Exam 4 Biol280
The nurse cares for clients with a variety of depression disorders. Which client statements suggest the diagnosis of dysthymia? Select all that apply.
"Every day for over 2 years I've been sad, tired, and can't seem to get my act together.", "For the last 4 years, I can't make a decision and am so worthless at work every day."
The nurse is about to administer lithium to a client with a bipolar disorder. Which statement by the client requires immediate follow up by the nurse?
"I feel like I can't stop moving my hands."
Which of the following statements made by a patient with polycythemia indicates an understanding of the disease?
"I have an overproduction of red cells from my bone marrow."
The nurse is reviewing a client's experience with cognitive behavioral therapy. Which statement by the client indicates the therapy has been effective?
"I wanted to run out of the grocery store, but I had no reason to."
Which statement by a patient with chronic heart failure indicates to the nurse that more teaching is needed?
"If I follow strict self-care, I can cure the disease."
Which of the following is the best response given to a patient by the nurse when a patient with heart failure asks for an explanation of his ejection fraction?
"It is the percentage of blood pumped by the heart with each beat."
Which response by the nurse is best when the mother states that she gives her 10-month-old baby 45 mg/day of iron?
"Let's talk about safe levels of iron intake for a 10- month-old."
Which statement by the mother of a baby with hydrocephalus indicates that the mother understands this condition?
"My baby has too much fluid in his brain."
The nurse is providing education to a client's family about cardiogenic shock. Which statement should be included in the education?
"The body works to shunt blood to major organs."
The nurse is providing discharge instructions to a client recently diagnosed with a bipolar disorder. Which statement by the client indicates an understanding of the condition?
"There's no way to know for sure how I developed this."
Which statement made by a patient with a biventricular pacemaker indicates that more teaching is needed?
"This pacemaker can deliver a shock if I develop a life-threatening heart rhythm."
The nurse is providing education to a client about anxiety disorders. Which statement by the client requires further follow up by the nurse?
"Usually anxiety lasts for weeks after a stressor is gone."
When caring for a patient with heart failure, which concept about cardiac output should the nurse keep in mind?
A faster heart rate increases the cardiac output.
When caring for a patient with increased intracranial pressure, which laboratory value trend requires immediate action by the nurse?
A rising PaCO2 level
A patient with an ischemic stroke has a blood pressure of 200/110 mmHg. Which action should the nurse anticipate?
Administering antihypertensives if the blood pressure exceeds 220/120 mmHg.
When checking the orders for a patient with hemorrhagic stroke, which order would be a cause for concern for the nurse?
Administering aspirin
The nurse is counseling a couple who would like to start a family. The man has sickle cell disease and the woman does not have sickle cell disease or the sickle cell trait. Which statement by the man indicates an understanding of the transmission of the disease?
All our children will have the sickle cell trait."
Which laboratory result confirms to the nurse that therapy for pernicious anemia has been effective?
An increase in vitamin B12 levels
Which cardiac arrhythmia is the nurse most likely to assess in a patient with an embolic stroke?
Atrial fibrillation
The nurse is teaching health promotion and maintenance to a patient with aplastic anemia. Which action by the patient should be a priority?
Avoiding crowds during flu season
The plan of care for a patient with anemia due to alcoholism should include administration of which vitamin?
B vitamins
A patient with heart failure reports some shortness of breathing with activity, such as cleaning the house or grocery shopping, but no shortness of breath at rest. According to the New York Heart Association staging system, the nurse would classify this patient as:
Class II
The critical care nurse is assessing a client for clinical signs of shock. Which assessment finding does the nurse understand to be a clinical sign of shock?
Cold, clammy skin
The nurse is caring for a client with major depression. Which statement about this condition does the nurse know to be true?
Depression can be a fatal illness.
The nurse is assessing a client diagnosed with major depressive disorder (MDD). Which assessment findings will the nurse anticipate? Select all that apply.
Diminished ability to think or concentrate, significant weight loss
Which vital signs would the nurse expect to find in a patient with anemia?
