NUR334: PrepU Review Chapters 11, 12, 13, 18, 19, 20

The mother of a newborn infant questions why her baby needs a vitamin K injection immediately after birth. The best response by the nurse would be

"Infants are not born with the normal intestinal bacteria that synthesize vitamin K for clotting."

On a routine physical exam visit, the physician mentions that they hear a new murmur. The patient gets worried and asks, "What does this mean?" The physician responds:

"One of your heart valves is not opening properly. We need to do an echocardiogram to see which valve is having problems."

When a 55 year old patients routine blood work returns, the nurse notes that their C-reactive protein (CRP) is elevated. The patient asks what that means. The nurse responds:

"This means you have elevated serum markers for systemic inflammation that has been associated with vascular disease."

The physician's order states, "Calculate the pulse pressure of the client's B/P." The blood pressure reading is as follows: systolic pressure of 146 mm Hg and a diastolic pressure of 82 mm Hg. The pulse pressure would be:

64 mm Hg.

The nursing is reviewing assessment data of four clients. Select the client who is at greatest risk for developing pernicious anemia.

A client who has undergone partial gastrectomy.

The nurse observes a client care technician obtain a blood pressure on an obese client using a BP cuff that is too small. The nurse is aware that this will result in:

A reading that is too high.

A lymph node biopsy pathology report notes the presence of Reed-Sternberg cells on a patient suspected of having a lymphoma. The nurse interprets the report as indicating which of the following?

Hodgkin's lymphoma.

Which of the following patients should most likely be assessed for orthostatic hypotension?

An elderly patient who has experienced two falls since admission while attempting to ambulate to the bathroom.

A 20-year-old male client is experiencing a severe immunologically mediated reaction in which histamines have been released into the blood. Select the type of reaction most likely occurring with this client.

Anaphylactic shock.

The nursing instructor, when teaching the students about coronary artery disease (CAD), identifies which of the following as the the main cause of CAD?

Atherosclerosis. Atherosclerosis is narrowing of the arteries due to plaque buildup.

The father of a 2-year-old boy recently diagnosed with hemophilia A asks the nurse how to prevent complications for his son. The best response would be:

Avoid administering aspirin and non steroidal anti-inflammatory drugs (NSAIDs).

A patient comes to the clinic following exposure to chicken pox. The patient states he had chicken pox as a child but was worried about getting sick again. Which of the following statements best explains humoral-mediated immunity to the patient?

B lymphocytes (B cells) in the body produce antibodies to fight infections. Once exposed, the cells retain memory and are able to quickly fight off pathogens during re-exposure and prevent the disease from reoccurring.

The client's primary care physician is reviewing assessment data of a client and suspects a diagnosis of acute leukemia. To confirm the diagnosis, which of the following tests would be performed?

Bone marrow analysis.

A 56-year-old male patient has been diagnosed with hypercholesterolemia. Which of the following are the lab results that support this diagnosis?

Cholesterol 250 mg/dL and HDL 32 mg/dL.

Which manifestation of left-sided heart failure can be diagnosed by examination of the lips and mucous membranes?

Cyanosis.

The nurse is caring for a client who has a low levels of T lymphocytes. The nurse plans care for a client with which of the following?

Decreased immune response.

The nurse reading a client's history and physical notes that the client has a history of leukopenia. The nurse interprets this to mean that the client has which of the following?

Decreased leukocytes.

All of the following interventions are ordered stat for a patient stung by a bee who is experiencing severe respiratory distress and faintness. Which priority intervention will the nurse administer first?

Epinephrine (ADRENALINE).

A patient with kidney failure has been admitted to the hospital for severe anemia. The patient has refused a blood transfusion. The nurse anticipates administering which of the following drugs to stimulate the production of red blood cells?

Erythropoietin (EPO).

There are two pathways that can be activated by the coagulation process. One pathway begins when factor XII is activated. The other pathway begins when there is trauma to a blood vessel. What are these pathways?

Extrinsic and intrinsic pathways.

The nurse's plan of care for a client with multiple myeloma should include interventions to prevent which of the following?

Fractures.

Anemia refers to a deficiency of:

Hemoglobin.

A young college football player was bought to the emergency room after collapsing on the football field during practice. When arriving he was unconscious and his ECG was abnormal. Subsequently he died after arresting in the emergency room. What does the physician suspect is the likely cause of this?

Hypertrophic cardiomyopathy.

Increased cardiac workload with left heart failure can result in which of the following change to the myocardial cells?

Hypertrophy.

A client with acute leukemia has developed gout. The nurse is aware that this results from:

Hyperuricemia (High uric acid in blood).

Which of the following is the main job of lymphocytes?

Immune reaction.

A patient was recently diagnosed with iron deficiency anemia. The nurse anticipates which of the following treatments to be prescribed?

Iron supplementation and dietary teaching.

A 30-year-old male brought to the emergency department has the following admission data: Blood pressure 50/30, pulse 100, respiratory rate 12, temperature 101°F. The nurse does not know the exact cause but does know that patient is in shock because of which of the following readings?

Low blood pressure.

A nurse sends a blood sample to the lab for analysis. Assuming the sample is normal, the nurse anticipates which of the following white blood cells (WBCs) will account for the highest percentage?

Neutrophils. Neutrophils constitute 55-65% of the total WBCs.

