Pathophysiology Exam 1
Which type of hypoxia would the nurse expect to find in a client with cyanide poisoning?
Answer: Histoxic Rationale: Histoxic hypoxia occurs in poisonings with substances such as cyanide that interfere with the cells' ability to use oxygen. Anemic hypoxia results from carbon monoxide poisoning or sickle cell disease, in which there is a problem with oxygen transportation. Ischemic hypoxia develops when tissues or organs are deprived of oxygen, resulting in cell death. Hypoxemic hypoxia occurs in emphysema because of a decreased O2 level.
The nurse is awaiting the transfer of a client with acid-base issues. Which element should the nurse recognize as the core of acid-base regulation in the body?
Answer: Hydrogen Rationale: The hydrogen ion is the central element when addressing acid-base balance issues. Sodium, calcium, and potassium are involved in proper muscle function.
Which is the correct definition of the term syndrome?
Answer: A group of signs and symptoms of a disease Rationale: A collective group of signs and symptoms that are a result of a disease state is referred to as a syndrome. For example, a client with carpal tunnel syndrome may experience signs of numbness, tingling, and weakness. A disorder is a disruption of physiological function. A disease is a situation that is impairing functional abilities. The individual's experience with a disease is referred to as an illness.
The nurse notes that a client has a lead concentration of 75 mcg/dL. Which prescription should the nurse expect to implement for this client?
Answer: Chelating agent Rationale: A chelating agent would be prescribed for a client with a lead concentration greater than 44 mcg/dL. Chemotherapy is prescribed for the client with cancer, not one with lead poisoning. Hyperbaric oxygen is used to treat carbon monoxide poisoning. Red blood cell transfusions may be used in the treatment of anemia related to radiation poisoning.
The nurse is providing care to a client whose laboratory results show a high iron concentration. In light of these findings, what parameter would the nurse include in the assessment? (Select all that apply.)
Answer: • Presence of edema • Skin color • Blood glucose level Rationale: A high iron concentration can affect the liver, pancreas, and heart. Therefore, the nurse would assess the skin for jaundice, the blood glucose level for an indication of diabetes mellitus, and the lower extremities for the presence of edema. Carbon monoxide poisoning, not iron, would cause changes in an individual's degree of orientation. Hyalinization of the glomeruli would necessitate assessment of urine color and amount.
Which complication of carbon monoxide (CO) poisoning can affect the fetus? (Select all that apply.)
Answer: • Seizures • Cerebral palsy • Congenital anomalies Rationale: CO poisoning is harmful to the fetus, causing seizures, cerebral palsy, and congenital anomalies. Hair loss results from exposure to ionizing radiation. Developmental delay occurs in lead poisoning.
Which factor would the nurse consider as a cause of lipid accumulation within the cells? (Select all that apply.)
Answer: • Starvation • Obesity • Alcohol Rationale: Lipids accumulate in the presence of obesity, alcohol ingestion, starvation, and diabetes mellitus. Radiation poisoning does not cause lipids to accumulate; it exerts teratogenic effects on the fetus and on cancers. Heart valve damage is caused by calcium deposits.
The nurse is reviewing health hazards with a group of industrial workers. Which symptom of air contamination should the nurse instruct the workers to report? (Select all that apply.)
Answer: • Wheezing • SOB • Coughing Rationale: Industrial workers may be exposed to different types of air pollutants and irritants. These irritants can cause coughing, wheezing, and shortness of breath. Arrhythmias can be caused by carbon monoxide poisoning. Peripheral edema is caused by cardiac, renal, or hepatic disorders.
What is the function of the cell membrane? (Select all that apply.)
Answer: • Hormone reception • Ionic control Rationale: The primary function of the cell membrane is to separate the intracellular contents from the extracellular environment. Other functions include controlling positively and negatively charged ion movement and providing a place for hormone receptors. Protein synthesis occurs in the endoplasmic reticulum. Nerve conduction, controlled by peroxisomes, takes place along neurons. Energy production takes place in the mitochondria.
The nurse reviews the different types of cellular growth patterns. Which pattern should the nurse identify that occur during pregnancy? (Select all that apply.)
Answer: • Hypertrophy • Hyperplasia Rationale: Increases in cell size (hypertrophy) and increases in cell numbers (hyperplasia) occur during pregnancy. Atrophy results from disuse. Dysplasia is the name for precancerous cell changes. Metaplasia is a reversible cellular change.
Which neuromuscular disorder resulting from a channelopathy might be found in a client? (Select all that apply.)
Answer: • Migraine • Epilepsy Rationale: Epilepsy and migraine headaches are believed to be caused by channelopathies. Spinal cord injury is usually the result of an injury. Muscular dystrophy is a genetic disorder that results in progressive muscle weakness. Sudden infant death syndrome is thought to originate in a cardiac channelopathy, not a neuromuscular disorder.
The nurse is managing the mechanical ventilation of a client with respiratory acidosis. Which intervention should the nurse identify for this client? (Select all that apply.)
Answer: • Provide bronchodilators as ordered. • Administer diuretics as ordered. • Administer bicarbonate. • Suction the airway as needed. Rationale: The client with respiratory acidosis on mechanical ventilation may receive bicarbonate to correct acidosis; the ventilator will provide breaths if the internal respiratory drive halts. Providing an open, effective airway through suctioning, diuretics, and bronchodilators all support ventilation. Hypoventilation is not desired in an acidotic state; the respiratory rate would not be decreased.
Which laboratory value should the nurse assess in a client with malnutrition and subsequent lack of ATP? (Select all that apply.)
Answer: • Sodium • Chloride • Potassium Rationale: Failure of the sodium-potassium pump affects sodium, chloride, and potassium levels. Therefore, the nurse should assess these lab values. Calcium and phosphorus are regulated by the parathyroid glands and the kidneys.
The nurse is preparing an information sheet on the role of the renal system in acid-base balance. Which piece of information should the nurse include? (Select all that apply.)
