EAQ2

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and a partial pressure of carbon dioxide (PCO 2) of 60 mm Hg. Which complication would the nurse suspect the client is experiencing? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Respiratory acidosis The pH indicates acidosis; the PCO 2 level is the parameter for respiratory function. The expected PCO 2 is 40 mm Hg. These results do not indicate a metabolic disorder or indicate respiratory alkalosis.

Which electrolyte deficiency triggers the secretion of renin? Sodium Calcium Chloride Potassium

Sodium Low sodium ion concentration causes decreased blood volume, thereby resulting in decreased perfusion. Decreased blood volume triggers the release of renin from the juxtaglomerular cells. Deficiencies of calcium, chloride, and potassium do not stimulate the secretion of renin.

Which intervention is the best approach to condom use for prevention of sexually transmitted infection? Use of spermicide Use of oil-based lubricants Use of a condom with oral sex Use of natural membrane condoms

Use of a condom with oral sex Condoms should be used with all sexual encounters, including oral sex, to reduce sexually transmitted infection. There is no evidence that spermicides prevent sexually transmitted infection. Oil-based lubricants can break down latex condoms permitting the transfer of disease. Natural membranes condoms allow the transfer of some infections.

When the nurse is analyzing an electrocardiogram (ECG), which waveform illustrates atrial depolarization? a b c d

a Option a reflects the P wave; it represents the electrical impulse starting at the sinus node and spreading throughout the atria (atrial depolarization). Waveform b reflects the QRS complex; it represents depolarization of the ventricles. Option c reflects the T wave; it represents repolarization of the ventricles. Waveform d reflects the U wave; it is believed to reflect late ventricular repolarization or repolarization of the Purkinje fibers; it is sometimes identified in clients with hypokalemia.

A client reports left-sided chest pain after playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse expects to identify which finding? Dull sound on percussion Vocal fremitus on palpation Rales with rhonchi on auscultation Absence of breath sounds on auscultation

Absence of breath sounds on auscultation The left lung is collapsed; therefore there are no breath sounds. A tympanic, not a dull, sound will be heard with a pneumothorax. There is no vocal fremitus because there is no airflow into the left lung as a result of the pneumothorax. Rales with rhonchi will not be heard because there is no airflow into the left lung as a result of the pneumothorax.

Which client finding would the nurse document as a pulse deficit? Blood pressure of 130/70 mm Hg indicating pulse deficit of 60 Capillary refill greater than 3 seconds indicating pulse deficit Apical pulse 86 and radial pulse 78 indicating pulse deficit of 8 Radial pulse 80 and pedal pulse 70 indicating pulse deficit of 10

Apical pulse 86 and radial pulse 78 indicating pulse deficit of 8 The apical rate is more rapid than the radial rate when a pulse deficit exists. An apical pulse of 86 with a radial pulse of 78 is a pulse deficit of 8. A blood pressure of 130/70 mm Hg is a pulse pressure of 60. Capillary refill greater than 3 seconds indicates circulation is sluggish. Radial pulse of 80 and a pedal pulse of 70 do not indicate a pulse deficit; a pulse deficit is the difference between the apical and peripheral pulses.

Which radiographic test is used to view the entire skeleton? Bone scan Gallium and thallium scan Computed tomography (CT) Magnetic resonance imaging (MRI) scan

Bone scan A bone scan is a radionuclide test in which radioactive material is injected so that the client's entire skeleton can be viewed. Gallium and thallium scans are similar to bone scans but are more specific and sensitive in detecting bone disorders. A CT scan is used to detect musculoskeletal problems primarily in the vertebral column and joints. An MRI scan is used to diagnose musculoskeletal disorders.

During an assessment, the nurse shines a light into the client's eyes and observes that the pupil remains dilated. Which cranial nerve (CN) would the nurse suspect to be affected? CN III CN V CN VII CN VIII

CN III CN III is the oculomotor nerve, which is responsible for pupillary constriction and accommodation. Damage to this nerve may result in failure of the pupils to constrict; thus the pupils will remain dilated even upon exposure to a light source. CN V is the trigeminal nerve, which is responsible for chewing. CN VII is the facial nerve; asymmetric facial movements indicate damage to this nerve. CN VIII is the vestibulocochlear nerve; decreased hearing acuity or hearing impairment or equilibrium impairment may indicate damage to CN VIII.

