patho final the point questions
The nurse is caring for a client in the burn unit who has sustained partial and full thickness burns over 16 percent of the body. What type of etiologic factor does the nurse recognize these burns are?
Physical forces
A client is taking a synthetic thyroid hormone for the treatment of hypothyroidism. The client develops signs and symptoms of hyperthyroidism. The nurse refers to this adverse extension of disease development as:
complications
A client complains of general malaise and fatigue and has a mild fever. The nurse would evaluate this stage of disease as the:
prodromal stage
After many years of cigarette smoking, a client is admitted to have a "mass" removed from the lung. When explaining the surgery and recovery, the physician notes that the client is likely to have a good amount of fibrosis develop at the surgical area. After the physician leaves the room, the client asks the nurse what was meant by "fibrosis" in the lung. The nurse bases the response on the fact that tissue repair can:
result in replacement tissue in the form of connective (fibrous) tissue, which leads to scar formation or fibrosis of the lung.
The first physical line of defense in innate immunity is:
skin and mucous membranes
The nurse is caring for a client with a stab wound. The nurse recognizes that deficiency of which of these elements of the blood will interfere with hemostasis at the site of injury?
Thrombocytes
The nurse is caring for a client who has experienced hypovolemic shock secondary to penetrating multiple trauma. When caring for the client postoperatively, which of these factors does the nurse recognize places the client at risk for poor wound healing?
Tissue hypoxia
The nurse is reviewing the following lab results of a client diagnosed with renal failure:pH: 7.24PCO2: 38 mm Hg (5.05 kPa)HCO3:18 mEq/L (18 mmol/L)The nurse would interpret this as:
Metabolic acidosis
A client has these arterial blood gas values: anion gap 20 mEq/L (20 mmol/L), pH 7.29, PCO2 37 mm Hg (4.92 mmol/L), HCO3- 11 mEq/L (11 mmol/L), base excess -6 mEq/L (-6 mmol/L). With what condition do these values correspond?
Lactic acidosis
The cardinal signs of inflammation include swelling, pain, redness, and heat. What is the fifth cardinal sign of inflammation?
Loss of function
A client asks the nurse to explain what the physician said about the prognosis for a current illness. What is the nurse's most appropriate response?
"A full recovery means the disease will pass."
Following surgery for appendicitis, a teenaged client notes four small "stab" wounds on the abdomen. The client is obviously worried about body appearance. The nurse explains, "Your body will heal quickly and tissue repair will allow for regeneration of any cells needed." The client asks, "What does regeneration mean?" The nurse responds that tissue repair by regeneration means:
"Any injured cells are replaced with cells of the same type. Therefore, after healing, the wound will look like your surrounding skin."
The employee health nurse is working with a nursing student who has just sustained a needlestick injury and has received a dose of hepatitis B immune globulin. The nurse is counseling the student about vaccination against hepatitis B. Which statement by the student indicates understanding?
"I need to start the hepatitis B vaccination series as soon as possible."
A pregnant client who has HIV asks the nurse if her baby will have the disease. The best response would be:
"The baby will test positive for the HIV antibody test result, although the child may not necessarily be infected with the virus."
The parents of a 2-year-old child ask the nurse why their toddler's wounds do not seem to heal as quickly as their older children. Which response by the nurse is most accurate?
"The younger child has an immature immune system with no experience with organisms."
A client is suffering from the effects of the opportunistic infection, Cryptosporidium parvum. An important nursing intervention would be to encourage which action?
Hydration
Shortly after being diagnosed with HIV, a client has begun highly active antiretroviral therapy (HAART). The client asks, "My doctor tells me that my viral load is going down. What does that mean?" The nurse's best response is:
"Your HAART medications are working to slow the progression of the disease."
A client has experienced an acute inflammatory response with an elevation of white blood cells. The nurse is reviewing the client's most recent lab results to determine if the counts have returned to a normal range. Select the result that suggests the client is now within normal range.