Answer: • The kidneys conserve bicarbonate to buffer systemic acidity. • Impairment of the renal system leads to concerns with acid-base balance. • The kidneys excrete the hydrogen ion buffered by ammonia. Rationale: The kidneys are essential to acid-base balance in the body through the conservation of bicarbonate and excretion of hydrogen-buffered ammonia. The renal system is relatively slow to respond, taking hours to see evidence of correction and days to resolve correction. Urine is acidotic because of the products of cellular metabolism.
The nurse is caring for a client who is suspected to have posttraumatic stress disorder (PTSD) or acute stress disorder (ASD). Which assessment question made by the nurse can assess which disorder the client may have?
Answer: "How long ago did your trauma occur?" Rationale: The significant difference between acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) is the onset of symptoms. In ASD, the onset of symptoms is expected to occur within 1 month of the traumatic event, and symptoms are not expected to last longer than 4 weeks. Avoidance of situations, flashbacks, and severe symptoms occur in both ASD and PTSD.
The nurse is caring for a client with emphysema. Which arterial blood gas pH value should the nurse identify that reflects acidosis in this client?
Answer: 7.25 Rationale: Acidosis is reflected by a pH lower than 7.35. The normal pH range is 7.35-7.45. A value greater than 7.45 indicates alkalosis.
Which client would the nurse consider as having a chronic disease or injury?
Answer: Client who has type 1 diabetes mellitus Rationale: A chronic disease has an enduring quality with lasting implications, such as type 1 diabetes mellitus. Acute diseases are temporary in nature, such as the yearly flu, strep throat, or broken bones.
The nurse is caring for a client whose spouse died six months ago from a traumatic incident. The client tells the nurse that they plan on starting a foundation focused on grieving spouses. In response to stress, what characteristic does the nurse recognize in the client?
Answer: Adapting Rationale: Coping is often seen as the short-term reaction in response to stress. The client who has had some time to grieve and now focuses on positive ways to manage stress is seen as adapting to the original stressor. Conversion involves the manifestation of a physiological condition or disorder in response to an acute stress response. Self-management is not a descriptive characteristic that is typically used to describe a response to stress.
A client is being treated for severe sepsis and chronic stress response. The healthcare provider suspects that the client has a dysfunction of the pituitary gland. The nurse recognizes that a dysfunction of the pituitary gland would likely have dysregulation of the release of which hormone?
Answer: Adrenocorticotropic hormone (ACTH) Rationale: The hypothalamic-pituitary-adrenal (HPA) axis involves the hypothalamus, which regulates the release of corticotropin-releasing hormone (CRH), which in turn stimulates the release of adrenocorticotropic hormone (ACTH) from the pituitary. The locus coeruleus-norepinephrine (LC/NE) system evokes the release of epinephrine and norepinephrine.
The nurse administers oxygen to a client with sickle cell disease. Which type of hypoxia is being treated by this intervention?
Answer: Anemic Rationale: In sickle cell disease, the red blood cells are sickle-shaped and lack enough hemoglobin to carry oxygen. Therefore, anemic hypoxia develops. Histoxic hypoxia occurs as a result of some kind of poisoning that interferes with the cells' ability to use oxygen. Ischemic hypoxia develops when tissues or organs are deprived of oxygen, resulting in cell death. Hypoxemic hypoxia occurs in emphysema as a result of a decreased O2 level.
A nurse is teaching an adult client about the quantity of fruits and vegetables that should be consumed daily. Which quantity is accurate according to the Dietary Guidelines for Americans?
Answer: At least 4.5 cups Rationale: An adult should consume at least 4.5 cups of fruits and vegetables daily in order to obtain a variety of vitamins, minerals, fiber, and phytochemicals.
The nurse is caring for a client with multiple fractures caused by a motor vehicle crash. Which cellular response should the nurse expect as a result of the client's immobility?
Answer: Atrophy Rationale: An immobile client will experience muscle atrophy as a result of lack of use. Metaplasia is a reversible cellular change that occurs in response to exposure to an irritant. Hyperplasia is an increase in the number of cells as a result of certain medications or during periods of growth. In hypertrophy, cells become larger because of increased workload.
The nurse is caring for several clients with mental health dysfunctions related to stress. Which client would the nurse determine likely has an adjustment disorder related to stress?
Answer: A middle-aged client who loses a job and begins to feel distress Rationale: Adjustment disorders develop after exposure to a clearly defined stressor of a less intense nature than those leading to the development of acute stress disorder (ASD) or posttraumatic stress disorder (PTSD). As with other psychiatric conditions, the individual with adjustment disorder will display significant disruption in the ability to function in society, along with a feeling of distress. Disruptions in daily functioning are expected to occur within 3 months of exposure to an event, and symptoms are not typically expected to occur for longer than 6 months. The less intense nature of losing a job in comparison with the other stressors described would lead to suggestion that that particular client is at greatest risk for the development of an adjustment disorder. Witnessing the death of a close friend as well as returning from a war zone would most likely lead to PTSD or ASD, because the client may have persistent flashbacks or dreams about the trauma. The child whose mother died may also experience PTSD or ASD; however, this client may only be experiencing grief.
Understanding the biophysiological concept of mobility is an important aspect of treating a client who has had a stroke. Which subconcept must the caregiver understand?
Answer: Balance Rationale: The caregiver must have an understanding of the subconcept of balance when caring for a client who has had a stroke. One common side effect of a stroke is imbalance. The subconcept of coagulation is associated with diseases such as pulmonary emboli and thrombocytopenia. The subconcept of hypoxia is associated with diseases such as asthma and anemia. The subconcept of hormonal regulation is associated with diseases such as diabetes mellitus and obesity.
The nurse cares for a client with dysoxia. What caused this health problem to occur?
Answer: Blockage of oxygen exchange in capillaries Rationale: Dysoxia is an imbalance between oxygen supply and oxygen demand that results in blockage of oxygen exchange in the capillaries. Inability to detoxify free radicals occurs in oxidative stress. Poor oxygenation resulting from higher altitudes causes hypoxemic hypoxia. Ribosomal dysfunction within cells causes impaired protein synthesis.
The nurse is investigating a food source as the cause of a client's pH of 7.48. Which food source should the nurse consider that may contribute to this pH?