To which part of the respiratory system would the client's radiology report refer when identifying the angle of Louis? Hilum Carina Alveoli Epiglottis

Carina Located at the level of the manubriosternal junction, the carina is also referred to as the angle of Louis. The mainstream bronchi, pulmonary vessels, and nerves enter the lungs through a slit called the hilum. Alveoli are small sacs that are the primary site of gas exchange in the lungs. The epiglottis is a small flap located behind the tongue that closes over the larynx during swallowing.

A client is admitted to the hospital after sustaining a head injury. Which assessment finding indicates increased intracranial pressure? Rise in respiratory rate Narrowing of pulse pressure Decrease in the level of consciousness Increase in the diastolic blood pressure

Decrease in the level of consciousness Decreasing level of consciousness occurs because of the brain's acute sensitivity to hypoxia. The respirations usually are depressed because of brainstem compression. The systolic pressure increases and the diastolic pressure decreases, resulting in a widening, not narrowing, pulse pressure. The peripheral vascular resistance is decreased when hypoxia occurs, thereby decreasing, not increasing, the diastolic blood pressure.

Which factors in a client's health history increase the risk of hearing loss? Select all that apply. One, some, or all responses may be correct. Diabetes Noisy environment Ear infections Vitamin C deficiency Loud music

Diabetes Noisy environment Ear infections Loud music Diabetes may decrease the blood supply to the ears and thereby decrease hearing acuity. Exposure to loud noise causes hearing loss. Past ear infections may lead to a decrease in hearing acuity. Exposure to loud music often may cause loss of hearing acuity. Deficiency of vitamin B 12 and folic acid may cause hearing loss, but vitamin C deficiency will not.

The nurse completes an admission assessment on a client who is diagnosed with myasthenia gravis. Which clinical finding would the nurse expect to identify? Problems with cognition Difficulty swallowing saliva Intention tremors of the hands Nonintention tremors of the extremities

Difficulty swallowing saliva Facial muscles innervated by the cranial nerves often are affected; dysphagia, ptosis, and diplopia are present. Myasthenia gravis is a neuromuscular disease with altered neuromuscular junction and receptors, not central nervous system symptoms (problems with cognition). Intention tremors of the hands are associated with multiple sclerosis. Nonintention tremors of the extremities are associated with Parkinson disease.

Which relationship between a client's burned body surface area and fluid loss would the nurse consider when evaluating fluid loss in a client with burns? Equal Unrelated Inversely related Directly proportional

Directly proportional There is greater extravasation of fluid into the tissues as the amount of tissue involved increases. Thus the relationship of fluid loss to body surface area is directly proportional. Formulas (e.g., Parkland [Baxter]) are used to estimate fluid loss based on percentage of body surface area burned. Equal, unrelated, and inversely related options are incorrect; the relationship is proportional.

Which report by the client post transrectal prostate biopsy needs to be communicated to the health care provider as a possible sign of infection? Soreness Rust-colored semen Light rectal bleeding Discharge from the penis

Discharge from the penis Discharge from the penis should be communicated to the health care provider for possible infection because discharge is an indication of infection. Soreness, rust-colored semen, and light rectal bleeding are expected after transrectal prostate biopsy.

Which hormone aids in regulating intestinal calcium and phosphorous absorption? Insulin Thyroxine Glucocorticoids Parathyroid hormone

Glucocorticoids Adrenal glucocorticoids aid in regulating intestinal calcium and phosphorous absorption by increasing or decreasing protein metabolism. Insulin acts together with growth hormone to build and maintain healthy bone tissue. Thyroxine increases the rate of protein synthesis in all types of tissues. Parathyroid hormone secretion increases in response to decreased serum calcium concentration and stimulates the bones to promote osteoclastic activity.

Which disease is caused by the virus that causes chickenpox? Athlete's foot Herpes zoster German measles Infectious hepatitis

Herpes zoster Invasion of the posterior (dorsal) root ganglia by the same virus that causes chickenpox can result in herpes zoster, or shingles. This may be caused by reactivation of a previous chickenpox virus that has lain dormant in the body or by recent contact with an individual who has chickenpox. Athlete's foot is caused by a fungus. German measles is caused by a virus, but not the herpes virus. Hepatitis type A is caused by a virus, but not the herpes virus.