4000 to 10,000 cells/μL
The nurse has just received the lab results of a client's calcium level. The nurse identifies a normal calcium level as:
9.0 to 10.5 mg/dL (2.25 mmol/L to 2.63 mmol/L))
The nurse is selecting a dressing for a vascular wound that has a dry wound surface. The most appropriate dressing for this wound is one that:
Adds moisture to the wound bed
Which client is most likely to experience impaired (slow) wound healing?
A client with a diagnosis of type 1 diabetes and a history of poor blood sugar control
syndrome
A compilation of signs and symptoms that are characteristic of a specific disease state.
A nurse documenting a client's health history places hypertension under which category?
Acquired
The nurse is evaluating the wounds of four clients. Select the client most likely to be treated with hyperbarically delivered oxygen.
An infected foot wound on a 45-year-old client with peripheral vascular disease
Some members of the population are so sensitive to certain antigens that they react within minutes by developing itching, hives, and skin erythema, followed shortly thereafter by bronchospasm and respiratory distress. What is this near-immediate reaction commonly known as?
Anaphylactic reaction
The cells that mediate humoral immunity do so because they are capable of producing:
Antibodies
A community health nurse who is attending a marathon recognizes that which types of hypotonic hyponatremia is likely when a client reports muscle weakness, cramping, and general fatigue in spite of adequate water hydration during the run?
Hypovolemic
Select the type of lymphocyte that matures in the bone marrow.
B lymphocytes
Which assessment should be prioritized in the care of a client who is being treated for a serum potassium level of 2.7 mEq/L (2.7 mmol/L)?
Cardiac monitoring looking for prolonged PR interval and flattening of the T wave
Which child has the highest risk of experiencing a wound complication?
Child recently been diagnosed with type 2 diabetes
A client with a history of heavy alcohol use has been admitted to a hospital with ABGs that indicate an acid-base imbalance. Which situation is most likely to result in an inappropriate pH for this client?
Low albumin and plasma globulin levels
Which client conditions would be considered a congenital defect? Select all that apply.
Club foot Cleft lip and palate Hypospadias
Adaptive immune responses, also called acquired or specific immunity, are composed primarily of which type of cells?
Lymphocytes
Which cells bind with major histocompatibility complex (MHC) class I molecules?
Cytotoxic T cells
Which of the types of T cells is responsible for destroying pathogens by punching holes in their cell membrane and by secreting cytokines/lymphokines?
Cytotoxic T cells
Which action will a nurse teach as tertiary prevention of disease? Select all that apply.
Daily foot inspection by clients with diabetes mellitus Taking antihypertensives for clients post-myocardial infarction
A clinical research study is evaluating cells that bridge both the innate and adaptive immune systems. A nurse has identified the dendritic cells (DCs) as a key component. Which statement validates this finding?
Dendritic cells (DCs) directly sense pathogens, capture foreign agents, and transport them to secondary lymphoid tissues. Once activated, they undergo a maturation process and function as antigen-presenting cells (APCs) capable of initiating adaptive immunity.
The nurse caring for a client with a large leg wound notes that the client's past medical history includes diabetes, chronic atrial fibrillation, asthma controlled by maintenance medication, and neuropathy. Which one has the greatest potential to negatively impact the healing of the client's wound?
Diabetes
The nurse is assessing a client for acute inflammation of a wound. For which symptom of infection does the nurse assess?
Edema
Immunologically active sites on antigens are recognized as:
Epitopes
The nurse is reviewing assessment documentation of a client's wound and notes "purulent drainage." The nurse would interpret this as:
Exudate containing white blood cells, protein, and tissue debris
Which body response to an acute inflammation will the nurse assess if the client is experiencing a systemic response?
Fever and tachycardia
When caring for a client during the proliferative phase of wound healing, the nurse teaches the client that which of these processes is taking place?
Fibroblasts secrete collagen for wound healing.
The basement membrane surrounding a client's foot wound remains intact, a fact that bodes well for the wound-healing process. Which components constitute this form of the extracellular matrix (ECM)? Select all that apply.