Answer: Broccoli Rationale: The client's pH is showing an imbalance toward alkalinity, which can be caused by an intake of broccoli. Oranges contain citric acid, and soft drinks and processed meats contain phosphoric acid, which would lower the pH.
Which chronic disorder is not considered common among U.S. youth?
Answer: Cancer Rationale: The most common chronic disorders among U.S. youth include: • Cystic fibrosis • Obesity • Hypertension • Sickle cell anemia • Diabetes
Anaerobic metabolism has led to the buildup of lactic acid in a client, resulting in severe acidosis. Which system of the body is contributing to this acidosis?
Answer: Cardiovascular Rationale: The cardiovascular system is responsible for perfusion of the tissues and delivery of oxygen to prevent anaerobic metabolism resulting in the production of lactic acid causing acidosis. The renal system is involved in the regulation of bicarbonate. The hepatic system can assist with the removal of bicarbonate. The gastrointestinal system contains hydrochloric acid, not lactic acid.
The nurse is preparing a 0.9% NaCl infusion for a client with metabolic alkalosis. In which situation would the delivery of 0.9% NaCl be contraindicated?
Answer: Client with an aldosterone-producing tumor Rationale: In the client with an aldosterone-producing tumor, the 0.9% NaCl infusion will be ineffective, because the client will continue to excrete potassium and reabsorb sodium and bicarbonate from the constant signal sent by the tumor. The clients receiving diuretics, losing gastric fluid through vomiting, and with fluid volume deficit in metabolic alkalosis may all benefit from the receipt of chloride through the 0.9% NaCl infusion.
A client has pitting edema. Which is a description of this condition?
Answer: Collection of fluid in interstitial spaces Rationale: Edema is a collection of fluid that is drawn out of intracellular spaces into interstitial areas. This fluid is not useful in maintaining fluid balance, and does not contribute to circulatory effort. Increased intracellular pressure may cause cells to burst, and an increase in circulating volume may result in hypertension and venous distension. Edema may occur as part of an inflammatory response, but the mechanism of edema is fluid in the interstitial spaces.
Which is a description of osmolarity?
Answer: Combined solute concentration in water Rationale: Osmolarity is the number of solute particles, or solute concentration in water. The amount of solute per kg of solution is the osmolality. The level of electrolytes in the bloodstream is not associated with solutes or dilution. The circulating volume in extracellular spaces is not described in terms of osmolarity or osmolality.
A client expresses extreme grief and stress after the recent death of the client's spouse. According to the transactional model of stress, which factor does the nurse recognize that determines the end result of the client's stress response?
Answer: Coping resources available in response to the event Rationale: According to the transactional model of stress, the coping resources available in response to the event determine the end result of the client's stress response. The sum total of life events, the characteristics of stressful events, and the cultural values attached to the event represent the stimulus conceptualization of stress, not the transactional model of stress.
A nurse is caring for a client with posttraumatic stress disorder (PTSD) who has a functional deficit of the prefrontal cortex due to a traumatic brain injury (TBI). From which outcome related to stress does the nurse suspect the client may be sustaining?
Answer: Decreased coping strategies related to the stress Rationale: A functional impairment of the prefrontal cortex may lead to decreased coping strategies related to stress. Blunted affect, increased anger, and inability to adapt are not associated with a functional impairment of the prefrontal cortex.
The public health nurse is describing the objectives of epidemiology to a newly hired nurse. Which objective would NOT be accurate?
Answer: Determining the function of a group of genes Rationale: Objectives of epidemiology include: • Identifying the cause of a disease • Evaluating existing preventative and therapeutic measures • Studying the prognosis of a disease • Identifying the risk factor of a disease
A client is recently diagnosed with a brain tumor located near the hypothalamus. The client reports increased anxiety due to the stress of the diagnosis. Based on the client's stress response and current condition, which clinical manifestation might the nurse find?
Answer: Dysregulation of catecholamine release Rationale: The hypothalamus releases hormonal mediators that have end effects on other organs, such as the adrenals. The adrenals release catecholamines and a tumor near the hypothalamus may cause a dysregulation of catecholamine release.
The nurse is caring for a client with a traumatic brain injury to the amygdala portion of the brain. What deficit or alteration would the nurse expect to find in regard to the client's interpretation of stress, as a result of the client's injury?
Answer: Emotion Rationale: The amygdala portion of the brain plays a role in the regulation of emotion and regulates fear and anxiety. Sleep is influenced by the pons. The brain stem controls vital functioning, such as breathing. The frontal lobe of the brain regulates speech.
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is experiencing worsening shortness of breath and chest tightness. Which term is correct in describing an increase in the severity of the disease?
Answer: Exacerbation Rationale: An exacerbation is an increase in the severity of a disease. Remission is a decrease in the severity of the disease. Etiology is the cause of the disease or disorder. Remission refers to a decrease in the severity of a disease. A chronic disease is a disease that is enduring and lasting in nature.
A nurse is educating a client regarding modifiable and nonmodifiable risk factors for developing coronary heart disease. Which nonmodifiable risk factor would the nurse present to the client?
Answer: Father having coronary heart disease Rationale: Nonmodifiable risk factors are factors that lead to a higher risk of developing a particular disease; however, they may not be altered. Examples of nonmodifiable risk factors include age, race, and family history. Factors that may be changed, such as smoking, exercise, and diet, are considered modifiable risk factors.
The nurse administers sodium bicarbonate to a client in diabetic ketoacidosis. While extracellular pH rises, which compound results in the decrease in intracellular pH?
Answer: H2CO3 Rationale: CO2 (carbon dioxide) and H2O (water) join to form H2CO3 (carbonic acid), which enters the cells, lowering the intracellular pH. Na HCO3 is sodium bicarbonate given to treat the client, and Na lactate is a by-product of sodium bicarbonate treatment.
The nurse is educating a client on the Dietary Guidelines for Americans (DGA) eating pattern options. Which pattern option should the nurse include in the education?