A client with a long history of stable angina suddenly experiences substernal pain that radiates to the left arm, neck, and jaw. He describes the pain as severe and feels as if he is suffocating. He has taken nitroglycerin and not experienced any relief. The client is most likely experiencing:

Onset of STEMI.

The nurse is reviewing the lipid results of four clients. Select the client at greatest risk for cardiovascular disease.

Patient with LDL cholesterol 205 mg/dL, HDL 40 mg/dL, and triglyceride level 150 mg/dL.

A patient presents to his physician with a red face, hands, feet, and ears; a headache; and drowsiness. A blood smear reveals an increased number of erythrocytes. Based on the laboratory results, the nurse prepares teaching material for which disease process?

Polycythemia.

A patient's blood pressure is persistently in the range of 130-135 mm Hg systolic and 85-88 mm Hg diastolic. The nurse knows that which of the following conditions correctly describes this patient's blood pressure?

Prehypertension.

A young man has been diagnosed with hemophilia, and the nurse is planning his discharge teaching. The nurse knows to include what in her discharge teaching?

Prevent trauma to the body.

A female client tells the health care provider that she has recently been experiencing episodes of changes occuring in the color of her fingertips especially when she experiences cold temperatures. She further states that the tips become pale, turn a bluish color, and then become reddened. The client is most likely experiencing:

Raynaud phenomenon.

Which of the following would be tested by a complete blood count (CBC)?

Red blood cells and platelets.

A 53-year-old man presents with inability to concentrate, itching in his fingers and toes, elevated blood pressure, and unexplained weight loss. He is diagnosed with primary polycythemia. The primary goal of his treatment will be to:

Reduce the viscosity of his blood.

The nurse is caring for a client diagnosed with sickle cell disease. Select the most important factor for the nurse to be aware of that may cause the cells to sickle.

Reduced oxygen tension while the client sleeps.

A 20-year-old college student being treated for a kidney infection developed a temperature of 104ºF in spite of treatment with antibiotics. Her pulse was high, her blood pressure was low, and her skin was hot, dry, and flushed. The nurse knows that this patient most likely is experiencing which of the following types of shock?

Septic.

When red blood cells age, which of the following organs are responsible for their destruction?

Spleen. Spleen is responsible for the destruction of mature (AGED) red blood cells.

A nurse has worked for 25 years and has recently noticed the development of varicose veins. Which part of the nurse's job is likely most responsible for the development of the varicose veins?

Standing upright for long periods.

An IV drug abuser walks into the ED telling the nurse that, "they are sick." They look feverish with flushed, moist skin; dehydrated with dry lips/mucous membranes; and, fatigued. The assessment reveals a loud murmur. An echocardiogram was order that shows a large vegetation growing on their mitral valve. The patient is admitted to ICU. The nurse will be assessing this patient for which possible life-threatening complication?

Systemic emboli, especially to the brain.

The nursing instructor is teaching the students about rheumatic fever. She tells the students that it is an important cause of heart disease and is very serious mainly for which reason?

The disabling effects that result from involvement of heart valves.

The nurse is caring for a 2-day-old newborn infant who appears lethargic and has a yellowish tint to the skin. Select the most likely cause of this newborn's signs and symptoms.

The inability of the immature liver to conjugate bilirubin.

When it is determined that a patient's red blood cells (RBCs) have a biconcave shape, which of the following will be the nurse's reaction?

The nurse will be pleased, as that shape allows for increased oxygen diffusion.

A client has been diagnosed with aortic stenosis and asks the nurse what this means. The most appropriate response would be:

The valve opening is narrowed and produces increased resistance to blood flow out of the left ventricle and into the aorta.

A nurse is treating a client with aplastic anemia. Due to the replacement of normal bone marrow with malignant cells, the nurse teaches the client to prevent scratches, scrapes, and cuts. What root cause likely underlies the client's increased risk for hemorrhage?

Thrombocytopenia.

A client with a suspected MI is brought to the emergency department by ambulance. The nurse caring for this client would expect to receive an order for which laboratory test to confirm a diagnosis of MI?

Troponin level.

A patient is told that she has cardiac valve leaflets, or cusps, that are floppy and fail to shut completely, permitting blood flow even when the valve should be completely closed. The nurse knows that this condition can lead to heart failure and is referred to as which of the following?

Valvular regurgitation.

A patient in the hospital following a repair of a left hip fracture is refusing to wear the intermittent pneumatic compression stockings ordered by the physician. The nurse explains to the patient that the compression stockings are essential in preventing which of the following?

Venous thrombosis.

A client with an apparent clotting disorder is admitted to hospital. His health record reveals that he has been treated for complications of chronic alcoholism for the past 10 years. The nurse should suspect what cause of his clotting disorder?

Vitamin K deficiency.

A nurse is caring for a client in the intensive care unit who has sustained severe trauma and now has developed disseminated intravascular coagulation (DIC). The nurse is aware that the client is experiencing:

Widespread coagulation and bleeding in the vascular compartment.

A client is prescribed an angiotensin-converting enzyme (ACE) inhibitor for treatment of hypertension. What expected outcome does the nurse expect this medication will have?

Will prevent the conversion of angiotensin I to angiotensin II.

A nurse will be providing care for a female patient who has a diagnosis of heart failure that has been characterized as being primarily right-sided. Which of the following statements best describes the presentation that the nurse should anticipate? The client:

has pitting edema to the ankles and feet bilaterally, decreased activity tolerance, and occasional upper right quadrant pain.