate from 100 to 150 beats per minute. What is an appropriate treatment plan?
A measurement is made from nose to earlobe and then to the epigastric area.
A gavage feeding is prescribed for an infant. How does the nurse determine the length of tube needed to reach the stomach?
Manage pain with oral pain medication.
A healthcare provider prescribes transdermal fentanyl 25 mcg/hr every 72 hours. During the first 24 hours after starting the fentanyl, what is the most important nursing intervention?
Usually they are unable to father children, although sexual function is not affected.
A male adolescent with cystic fibrosis (CF) whose parents are both carriers of the disease asks the nurse, "When I have children, could they have cystic fibrosis like me?" What information regarding men with CF should the nurse base the response on?
Caring for the newborn in the same manner as any other newbor
A neonate is born with exstrophy of the bladder, and the parents are visibly upset. They are told that corrective surgery will be performed as soon as possible. How can the nurse best assist the parents at this time?
The red blood cells will not be destroyed by maternal anti-Rh antibodies
A newborn is Rh positive, and the mother is Rh negative. The infant is to receive an exchange transfusion. When the parents ask why their baby will receive Rh-negative blood, what explanation does the nurse provide?
Restores negative pressure in the pleural space
A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who develops a pneumothorax and has a chest tube inserted. Which primary purpose of the chest tube will the nurse consider when planning care?
rubber tipped syringe
A nurse is caring for an infant after a cleft lip repair. Which item should the nurse use to feed the infant for several days after the surgery?
these children digest little food because pancreatic enzymes are blocked
A nurse is caring for several school-aged children with cystic fibrosis. Why does the nurse anticipate that these children will probably be small and underdeveloped for their age?
Clear breath sounds
A nurse is evaluating the effectiveness of treatment for a client with excessive fluid volume. What clinical finding indicates that treatment has been successful?
A first cousin underwent surgery for HPS
A nurse is obtaining a health history from the mother of a 2-month-old infant with a diagnosis of hypertrophic pyloric stenosis (HPS). What is the most significant finding about the cause of the infant's HPS?
closest to the ankle
A nurse is planning to obtain a blood specimen from a 4-week-old high-risk infant in the neonatal intensive care unit to test for hypoglycemia. At which point on the bottom of the infant's foot should the automatic lancet device be placed?
Sodium bicarbonate
A nurse is reviewing how a hyperglycemic client's blood glucose can be lowered. The nurse recalls that the chemical that buffers the client's excessive acetoacetic acid is what?
muscle tone and contractility absent paralysis of all extremities
A nurse is reviewing the assessment findings of four different clients.Which client should the nurse most likely anticipate to have defects in the spinal cord?
Promotes production of hemoglobin
A nurse is teaching a pregnant client with sickle cell anemia about the importance of taking supplemental folic acid. How does folic acid help this client?
In utero through the placenta
A nurse suspects that a newborn has toxoplasmosis, one of the TORCH infections. How and when may it have been transmitted to the newborn?
Giving the infant finger foods such as dry cereal and chopped meat
A pale, lethargic 1-year-old infant weighs 28 lb (12.7 kg) and has a hemoglobin level of 9 g/dL (90 mmol/L). The parent tells the nurse that the infant refuses solid food when it is offered by spoon and drinks between four and six full bottles of milk per day. What should the nurse recommend?
Allow the intestinal tract to rest
A severely dehydrated infant with gastroenteritis is admitted to the pediatric unit. Nothing-by-mouth (NPO) status is prescribed. The parents ask why their baby cannot be fed. The nurse explains that it is necessary to do wha
The perception that the rod is a body intrusion
An adolescent sustains a sports-related fracture of the femur, and open reduction and internal fixation with a rod insertion is performed. After the surgery, a nurse notes that the adolescent is very upset. In light of the client's developmental level, what does the nurse conclude is the most likely explanation for this distress?
decreased blood pressure
When performing a postoperative assessment, which parameter would alert the nurse to a common side effect of epidural anesthesia?
Protecting the skin surrounding the exposed bladder
Which information should be included in the teaching plan for the mother of a newborn with exstrophy of the bladder?
5% dextrose in normal saline
Which intravenous fluid should the nurse classify as hypertonic?
rubber tipped synringe
Which item should a nurse use to feed an infant born with a unilateral cleft lip and palate?
defect in hypothalamus
Which medical condition could most probably result in clients developing primary diabetes insipidus (DI)?
dyslpasias, distruptions, defomations, malformations
Which of the following are congenital anomalies or birth defects seen in children? Select all that apply.
Juxtaglomerular cells of the arteriole
Which part of the kidney produces the hormone bradykinin?
Persistent vomiting
A nurse in the emergency department is assessing a 10-month-old infant who was injured in an automobile collision. The infant, who is quiet but does not appear lethargic, has a large hematoma on the left temporal area. What sign of neurologic involvement is the most critical to identify?
HR acceleration in the last half of pregnancy
A nurse in the prenatal clinic is caring for a client with heart disease who is in her second trimester. Which hemodynamic change of pregnancy is likely to affect the client at this time?