Answer: Healthy Mediterranean-Style Rationale: The three eating pattern options that are outlined by the DGA are Healthy Mediterranean-Style, Healthy Vegetarian, and Healthy U.S.-Style.
Isotonic fluid loss will have which result on serum sodium?
Answer: Normal sodium level Rationale: In isotonic fluid volume deficit, fluid is lost, but sodium levels remain unchanged. Care must be taken when replacing fluids in order to prevent hypokalemia, which can result in fluid being moved into the extracellular spaces.
The nurse receives a client's arterial blood gas (ABG) pH result of 7.27. Which change in potassium does the nurse anticipate that this client will have?
Answer: Hyperkalemia Rationale: The client with a pH of 7.27 is acidotic, which will result in hyperkalemia caused by the movement of potassium out of cells to allow the entry of hydrogen ions into cells. Hypokalemia would occur with alkalosis, as potassium moves into the cells to move hydrogen out of the cells. An acidotic state would not result in a normal potassium or hemolyze the blood sample.
Which electrolyte imbalance will the nurse observe in a client with hypotension?
Answer: Hyponatremia Rationale: Hyponatremia is often associated with reflex hypotension, when the renal system works to rid the body of excess fluid to concentrate sodium ions and increase sodium levels. Hypernatremia results in hypertension, due to the increase in circulating volume in an attempt to dilute increased sodium levels. Potassium imbalances may result in cardiac manifestations but are not directly related to hypotension or hypertension.
After caring for a client, the nurse forgets to wash their hands and subsequently causes an infection in another client due to this error. Which term describes the illness caused by a healthcare provider?
Answer: Iatrogenic Rationale: When the etiology of a disease is due to an error by a healthcare provider, it is termed iatrogenic. Genomics refers to the study of the function of groups of genes in terms of mediating physiological function. Idiopathic refers to a disease in which the cause cannot be determined. The term syndrome refers to a group of signs and symptoms due to a disease state.
A client has been diagnosed with the flu and is experiencing lethargy. What term is used to describe this individual's experience with the flu?
Answer: Illness Rationale: The term illness is used to describe the individual's experience with a certain disease. In this case, the individual has the flu, which is the disease, and their experience includes lethargy. Disease refers to a situation that is impairing functional ability in some way. The term disorder is used to describe a disruption of physiological or psychological function. The term syndrome refers to a group of signs or symptoms associated with a disease.
In 2014, there were 19,999 new cases of syphilis reported in the United States. What term describes this number?
Answer: Incidence Rationale: Incidence refers to the number of new cases of a particular disease or condition in a defined population within a defined period.
The nurse should suggest which dietary change for a client with chronic hypocalcemia?
Answer: Increase consumption of dairy and green, leafy vegetables Rationale: Dairy products and green, leafy vegetables are good sources of calcium, and should be consumed by those with hypocalcemia. Decreasing fluid intake will not have an effect on calcium levels. Increased use of table salt is usually recommended for those with chronic hyponatremia. Increased consumption of citrus and bananas is a recommendation for those with hypokalemia.
Which recommendation should the nurse provide to a client with a potassium level of 2.3 mEq/L?
Answer: Increase intake of citrus fruit Rationale: Citrus fruit is high in potassium, as are bananas, melons, lean meats, milk, vegetables, and whole grains. These foods should be recommended to clients with hypokalemia in order to increase potassium. Dairy intake is usually recommended for those with hypocalcemia. Decreasing fluid intake is not a recommended dietary change in those with hypokalemia. Avoiding red meat may be a recommendation for those with certain clotting disorders, but is not a consideration for hypokalemia.
An increase in sodium in the bloodstream will have which effect on antidiuretic hormone (ADH) secretion?
Answer: Increased secretion Rationale: An increase in sodium in the bloodstream will result in an increased attempt by the body to retain fluid. This is a regulatory response to dilute the concentration of sodium. Antidiuretic hormone (ADH) regulates the amount of fluid in the body by retaining fluid. An increase in secretion of ADH will occur as a response to an increased level of sodium.
Which type of fluid makes up the largest volume of fluid in the body?
Answer: Intracellular fluid (ICF) Rationale: Intracellular fluid makes up the largest volume of fluid in the body (63-70%). Extracellular fluid includes the remaining 30-37% of body fluid and consists of intravascular (includes plasma), interstitial, and transcellular fluids. Solutes are solid particles. Next Question
A client reports substernal chest pain that radiates down the left arm. Laboratory and diagnostic test findings indicate myocardial infarction (MI). Which type of hypoxic event is the client experiencing?
Answer: Ischemic hypoxia Rationale: Ischemic hypoxia occurs as a result of a cardiac or vascular event. This client has sustained a cardiac event, an MI; therefore, the client has ischemic hypoxia. Anemic hypoxia occurs in carbon monoxide poisoning. Histoxic hypoxia occurs as a result of poisoning. Hypoxemic hypoxia is the result of inadequate oxygenation due to poor ventilation, such as in COPD.
A 2-year-old child has had diarrhea and vomiting for three days. The child is at high risk for which type of fluid imbalance?
Answer: Isotonic fluid volume deficit Rationale: Isotonic fluid volume deficit occurs when electrolytes and fluids are lost at the same rate, resulting in an overall fluid volume deficit. Pediatric clients are at especially high risk for this type of dehydration because their body weight is composed of a high percentage of water. Hyponatremia is not as likely, because the concentration of electrolytes does not change much. Third spacing is an accumulation of fluid in extracellular areas. Hypertonic fluid volume deficit occurs when intracellular pressure increases.
In 2015, there were 147,101 deaths due to chronic lower respiratory diseases in the United States. Which term describes this data?
Answer: Mortality Rationale: Mortality is defined as the number of deaths in a given population.
The nurse taps the facial nerve of a client with metabolic alkalosis. Which finding should the nurse expect that is consistent with this acid-base imbalance?
Answer: Movement of the face, lip, and nose Rationale: Movement of the face, lip, and nose with stimulation of the facial nerve is a positive Chvostek sign, displaying neuromuscular excitability associated with alkalosis. Pain occurs in an infection or inflammation, not alkalosis. Ocular tearing and lack of facial movement are not indications of alkalosis.