Fibrous structural proteins Proteoglycans Adhesive glycoproteins
A client with poor arterial circulation in the lower limbs has developed areas of inflammation and "weeping" clear serous exudate. Chronic inflammation can be associated with which changes in physiological response? Select all that apply.
Formation and development of new blood vessels The death of one or more cells in the body within a localized area
A student nurse is accidentally stuck by a needle. To decrease the risk of blood-borne pathogens and to provide immediate protection from infection, the emergency room nurse expects to administer:
Gamma globulin
The nurse is caring for a client whose temperature is increasing. Which other vital sign/body response will the nurse monitor for an increase?
Heart rate
A client has recently received a pneumococcal vaccine and the client's B cells are consequently producing antibodies. Which cells may enhance this production of antibodies?
Helper T cells
Which immunoglobulin is primarily found in secretions and has a primary function of providing local immunity on mucosal surfaces?
IgA
A client experiences an allergic reaction. Select the immunoglobulin that would bind to mast cells and release histamine.
IgE
Which immunoglobulin (Ig) is released in response to allergy or parasitic infections?
IgE
The nurse is aware that the only class of immunoglobulins to cross the placenta is:
IgG
The nurse is reviewing the functions of immunoglobulins and determines which immunoglobulin is associated with its correct action?
IgM, the first antibody to be produced by a developing fetus.
The nurse is caring for a client with ketoacidosis who is complaining of increasing lethargy and occasional confusion following several weeks of rigid adherence to a carbohydrate-free diet. The nurse understands which phenomenon is most likely occurring?
In the absence of carbohydrate energy sources, her body is metabolizing fat and releasing ketoacids.
If a client has a bacterial infection in the blood, the nurse will note which laboratory value that correlates with this?
Increased neutrophils
Lymph fluid arises directly from which space?
Interstitial
Which actions will a nurse teach as primary prevention of disease? Select all that apply.
MMR vaccination to school-aged children wearing a seat belt when in a motor vehicle
The rehabilitation nurse is caring for a client who is recovering from a cerebrovascular accident (CVA) with hemiplegia. The family asks the nurse if the paralysis will be permanent. Upon which of these physiologic rationales should the nurse base the response?
It is likely that paralysis is permanent, as nerve cells do not normally regenerate.
The nurse is caring for a client who has AIDS and suffers from wasting syndrome. What is the priority nursing consideration for this client?
Nutrition
When attempting to reach a health diagnosis, the health care provider commonly applies four primary steps. Place the steps for reaching a diagnosis in order. Use all the options.
Obtain clinical history. Conduct a physical examination. Perform diagnostic testing. Determine the most likely cause of the client's presentation.
The process by which microbes are coated to allow for more efficient recognition by phagocytes is known as:
Opsonization
s the main effect of HIV infection?
Poor helper T-cell function
The nurse is assessing the wound of a postoperative client. The client has a 6-inch abdominal wound that is well approximated and closed with surgical suture. The wound does not display any redness or drainage. The nurse would document the healing process as:
Primary intention
A client sustained an injury 3 days ago. The nurse is assessing the status of the wound and anticipates the wound to be in which phase of healing?
Proliferative
Hyperbaric treatment for wound healing is used for wounds that have problems in healing due to hypoxia or infection. It works by raising the partial pressure of oxygen in plasma. How does hyperbaric oxygen treatment enhance wound healing?
Promotion of angiogenesis
Which assessment data would a nurse identify as a complication of a disease or disorder?
Pulmonary emboli following deep vein thrombosis (DVT)
The nurse would identify the presence of granulation tissue at a wound site by which characteristic?
Red, moist tissue
A client in the acute stage of inflammation will experience vasodilation of the arterioles and congestion in the capillary beds. The nurse would assess the client's skin for:
Redness
The nurse notes that a colleague neglects to wipe away the first drop of blood from the sample during point-of-care blood glucose testing; this in contradiction of the unit policy. What action should the nurse take first?