Fat globules
A nurse is assessing a client for possible malabsorption syndrome. Which stool assessment finding will support this diagnosis?
Joints
A nurse is assessing an adolescent child with the diagnosis of hemophilia. In what part of the body does the nurse expect bleeding to occur?
Periorbital edema
A nurse is assessing the condition of a school-aged child with acute glomerulonephritis. What clinical finding does the nurse anticipate?
histamine
A nurse is caring for a client with pruritic lesions from an IgE-mediated hypersensitivity reaction. Which mediator of injury is involved?
The eustachian tube is short and horizontal
The parent of a 10-month-old infant with otitis media tells the nurse in the pediatric clinic that this is the baby's third episode in 3 months. The infant is tugging at the ear but is not acutely ill. What factor should the nurse consider before responding?
Pancreatic scarring predisposes the child to diabetes
The parents of a 12-year-old boy with cystic fibrosis (CF) ask the nurse why he needs a glucose tolerance test. What information should the nurse consider before replying?
A saclike cyst of meninges, containing a portion of spinal cord and fluid, is protruding through a defect in the spine.
The parents of an infant born with a myelomeningocele are confused about what the primary healthcare provider has told them about the condition. What should the nurse consider before answering the parents' questions in language that they will understand?
Undigested fat
The parents of an infant with newly diagnosed cystic fibrosis ask a nurse what causes the foul-smelling, frothy stool. What is the best response by the nurse?
This is a condition with an excellent prognosis.
The parents of an infant with pyloric stenosis ask a nurse many questions about the problem. What information should the nurse communicate when answering these questions?
To evaluate for clavicle fracture
While assessing a neonate who was born at 42 weeks of gestation via vaginal delivery, the nurse finds that the neonate has a birth weight of 9 lb (4.1 kg). The nurse also assesses for Moro reflex and focal swelling or tenderness in the neonate. Why does the nurse perform these interventions?
Contracture
While assessing an immobilized client, the nurse notes that the client has shortened muscles over a joint, preventing full extension. What is this condition known as?
folic acid
While counseling the parents of an adolescent with anemia related to an inadequate diet, a nurse explains that several different nutrients, including protein, iron, and vitamin B12, are involved. What other nutrient should the nurse include in the teaching?
Notify the healthcare provider if diarrhea develops
A healthcare provider prescribes ampicillin for a client with an infection. What information should the nurse include in the teaching plan about this medication?
It may turn the urine bright yellow
A healthcare provider prescribes a vitamin tablet that contains vitamin B complex. What should the nurse teach the client?
Performing Postural Drainage
A 15-year-old with cystic fibrosis (CF) is admitted with a respiratory infection. The nurse determines that the adolescent is cyanotic, has a barrel-shaped chest, and is in the 10th percentile for both height and weight. What is the priority nursing intervention?
glucagon
A 17-year-old student with type 1 diabetes asks the nurse which hormone causes the blood glucose level to rise. When responding, the nurse should explain in language that the client can understand that liver glycogenolysis is stimulated by a hormone secreted by the islets of Langerhans. Which hormone is this?
a pacifier will be offered to decrease gagging and allow easier insertion of the tube.
A 2-month-old infant is to have a nasogastric tube inserted. What does the nurse expect to happen?
Rectal biopsy
A 3-month-old infant with chronic constipation has a tentative diagnosis of Hirschsprung disease. What definitive diagnostic test does the nurse expect to prepare the infant for?
The risk for placental insufficiency A history of stillbirth from her last pregnancy Maternal history of hypertension
A 37-year-old client with hypertension, type 1 diabetes and good glycemic control is pregnant for the third time. Her first child is 4 years old, and her second pregnancy resulted in a stillbirth. She is seen in the antepartum testing unit for a nonstress test (NST) at 33 weeks' gestation. What are the primary risk factors in the client's history that indicate the need for a nonstress test? Select all that apply.`
has emotional effect on the parents
A 4-month-old infant is admitted to the pediatric unit for cleft lip repair. The nursing assistant asks the nurse why the repair is being done at this age. What is the best response the nurse can give as to why cleft lip repair is performed so soon?
inhibition of tear production
The nurse reviews the diagnostic reports of a client and discovers that the client has an injury to cranial nerve VII. What will the nurse observe upon assessment?
Deafness and cardiac anormalities
The nurse suspects that a newborn's mother contracted rubella during the first trimester of pregnancy. Which newborn problems support this assumption? Select all that apply.
pressure dressing
After an above-the-knee amputation for bone cancer, an adolescent boy is returned to his room. He is monitored closely because of the potential for hemorrhage from the residual limb. What should the nurse plan to keep at the bedside?
The infant is developing normally: at 6 months: 6.08 kg, height: 25.5 in head circumference: 44 cm
After completing the physical examination of a 6-month-old infant, the nurse compares the infant's height, weight, and head circumference with the previous findings. What does the nurse infer from these findings?
occurs after the first bleeding
After her baby undergoes corrective surgery for hypertrophic pyloric stenosis, the mother is asked to offer the first feeding. The infant sucks it eagerly and vomits immediately. What is the nurse's explanation to the mother?