The nurse is caring for a client who has type 2 diabetes mellitus. Which risk factor would the nurse look for in the client's history?
Answer: Obesity Rationale: A risk factor is something that puts a client at a greater risk of developing a certain disease. For example, obesity, insulin resistance, sedentary lifestyle, and high blood pressure are all risk factors for developing type 2 diabetes mellitus.
The nurse is caring for a client admitted with an exacerbation of chronic obstructive pulmonary disease (COPD) and hypoxemic hypoxia. Which laboratory finding supports this diagnosis?
Answer: PaO2 of 55 Rationale: When PaO2 is less than 80 mmHg, hypoxemic hypoxia is diagnosed. This client has normal pH and HCO3 readings and a high PaCO2 as a result of the COPD.
Which complication should the nurse expect to find in a client with damage to the endoplasmic reticulum (ER) within the cells?
Answer: Pancreatic enzyme deficiency The endoplasmic reticulum (ER) is responsible for communicating and transporting substances within the cells. Damage to the ER can result in pancreatic enzyme deficiency and decreased plasma protein production. Tay-Sachs disease is caused by damage to the lysosomes. Damage to the Golgi complex can result in a decrease in growth hormone. Damage to the peroxisomes can lead to nerve conduction abnormalities.
Which is the most prevalent intracellular ion?
Answer: Potassium Rationale: Potassium is the most prevalent ion in the intracellular fluid with a normal level of 3.5-5.0 mEq/L. Potassium regulates ICF osmolality and is involved in maintaining the resting membrane potential. It is also an essential component in the Na+/K+ pump, is exchanged for H+ as part of the buffering mechanism to maintain blood pH, and facilitates glycogen storage in liver and skeletal muscle cells. Sodium is the most prevalent extracellular fluid. Calcium facilitates the sodium-potassium pump, which provides stimulation and resting potential to cells. Phosphate is not a prevalent intracellular ion.
The nurse is caring for a client with renal failure, contributing to acid-base balance issues. What is the role of the kidneys in acid-base balance?
Answer: Regulate the release of bicarbonate Rationale: The kidneys regulate the release of bicarbonate and the hydrogen ion, which contributes to the maintenance of pH in the body. The gastrointestinal system produces hydrochloric acid for food digestion. The cardiovascular system perfuses tissue with oxygenated blood to prevent lactic acid buildup from anaerobic metabolism. The lungs eliminate carbon dioxide waste from the body.
The nurse is caring for a client retaining carbon dioxide. Which system of the body is malfunctioning leading to this acidosis?
Answer: Respiratory Rationale: The malfunction of the respiratory system leads to the retention of carbon dioxide, which causes acidosis. The renal system regulates the hydrogen ion and bicarbonate. The hepatic system can assist with the removal of bicarbonate. The cardiovascular system is responsible for organ perfusion of the lungs and kidneys to adequately maintain fluid-base balances.
During a physical examination, the nurse charts that a client appears lethargic, has a temperature of 102degrees° F, blood pressure of 118/75 mm/Hg, and is feeling sharp lower quadrant abdominal pain. Which of these observations would be considered a symptom?
Answer: Sharp lower quadrant abdominal pain Rationale: A symptom is a subjective sensation perceived by an individual that is not observable. The sharp lower quadrant abdominal pain is a subjective sensation. The temperature, blood pressure, and lethargy are all observable signs.
A nurse is caring for a client who is going through a divorce and a custody battle of the couple's children. The client states, "My life has been difficult, but I'm managing." The nurse would recognize the client as being in which stage of the general adaptation syndrome (GAS) model?
Answer: Stage of resistance Rationale: The client is in stage 2 of the GAS model, also known as the stage of resistance, in which a period of homeostasis has been reached. Phase 1 is the alarm reaction, which includes shock as the body prepares for the cascade of physiological reactions to the stress and countershock as the body's defenses are triggered. Phase 3 is the stage of exhaustion where the body cannot maintain its adaptation to the stressor, and energy and resources become depleted. There is no stage of transition in the GAS model.
A nurse is caring for a client who has experienced a traumatic event. Which manifestation would indicate that the client has acute stress disorder (ASD) versus posttraumatic stress disorder (PTSD)?
Answer: Symptoms appear within the first couple weeks of the traumatic event Rationale: Clients with acute stress disorder (ASD) exhibit symptoms within 1 month of the traumatic event, and symptoms are not expected to last longer than 4 weeks. Posttraumatic stress disorder (PTSD) symptoms are expected to take longer than 1 month to exhibit. Clients with ASD or PTSD exhibit the following: (1) persistent reexperiencing of the traumatic event through flashbacks or dreams; (2) persistent attempts to avoid stimuli perceived to be associated with the traumatic event, in combination with a general lack of interest in activities, along with a lack of affect; and (3) persistent symptoms of increased arousal.
The nurse is expecting a client transfer with alkalosis. Which characteristic in the client reflects alkalosis?
Answer: The blood is more basic than normal. Rationale: Alkalosis is blood that is more basic than normal. Blood that is more acidic than normal is acidosis, which would also reflect a low pH value. The lack of a strong base in the blood would promote acidosis.
Which early clinical manifestation should the nurse expect in a client with hypernatremia?
Answer: Thirst Rationale: Thirst occurs in early hypernatremia when intracellular fluid is pulled into extracellular fluid spaces, shrinking cells and causing dryness of mucous membranes. Edema is a later sign of hypernatremia, and occurs as a result of fluid being drawn into extracellular and interstitial spaces. Nausea is not a manifestation of hypernatremia. Increased urine output is a later manifestation of hypernatremia through the renin-angiotensin-aldosterone (RAAS) cycle, as increased fluid is released to dilute increased sodium levels.
The nurse is caring for a client with an acid-base imbalance. Which cardiovascular clinical finding indicates to the nurse that the client may have acidosis?
Answer: Vasodilation of blood vessels Rationale: Acidosis causes vasodilation due to impaired sodium entry into the vascular smooth muscle. Vasodilation causes warm skin and hypotension. Acidosis has a negative inotropic effect on the heart, resulting in decreased contractility.