Heart rate 108 beats/minute, respirations 26 breaths/minute
When administering medications, which concept pertaining to the blooddash brain barrier must the nurse understand?
Highly lipophilic medications cross the blooddash brain barrier directly.
The nurse is providing education to a client about recent brain imaging, which shows hippocampal volume loss. What is the nurse's understanding of this finding?
Hippocampal volume loss may be linked with depression, impaired learning, and memory.
When assessing a patient following an aneurysmal subarachnoid hemorrhage, the nurse should be alert for delayed cerebral ischemia during which time period?
In 3 to 14 days
The nurse is reviewing orders for a client with a diagnosis of septic shock. Which order will the nurse verify with the health care provider before proceeding?
Intravenous furosemide
The nursing history indicates that a patient with sickle cell disease (SCD) has had numerous blood transfusions in the last three months. When assessing the patient, the nurse should be alert for which condition?
Iron overload
The nurse is performing a psychosocial assessment on an adolescent client. Which special considerations should the nurse take while performing the assessment? Select all that apply.
It is important to differentiate between normal fears and those that interfere with normal function, Feelings of embarrassment may interfere with the assessment of adolescents.
Which information should the nurse include in a teaching care plan for a patient with moyamoya disease?
It may be caused by a genetic disorder.
The nurse is caring for an older adult client with a diagnosis of major depressive disorder (MDD). What is the nurse's understanding of the presentation of depression in this client?
It may present in the context of cardiovascular disease, dementia, or stroke.
The nurse is providing care to a client with multiple organ dysfunction syndrome (MODS). What does the nurse understand is occurring in the body's cells as a result?
Lactic acid production increases
The emergency department nurse is assessing a client in shock. The nurse understands that shock can be caused by which conditions? Select all that apply.
Low blood volume, obstruction of blood flow, failure of the heart to pump, inflammatory vascular disease
The nurse is caring for a client with a bipolar disorder. The nurse understands that the client's condition is characterized by which types of episodes? Select all that apply.
Manic, depressive, hypomanic
Which action would the intensive care nurse take to measure the preload of a patient with heart failure?
Measure the pulmonary artery pressure.
Which assessment data indicates to the nurse that a patient has a chronic iron deficiency?
Microcytic, hypochromic red blood cells
When assessing a patient with manifestations of a stroke, the nurse keeps in mind that embolic strokes most commonly occur in which artery?
Middle cerebral artery
The nurse is providing education to a client about the role of neurotransmitters in depression. Which areas of cognition does the nurse review as being mediated by serotonin? Select all that apply.
Optimism, impulsivity, positive mood
To increase absorption of dietary iron, the nurse recommends that a patient with anemia drink which beverage with meals?
Orange juice
The nurse should expect to assess which findings in a patient with a right anterior cerebral artery stroke?
Paresis and sensory loss of the left leg and foot
When assessing a patient, which finding by the nurse would support a diagnosis of left-sided heart failure?
Paroxysmal nocturnal dyspnea
The nurse is reviewing the plan of care for a client with hypovolemic shock. Which objectives does the nurse recognize are relevant for this client? Select all that apply.
Prevent further fluid loss, replace lost fluids, maximize oxygen delivery
The nurse is developing a community program about stroke risk factor reduction. Which would the nurse explain is a non-modifiable risk factor?
Prior stroke or TIA
The nurse is caring for a client presenting with confusion, angina, and muscular pain. The nurse understands that these findings are consistent with which stage of shock?
Progressive shock
The nurse is preparing to admit a client diagnosed with anaphylactic shock. The nurse understands that anaphylactic shock can have which triggers?
Proteins, drugs, foods
The nurse would expect to assess third nerve palsy in patient with an ischemic stroke involving which artery?
Proximal posterior cerebral artery
When assessing a patient with heart failure affecting only the left ventricle, the nurse would expect which of the following conditions?