By focusing on simple anatomic diagrams
An 8-year-old child is being prepared for surgery the next day. How should the nurse present preoperative instructions to this child?
Notify the practitioner
An infant with a diagnosis of failure to thrive has been receiving enteral feedings for 3 days. All feedings have been retained, but the skin and mucous membranes are dry, and the infant has lost weight. What should the nurse do first in light of these findings?
reduced outflow of aqueous humor (increased intraocular pressure)
The nursing is caring for four different clients with eye disorders.Which client should be assessed for asthma before prescribing beta-adrenergic blockers?
carina
Which part of the respiratory system is referred to as Angle of Louis?
type IV
Which type of hypersensitivity reaction will occur when the client's T cytotoxic cells are involved as the mediators of injury?
skim milk and kale
During a physical examination, the nurse finds that a 3-year-old child has markedly fewer teeth than expected for that age. Which foods should be included in the child's diet to promote tooth formation? Select all that apply.
Breast development occurred by 15 years of age
During assessment, the nurse asks a client about developmental milestones such as the age at which thelarche and menarche occurred. The nurse determines that the client experienced pubertal delay. Which finding in the client's history supports the nurse's conclusion?
"I can express milk by hand or with a breast pump." "I can store expressed milk in the refrigerator for 5 days
During follow-up visits, the nurse informs the mother of a 3-month-old infant how to feed the infant expressed milk. Which statements by the mother indicate effective learning? Select all that apply.
Bleeding tendencies and diarrhea
For which side effects should a nurse assess a client with cancer who is being treated with chemotherapeutic agents? Select all that apply.
Orthopnea
Immediately after being placed in the supine position, an adolescent child experiences shortness of breath and must sit up to breathe. What term should the nurse use to document this clinical phenomenon?
feeding properly mashed sweet potatoes to the child
The nurse teaches a mother about the dietary measures to be followed for her 5-month-old infant. During the follow-up visit, the nurse finds that the child has indigestion. Which action by the mother is responsible for this situation?
"I should call my child by name.", "I should start oral hygiene in my child., "I should not leave the child with an unfamiliar relative.
The nurse is teaching a mother about the developmental behaviors of a 7-month-old infant. Which statement by the mother indicates effective learning? Select all that apply.
Atherosclerotic plaques within arteries
The healthcare provider makes the diagnosis of transient ischemic attacks (TIAs). The client asks the nurse, "What causes TIAs?" When preparing a response in language the client will understand, the nurse considers that TIAs are caused by which factor?
The infant has a prominent clitoris, hair of infant is fine and feathery, infant shows no resistance to the heel to ear maneuver
The nurse is assessing a female preterm neonate after delivery. Which assessment findings does the nurse document in the hospital reports of the infant? Select all that apply.
A body weight of 3500 g
The nurse is assessing a newborn immediately after birth. Which finding indicates normal development?
weight at birth: 2.5 weight at 2.5 yrs: 14 motor skills: builds tower
The nurse is assessing four 2.5-year-old children in a pediatric center. Which child would require further assessment?
Absence of menstruation
The nurse is caring for a client who is diagnosed with hyperpituitarism due to a prolactin-secreting tumor. Which clinical manifestation can help confirm the diagnosis?
chills, hypotension, tachycardia
The nurse is monitoring a client who is having a third transfusion of packed red blood cells. Which of these may be evident if the client is experiencing a febrile transfusion reaction? Select all that apply.
A low hemoglobin level causes reduced oxygen-carrying capacity
The nurse is monitoring a client's hemoglobin level. The nurse recalls that the amount of hemoglobin in the blood has what effect on oxygenation status?
low grade fever
The nurse is teaching a group of parents about the side effects of vaccines. Which side effect should the nurse include in teaching about the Haemophilus influenzae (Hib) vaccine?
Extracellular fluid (ECF) compartment contraction
The nurse observes that an infant has lost 5% of body weight a few days after birth. Which reason does the nurse attribute to this weight loss?
Phenytoin decreases warfarin's anticoagulant effect
Warfarin is prescribed for the client who takes phenytoin for a seizure disorder. Why must the nurse observe the client closely during the initial days of treatment with warfarin?
Dietary history Signs of malnutrition Familial stress factors Parent and infant interaction Sustained growth under 5th percentile
What considerations should be included in caring for an infant who is failing to thrive (FTT)?Select all that apply
Increase in length of vocal cords by 0.4 inch (1 cm), Uncontrollable shifting of the voice from deep to high tones
What growth changes are observed in a male client during adolescence? Select all that apply.
Teaching the family how to limit sickling episodes
What is the most appropriate nursing intervention for an adolescent child with sickle cell anemia?
Cheese-like substance on the skin
Which finding indicates that a newborn has vernix caseosa?