A perimenopausal woman is prescribed calcium supplements. Which vitamin would be prescribed?
Answer: Vitamin D Rationale: Vitamin D is given along with calcium because it increases absorption of calcium. Vitamin C has other health benefits, but is not associated with calcium absorption. Vitamin B and Vitamin E may be given for various deficiencies, but are not routinely prescribed along with calcium.
The nurse caring for a pediatric client should consider which condition as a risk for hypokalemia?
Answer: Vomiting and diarrhea Rationale: Pediatric clients are at greatest risk of hypokalemia as a result of fluid loss from vomiting and diarrhea. Infections may result in other manifestations and electrolyte imbalances. Increased fluid intake may result in hyponatremia, and increased sodium intake will likely result in hypernatremia.
The nurse is caring for a client with respiratory acidosis. Which clinical manifestation indicates to the nurse that this acid-base imbalance is impacting the client's metabolism?
Answer: Weakness Rationale: Respiratory acidosis would result in weakness, not hyper-excitability, from the depression of the enzyme phosphofructokinase. Anxiety and confusion are central nervous system manifestations of alkalosis.
A client has been diagnosed with congestive heart failure. Which symptom should the nurse instruct the client to report to their healthcare provider immediately, as a sign of possible fluid retention?
Answer: Weight gain Rationale: A weight gain of 3-5 lbs. over one to two days in any client with possible fluid excess should be reported to the healthcare provider. This may be observed prior to any shortness of breath or visible edema. Increased thirst is possibly a sign of hypernatremia or dehydration. Fatigue may be a symptom of other disease processes, and increased urine output is likely the result of increased fluid intake.
The nurse is caring for a client with a new onset of diabetic ketoacidosis. Which arterial blood gas (ABG) result does the nurse anticipate?
Answer: pH 7.30 PCO2 35 HCO3 22 Rationale: Diabetic ketoacidosis would cause metabolic acidosis reflected in an acidotic pH value of 7.30, normal carbon dioxide (because this is not a respiratory issue) reflected in the PCO2 value of 32, and bicarbonate that has not yet responded reflected in the normal HCO3 value of 22. An ABG of pH 7.27 PCO2 62 HCO3 32 is respiratory acidosis with the beginning of compensation reflected in a low (acidotic) pH, high PCO2 reflecting carbon dioxide retention causing acidosis, and high bicarbonate attempting to buffer the acidity. An arterial blood gas (ABG) of pH 7.37 PCO2 40 HCO3 23 is normal. An ABG of pH 7.48 PCO2 30 HCO3 24 shows respiratory alkalosis with a high pH (alkaloid), low PCO2 (hyperventilation resulting in blowing off too much CO2), and compensation of bicarbonate at a normal level.
The nurse is caring for a client with chronic lung disease, who has profound respiratory acidosis. Which arterial blood gas (ABG) result demonstrates complete compensation?
Answer: pH 7.36 PCO2 50 HCO3 32 Rationale: Complete compensation of respiratory acidosis returns the client to a normal pH reflected by a pH of 7.36, contains the chronically high PCO2 level of 50 related to lung disease, which caused the acidosis, and reflects the buffering of HCO3 at a high level of 32, which is responsible for bringing the pH back to a normal level. The values of an arterial blood gas (ABG) with pH 7.28 PCO2 58 HCO3 25 indicate acidosis from a high PCO2 with no action of compensation in a normal HCO3 level. The ABG with pH 7.32 PCO2 55 HCO3 30 shows continued acidosis from a high PCO2 with the evidence of the action of compensation in a high HCO3 level; allowed to continue, complete compensation may be achieved. The ABG of pH 7.44 PCO2 40 HCO3 24 contains all normal values where chronic lung disease is not reflected.
The nurse notes that a client with prolonged vomiting has a carpal spasm when the blood pressure cuff is inflated. Which finding should the nurse anticipate when the arterial blood gas (ABG) results are posted?
Answer: pH of 7.53 Rationale: A carpal spasm when a blood pressure cuff is inflated is a positive Trousseau sign. This indicates alkalosis that would be reflected in a pH of 7.53. A pH of 7.23 or 7.33 indicates acidity. A pH of 7.43 is normal.
Which condition may cause edema? (Select all that apply.)
Answer: • Burns • Heart failure • Venous obstruction Rationale: Venous obstruction can cause an increase in capillary hydrostatic pressure, which occurs as a result of sodium and water retention. Venous obstruction contributes to localized edema from an increased fluid pressure in the capillaries, resulting in leakage of fluid into the interstitial space. In heart failure, compensatory mechanisms contribute to the retention of sodium and water as a result of the decreased cardiac output. The retention of sodium causes an increase in circulating plasma volume, contributing to an increase in capillary pressure. Because of the heart's diminished ability to increase the force of contraction in response to the increased volume, edema occurs from the shift of fluid into the interstitial space. Burns cause damage to the integrity of the endothelium and may increase capillary membrane permeability, thereby causing a shift of fluid into the interstitial space. Thirst and hypotension are often a result of fluid volume deficit.
A client with inflammatory bowel disease asks the nurse why the condition seems to get worse when the client is under stress at work. What would be the nurse's correct response?
Answer: "Changes occur in the brain when you are stressed, increasing substances that lead to further damage inside the bowel." Rationale: Stress-related changes in structures within the central nervous system (CNS) may play a role by contributing to a pattern of ongoing epinephrine and norepinephrine release. This ongoing pattern of sympathetic response may also contribute to hypersecretion of gastric acid. Over time, the circulation of the gastrointestinal tract can be disrupted, contributing to localized ischemia and further damage. While it is true that anxiety may occur with stress, it is not a guaranteed result of the stress response, and it is not directly associated with the development of or worsening of inflammatory bowel disease. Bowel permeability usually increases as a result of inflammation and bowel motility decreases.
A nurse is educating a client on the types of fruits and vegetables they should consume. Which statement would be accurate to provide to this client?
Answer: "Consume highly pigmented fruits and vegetables." Rationale: Highly pigmented fruits and vegetables such as beets, spinach, squash, and berries are more beneficial to a diet.