Which clinical indicator is the nurse most likely to identify when exploring the history of a client with open-angle glaucoma? Constant blurring Abrupt attacks of acute pain Sudden, complete loss of vision Impairment of peripheral vision

Impairment of peripheral vision Open-angle glaucoma has an insidious onset, with increased intraocular pressure on the retina and blood vessels in the eye. Peripheral vision is decreased as the visual field progressively diminishes. Constant blurring may occur with untreated acute angle-closure glaucoma. Pain occurs in acute angle-closure, not open-angle, glaucoma. Occlusions of the central retinal artery or retinal detachment will cause a sudden loss of vision.

Which age-related effects on the immune system occur in the older client? Increased autoantibodies Increased expression of IL-2 receptors Increased delayed hypersensitivity reaction Increased primary and secondary antibody responses

Increased autoantibodies The effects of aging on the immune system include increased autoantibodies. Expression of IL-2 receptors, delayed hypersensitivity reaction, and primary and secondary antibody responses decrease in older adults because of the effects of aging on the immune system.

Which clinical finding occurs due to thinning of the subcutaneous layer? Decreased tone and elasticity Decreased sensory perception Increased risk for hypothermia Increased susceptibility to dry skin

Increased risk for hypothermia Thinning of the subcutaneous layer results in increased risk for hypothermia. Degeneration of elastic fibers in the dermis results in decreased tone and elasticity. In the dermis, reduced number and function of nerve endings leads to decreased sensory perception. A decrease in dermal blood flow results in increased susceptibility to dry skin.

Which cytokine stimulates the liver to produce fibrinogen and protein C? Interleukin-1 Interleukin-6 Thrombopoietin Tumor necrosis factor

Interleukin-6 Interleukin-6 stimulates the liver to produce fibrinogen and protein C. Interleukin-1 stimulates the production of prostaglandins. Thrombopoietin increases the growth and differentiation of platelets. Tumor necrosis factor stimulates delayed hypersensitivity reactions and allergies.

Which component of skin maintains optimal barrier function? Keratin Melanin Collagen Adipose tissue

Keratin Keratin is a protein produced by keratinocytes that helps maintain optimal barrier function. Melanin pigment is produced by melanocytes and gives color to the skin. Collagen is a protein produced by fibroblasts. Its production is increased during tissue injury and helps form scar tissue. Adipose tissue is the subcutaneous fat that insulates the body and absorbs shock.

On the third postoperative day after a subtotal gastrectomy, a client reports severe abdominal pain. The nurse palpates the client's abdomen and determines rigidity. Which action would the nurse perform first? Assist the client to ambulate. Obtain the client's vital signs. Administer the prescribed analgesic. Encourage use of the incentive spirometer.

Obtain the client's vital signs. Rigidity and pain are hallmarks of bleeding from the suture line or of peritonitis; vital signs provide supporting data. The nurse assists the client to ambulate if pain was the result of flatulence; however, rigidity is associated with bleeding or peritonitis, and the nurse needs additional data. An analgesic may mask the symptoms, thereby delaying diagnosis. Encouraging use of the incentive spirometer is unrelated to the symptoms presented.

Where is the blood pressure cuff placed on a client with a dialysis access fistula in the right arm? On the left arm Over the fistula Below the fistula Above the fistula

On the left arm If the fistula is located in the right arm, then the left arm should be used for blood pressure cuff placement. Blood pressure cuffs or any other restrictive devices should not be placed on the arm with a dialysis access fistula including above, below, or over the fistula site.

The nurse is caring for a client with suspected appendicitis. Which assessment finding would the nurse determine would further support the diagnosis? Fever and malaise Nausea and vomiting Absolute constipation Pain in right lower quadrant

Pain in right lower quadrant Pain shifting to the right lower quadrant between the anterior iliac crest and the umbilicus is McBurney point and is indicative of appendicitis. The client may also have fever, nausea, and vomiting, but these can occur with other infectious processes. Absolute constipation occurs with many bowel obstructions.

When obtaining a health history from a client recently diagnosed with type 1 diabetes, the nurse expects the client to report which clinical manifestation? Nervousness Polyuria Nocturia Diaphoresis

Polyuria Excessive thirst (polydipsia), excessive hunger (polyphagia), and frequent urination (polyuria) are caused by the body's inability to metabolize glucose adequately. Lethargy, not nervousness, occurs because of a lack of metabolized glucose for energy. Frequent urination occurs throughout a 24-hour period because glucose in the urine pulls fluid with it. Diaphoresis occurs with severe hypoglycemia, not hyperglycemia.