Pulmonary venous congestion
A child with sickle cell anemia is admitted to the pediatric unit for erythrocytapheresis. The nursing plan of care should include preparing for which of the following treatments?
Red blood cell exchange
Which instruction should be included in the teaching plan for a patient with hemochromatosis?
Reduce intake of foods high in iron.
Which laboratory assessment data indicates to the nurse that a patient has anemia?
Reduced erythrocytes
The nurse caring for a patient with anemia of chronic disease (ACD) would expect which of the following laboratory results?
Reduced transferrin saturation
The nurse is assisting with a client undergoing a sequential organ failure assessment (SOFA). Which systems will the nurse anticipate being included in the assessment? Select all that apply.
Respiratory, cardiovascular, neurological
Which information should the nurse include in a teaching care plan for a patient with systolic heart failure?
Restrict salt intake.
The nurse instructs a patient who had a TIA to take which action if he experiences symptoms of a TIA in the future?
Seek urgent medical care.
The critical care nurse is preparing to admit a client with suspected hypovolemic shock to the intensive care unit. Which laboratory tests does the nurse anticipate to be included in the client's plan of care? Select all that apply.
Serum lactate concentration, blood glucose level, complete blood count (CBC)
A baby has been brought to the emergency department unresponsive. The parent reports that the baby was in a motor vehicle accident, but the nurse notes no physical signs of trauma. A physical examination reveals retinal hemorrhages. Which diagnosis does the nurse suspect?
Shaken baby syndrome
A patient with heart failure reports some shortness of breathing with activity, such as cleaning the house or grocery shopping, but no shortness of breath at rest. According to the American College of Cardiology (ACC)/American Heart Association (AHA) staging, the nurse would classify this patient as:
Stage C
Which manifestation does the nurse expect a patient to exhibit in high-output heart failure?
Strong peripheral pulses
When performing an assessment of the central nervous system, which concept should the nurse keep in mind?
The brain receives about 15% of the cardiac output.
The nurse is caring for a client with major depression who is hospitalized for failure to thrive. The nurse understands that which body system is directly tied to emotional regulation?
The immune system
The nurse is caring for a client with early shock. The nurse understands that which mechanism in the body is maintaining the client's blood flow?
The kidneys respond to poor perfusion by activating the renin-angiotensin-aldosterone system.
A history and assessment of a patient with normal pressure hydrocephalus will most likely reveal:
an older adult
When caring for a patient who has advanced from stage C to stage D of the American College of Cardiology (ACC)/American Heart Association (AHA) heart failure classification system, the nurse instructs the patient and family that this stage includes the addition of:
interventional therapy with left ventricular assist device or heart transplantation.
During the admission history of a patient with myelodysplastic syndrome, the nurse should question the patient about exposure to:
radiation.
When assessing the patient with high-output heart failure, the nurse is most likely to find
validation and hypertension
When planning care for a patient with heart failure, which concept should the nurse keep in mind?
The sympathetic nervous system is activated when cardiac output drops.
What response should the nurse give when a patient with heart failure asks what the physician meant by saying his left ventricular assist device (LVAD) was destination therapy?
"Your LVAD will support your heart because you are not a candidate for heart transplant."
The nurse is providing dietary instructions to a pregnant patient. The nurse recommends that the daily intake of iron should be:
27 mg/day
When assessing a patient with traumatic brain injury, which cerebral blood flow would the nurse consider normal?
750 millimeters of blood/minute
When a patient is suspected of having a brain arteriovenous malformation (AVM), which of the following may be auscultated?
A cerebral bruit
The emergency department nurse receives a call about an incoming client with hypovolemic shock. The nurse understands that which conditions can result in hypovolemic shock? Select all that apply.
Blood loss, diuresis, severe burns
The nurse is preparing to administer a client's medications. Which medications does the nurse recognize are used to treat the client's diagnosis of cardiogenic shock? Select all that apply.
Diuretic therapy, nitroglycerine therapy, thrombolytic therapy
Which of the following medications would the nurse anticipate administering to a patient with systolic heart failure to reduce fluid volume and relieve congestion?