A client at the clinic reports nausea, vomiting, and weakness but says the symptoms only occur at home, not at work or outside. Which question should the nurse ask first?
Answer: "Do you have a carbon monoxide detector?" Rationale: The occurrence of these symptoms only in the client's house should lead the nurse to suspect carbon monoxide poisoning. Seasonal allergies would cause symptoms of sneezing and nasal congestion when the client is outside, not inside. Pregnancy would cause nausea and vomiting in the morning, not just when the client is inside the house. The nurse would ask about gastrointestinal problems, but that would not be the first question asked.
The nurse is explaining the term genomics to a colleague. Which statement is accurate?
Answer: "Genomics refers to the study of the function of groups of genes." Rationale: Genomics examines the function of groups of genes in terms of mediating physiological function.
A nurse is caring for a client who has recently been diagnosed with multiple sclerosis (MS). The nurse explains to the client that individuals with MS report that psychological stress often causes exacerbation of the disease. Which statement to the client explains why this happens?
Answer: "Inflammatory mediators contribute to the destruction of brain myelin." Rationale: Dysregulation of both pro-inflammatory and anti-inflammatory mediators, which result from an inappropriate stress response, may contribute to the development of multiple sclerosis. Excess cholesterol, dysregulation of catecholamines, and chronic infection all may contribute to illness or disease; however, these are not the primary factors of how multiple sclerosis may develop as a result of chronic stress and inflammation.
A nurse is teaching a client who has been newly diagnosed with type 2 diabetes mellitus about sodium consumption. Which statement by the nurse would be accurate?
Answer: "Limit sodium intake to less than 1,500 mg/day." Rationale: Clients with diabetes, hypertension, or chronic kidney disease should limit their sodium intake to less than 1,500 mg/day.
The public health nurse is presenting gender disparities in morbidity and mortality to colleagues. Which statement would not be accurate?
Answer: "Men have lower morbidity and mortality rates from diabetes." Rationale: In general, men have higher morbidity and mortality rates from disease, such as hypertension, coronary artery disease, cancer, and diabetes.
The client with myasthenia gravis asks the nurse why an arterial blood gas (ABG) test is needed. How should the nurse respond?
Answer: "Poor chest muscle function can impact breathing and result in respiratory acidosis." Rationale: Poor chest muscle function in myasthenia gravis can impact breathing, causing hypoventilation, and result in respiratory acidosis. Severe hypokalemia can cause an acidotic state and is not associated with myasthenia gravis. The thymus gland involvement with myasthenia gravis does not impact metabolic acid-base balance. If a client were to hyperventilate, the result would be respiratory alkalosis through the loss of carbon dioxide.
The nurse is teaching a client with anxiety how to prevent respiratory alkalosis. Which intervention should the nurse include in the teaching?
Answer: "Recognize the triggers for anxiety and apply effective coping methods." Rationale: The goal of respiratory alkalosis prevention would be to treat the underlying cause; in this case, identifying the triggers for anxiety and applying effective coping methods. During an anxiety attack, the client should slow breathing, not take quick breaths, bend down, and take breaths between the knees, or limit breathing to the mouth.
A client presents to the healthcare provider's office reporting worsening of gastroesophageal reflux disease (GERD). Which statement should the nurse use when teaching the client about the role of stress and the exacerbation of GERD?
Answer: "Stress increases the amount of gastric acid, worsening the condition." Rationale: The sympathetic response related to the stress response increases the amount of gastric acid, which may increase symptoms associated with gastroesophageal reflux disease (GERD). The stress response has been shown to increase hormonal mediators, increase motility of the colon, and does not increase the pH or alkalinity of gastric acid.
The nurse educator is teaching a group of nurses on the pathogenesis of stress in the acute care client. Which statement will the nurse use when discussing the role of the hypothalamic-pituitary-adrenal (HPA) axis and the pathogenesis of stress?
Answer: "The HPA regulates the release of CRH, which stimulates the release of ACTH." Rationale: The hypothalamic-pituitary-adrenal (HPA) axis involves the hypothalamus, which regulates the release of corticotropin-releasing hormone (CRH), which in turn stimulates the release of adrenocorticotropic hormone (ACTH) from the pituitary. ACTH in turn stimulates the release of cortisol from the adrenal glands. The HPA axis does not directly regulate the release of norepinephrine, epinephrine, or dopamine.
A nurse is caring for a client with posttraumatic stress disorder (PTSD) after a near-death experience in combat. The nurse is explaining to the client's family member the role of the brain in the development of PTSD. Which statement will the nurse include in the teaching?
Answer: "The prefrontal cortex releases a neurohormone that changes the structure of neurons in the brain." Rationale: The release of the neurohormone dopamine from the prefrontal cortex is enhanced in the presence of stressors of great intensity or long duration. This release of dopamine has been thought to contribute to the development of PTSD through effects on neurons in the prefrontal cortex, leading to a state of hyper-vigilance. Hormones or neurotransmitters are released in the brain, not chemicals, and they do not change the blood vessels in the brain.
The staff nurse is mentoring a student nurse on the effects of the stress response. Using the stimulus conceptualization of stress, how will the staff nurse respond to the student nurse's question regarding the purpose of the sympathetic response during stress?
Answer: "The sympathetic response is a protective response of the body to an emotional state." Rationale: According to the stimulus conceptualization of stress, the sympathetic response is a protective response of the body to an emotional state. Coping and adaptation are not guaranteed with a sympathetic response, nor is the response considered harmful.
A public health nurse is teaching a group of adults with coronary artery disease on cardiac rehabilitation topics. What statement should the nurse include in teaching when educating about the effects of mental stress and the presence of coronary artery disease?
Answer: "There is an increased risk for developing myocardial ischemia while performing routine daily tasks." Rationale: Individuals with coronary artery disease have been demonstrated to experience episodes of myocardial ischemia in response to mental stress occurring during the performance of routine daily activities. Dysrhythmia and hypertension may be present with coronary artery disease; however, these factors are not directly related to mental stress and the presence of coronary artery disease.