Remind the colleague that the purpose of discarding the first drop is to improve the reliability of the results.
client who had an implantable cardioverter-defibrillator (ICD) returns the next week with a fever, chills, and elevated WBC. The physician suspects the wound is infected. If this wound does not respond to antibiotic therapy, the nurse can anticipate the client will undergo:
Removal of device
A nurse is assessing a client for the classic signs of acute inflammation. The nurse would assess the client for:
Rubor, swelling, and pain
A client has been identified as having an excess of macrophage inhibitory factor, causing the client to have inhibited movement and activity of macrophages. Which process should the health care team expect to remain unaffected?
Specificity and memory of the immune response
When caring for a client with a wound that is healing by primary intention, the nurse recognizes which characterization best describes this type of wound?
Surgical incision
A nurse has just learned that her child has a life-threatening complement disorder known as hereditary angioneurotic edema (HAE). Due to deficiency in C1-INH, the nurse needs to be prepared for which possible life-threatening clinical manifestation?
Swelling of the airway
A nurse is caring for a client with a low sodium level and increased water retention. Hematocrit and blood urea nitrogen levels are decreased, urine osmolality is high, and serum osmolality is low. A chest x-ray shows a possible lung mass. Based on these findings, which problem could the client be diagnosed with?
Syndrome of inappropriate antidiuretic hormone (SIADH)
Which statement explains how T lymphocytes and B lymphocytes differ?
T lymphocytes mature in the thymus gland; B lymphocytes mature in the bone marrow.
What is the nurse's expectation about a client's ability to compensate for a metabolic blood gas disorder?
The client will compensate with the respiratory system.
In an attempt to best explain the innate immune system to a class of first-year nursing students, the instructor should describe what characteristic?
The response of the innate immune system is rapid, usually within minutes to hours, and prevents the establishment of infection and deeper tissue penetration of microorganisms
The nurse is caring for a client with an infected wound that is left to heal by secondary intention. Which observation does the nurse expect to make during assessment of the wound area?
The wound is healing slowly with epithelial and scar tissues present.
The nurse is obtaining blood pressure readings on a manual sphygmomanometer, obtaining below-normal readings. When taking the blood pressure reading with an electronic sphygmomanometer, the readings are with normal limits. Which parameter concerns the nurse regarding the manual cuff reading?
Validity
When the nurse questions the blood glucose level obtained via a glucometer, a serum blood level is ordered. This protocol is directed toward ensuring which measure of standardization?
Validity
Which condition is an example of wound healing by secondary intention?
an infected burn of the arm
Substances foreign to the host that can stimulate an immune response are known as:
antigens
A client with COPD controlled with long-term corticosteroids has developed an infection following bowel surgery. The nurse anticipated this complication since steroids:
impair the phagocytic property of leukocytes.
A client is experiencing the early stages of an inflammatory process and develops leukocytosis. The nurse recognizes this as a/an:
increase in circulating neutrophils.
In 2014, an outbreak of Ebola virus disease began in West Africa in which there was a sharp increase in the number of people being diagnosed with this disease. At the same time, a very high proportion of those who were diagnosed died from the disease. The epidemiologic characteristics of this disease include:
increased incidence and high mortality.
sequalae
lesions or impairments that follow or are caused by a disease
Which unit of measure best describes the concentration of solute in a particular volume of fluid based on electrolyte equivalency?
mEq/L
While explaining immunity to a client, the nurse responds, "The body's internal organs are protected from pathogens because:
our mucosal tissue contains all the necessary cell components to fight a pathogen with an immune response."
The nurse is caring for a client with metabolic alkalosis. Which of these arterial blood gas results supports this diagnosis?
pH of 7.50 and HCO3 of 45 mEq/L (45 mmol/L)
The nurse is conducting a staff educational program on screening tests. The nurse determines that the participants understand the information when they identify the proportion of true positive test results in a given population as being:
positive predictive value.