Diuretics
The nurse is caring for a client with generalized anxiety disorder. Which neurotransmitters does the nurse understand are tied to the pathogenesis of this condition? Select all that apply.
Dopamine, serotonin
Which data in a patient undergoing pulmonary heart catheterization confirms a diagnosis of systolic heart failure?
Elevated pulmonary artery wedge pressure
The nurse is preparing to administer paroxetine to a client with an anxiety disorder. The nurse understands which statement about this medication to be true?
This is often a drug of choice for anxiety treatment
The nurse is teaching a community health class about the early detection and diagnosis of bipolar disorders. Which statement will the nurse include in the teaching?
"The onset of bipolar disorders may occur at any time in life."
Which of the following should be included in the teaching plan for a child with sickle cell anemia?
Encourage intake of plenty of fluids.
The effectiveness of erythropoietin therapy in the patient with renal disease can be confirmed by which laboratory finding?
Erythrocytes 4.4 million/mm3
The nurse is assessing a client for hypomania. Which findings does the nurse associate with this condition? Select all that apply.
Euphoria, increased energy
The nurse is caring for a client with social anxiety disorder. Which distinguishing features does the nurse understand to be associated with this condition? Select all that apply.
Fear of being exposed to scrutiny, avoidance of known stressors
The nurse is caring for a client with an acute myocardial infarction. The nurse understands that this condition results in cardiogenic shock by which mechanism?
Increased left ventricular pressure
To effectively care for patients with heart disease, the staff development nurse is teaching new nurses hired for the intensive care unit about the Frank-Starling law. Which concept will the instructor teach?
Increasing preload causes an increase in left ventricular contractility.
Which finding would the nurse expect when assessing a patient with a spinal subarachnoid hemorrhage?
Neck stiffness and photosensitivity
Which finding would the nurse expect when assessing a patient with diastolic heart failure?
Normal ejection fraction
The nurse is providing education about anaphylaxis to a parent at a well-child visit. Which agents does the nurse include when reviewing common causes of anaphylaxis in children? Select all that apply.
Nuts, bees stings
The nurse is providing discharge instructions to a client hospitalized with a bacterial infection. Which statement will the nurse include in the education?
"An unresolved infection may result in septic shock."
While assessing a client, the nurse notes stridor, tachycardia, edema, and hives. The nurse understands that these findings are consistent with which type of shock?
Anaphylactic
The nurse is providing education to a client about how the body responds to pulmonary emboli. Which statement will the nurse include in the teaching?
"This condition raises the risk for obstructive shock."
Which first-line medication would the nurse anticipate being in the plan of care for a patient with systolic heart failure to reduce vasoconstriction and afterload?
ACE inhibitor
During physical examination of a patient with sickle cell disease in a vaso-occlusive crisis, the nurse would be most likely to assess which hallmark finding?
Acute pain
Which nursing intervention should be included in the plan of care for a patient with polycythemia vera?
Administer anticoagulants.
A patient on warfarin fell and hit his head on an icy sidewalk and has been diagnosed with a subdural hematoma. Which intervention should be included in the nursing plan of care this patient?
Administer vitamin K
The nurse is reviewing medications for a client with anaphylactic shock. Which medication would the nurse anticipate to be included in the client's plan of care? Select all that apply.
Beta agonist treatment, epinephrine treatment, diphenhydramine infusion treatment
The nurse is assessing a client exhibiting a sudden sense of fear and dread, heart palpitations, and shortness of breath. The nurse understands these findings to be consistent with which condition?
Panic attack
While the nurse is reviewing the client's medication list, the client notes the use of an MAO inhibitor. Which medications does the nurse understand are MAO inhibitors?
Tranylcypromine, isocarboxazid
The nurse is caring for a client with multiple organ dysfunction syndrome (MODS). Which statement about this condition does the nurse know to be true?
Variable clinical presentations occur