The nurse is discussing Tay-Sachs disease with a parent of an infant who was just found to have the disorder. Which statement made by the parent indicates an understanding of the disorder?
Answer: "This disease results from a deficiency in the lysosomal enzymes in the cells." Rationale: Tay-Sachs disease is a result of an inability on the part of the lysosomes within the cells to break down molecules. Alcohol consumption during pregnancy does not cause this disorder; instead, it can result in fetal alcohol syndrome. Asthma, not Tay-Sachs disease, has been linked to a calcium channelopathy. Disorders of the endoplasmic reticulum cause problems with pancreatic enzyme production.
A high school student reports to the school nurse's office with complaints of increased heart rate and nervousness prior to taking an exam later in the day. The student asks the nurse why these symptoms are occurring. Which statement would be the nurse's correct response?
Answer: "You are experiencing a stressor, which is causing you anxiety." Rationale: Explaining to the student that they are experiencing a stressor that is causing anxiety is the correct response because it is the most accurate. A high school student is developmentally able to understand the reason why these symptoms are occurring. "Sick," "nervous," and "scared" are not accurate terms to describe the student's symptoms.
A client reports concern and worry over work obligations at the law firm where the client works. The client states, "My stomach has really been bothering me. I have constant acid indigestion. I've never had this before. Why is this happening?" Which response by the nurse addresses the client's concern?
Answer: "Your nervous system is responding to the stress and causing an increase in the secretion of gastric acid." Rationale: Stress-related changes in neuroanatomic structures of the central nervous system (CNS) may play a role by contributing to a pattern of ongoing epinephrine and norepinephrine release. This ongoing pattern of sympathetic response may also contribute to hypersecretion of gastric acid, which is causing the client acid indigestion. Although stress has been shown to increase motility of the colon, the client would most likely also complain of cramping and diarrhea. Stress could be manifested by inappropriate lifestyle choices such as poor nutrition, but no information is provided to support this factor. Addressing work obligations is important but does not address the client's immediate concern.
Which assessment finding should lead the nurse to suspect that a client has severe carbon monoxide (CO) poisoning?
Answer: Cherry-red skin color Rationale: Cherry-red coloration of the skin occurs when CO binds to the heme pigment in hemoglobin during CO poisoning. It is a later sign. Diarrhea results when an individual is exposed to ionizing radiation. Headaches are an early sign of CO poisoning. Lack of urine output is a sign of renal failure in clients with lead poisoning.
Which condition should the nurse expect in a client with hypochloremia?
Answer: Diarrhea, vomiting, or GI suctioning Rationale: Hypochloremia is most commonly the result of a loss of GI secretions, such as in instances of vomiting, diarrhea, or GI suctioning. Fluid volume excess is often a result of an elevated sodium level, which does not have an effect on chloride. Hypochloremia does not usually occur independently, but as a result of increased calcium—the two electrolytes have an inverse relationship. Secretion of aldosterone leads to the retention of fluid, but does not have an effect on chloride.
The nurse is caring for a client with hyponatremia. Which effect should the nurse expect this condition to have on the kidneys?
Answer: Increased urine production Rationale: A decrease in serum sodium will stimulate the renin-angiotensin-aldosterone (RAAS) cycle in the kidneys, resulting in an increase in urine production and attempt to expel fluid to increase the concentration of sodium. This results in a large amount of dilute urine being formed. Aldosterone is produced through the renin-angiotensin-aldosterone (RAAS) system, which regulates the amount of fluid in the body. Calcium absorption is not affected by sodium levels.
The nurse should expect which ECG change in a client with hyperkalemia?
Answer: Tall, peaked T waves Rationale: Hyperkalemia results in tall, peaked T waves or S-T segment changes on the ECG waveform. This is the result of cardiac muscle excitability and lack of resting potential that results from an increase in potassium. Inverted P waves represent atrial abnormalities. Widened QRS complex represents a delayed electrical conduction system. Heart block occurs when there is a blockage of one or more of the cardiac conduction pathways.
The nurse caring for a client with hypercalcemia should monitor for which effect on serum phosphate?
Answer: There is a decreased phosphate level. Rationale: Calcium and phosphate are both positively charged ions, and have an inverse relationship with each other. The increased level of one of the electrolytes will decrease the level of the other. When correcting hypercalcemia, phosphate levels will increase, and this should be monitored.
Which clinical manifestations should the nurse expect to observe in a client with dehydration?
Answer: Weakness, thirst, fatigue Rationale: Signs of dehydration include thirst, weakness, and fatigue. These signs can be followed by confusion, altered mental status, and coma. Excessive sweating may be a precursor to dehydration, but dehydration usually results in decreased sweating. Nausea, vomiting, and chills may be risk factors for dehydration, but are not manifestations. Excessive salivation does not occur as a result of dehydration. Fever and coma are advanced signs of dehydration.
A community health nurse is teaching a class on how personality impacts the risk for cardiac disease. Which statement will the nurse include in the teaching?
Answer: "A negative personality increases chronic inflammation, contributing to plaque buildup in the vessels." Rationale: Psychosocial stress has been found to be a major contributing factor to acute myocardial infarction. The presence of increased levels of hostility and anxiety are associated with the incidence of coronary artery disease, and individuals whose personality is characterized by increased negative affect are more likely to experience increased cardiovascular mortality and morbidity.
An adult client asks the nurse to explain the results of a Pap test that indicate cervical dysplasia. Which response should the nurse make?
Answer: "This means you're at higher risk for cancer." Rationale: Dysplasia of the cervical cells is a change that could become cervical cancer. The HPV vaccination is administered during the teen years, not at 22 years. Cervical dysplasia is not a sexually transmitted infection, and it does not require the client to undergo total hysterectomy.
The nurse is teaching a client about the benefits of whole grains. Which statement by the nurse is accurate?
Answer: "Whole grains are nutrient-dense." Rationale: Whole grains should be at least half of the daily intake of grains. Whole grains promote satiety, moderate calorie intake, and are nutrient-dense. Whole grains include oatmeal, popcorn, and couscous.
