Pathophysiology EAQ
A nurse is caring for a client with a diagnosis of right ventricular heart failure. The nurse expects what assessment findings associated with right-sided heart failure? Select all that apply. Dependent edema Swollen hands and fingers Collapsed neck veins Right upper quadrant discomfort Oliguria
Dependent Edema, Swollen Hands and Fingers, Right Upper Quadrant Discomfort
Which statement indicates that a client understands the ways HIV is transmitted? Select all that apply. "I can contract HIV by participating in oral sex." "I can contract HIV by eating from used utensils." "HIV is contracted by using contaminated needles." "I can contract HIV by using the bathroom of a person who is HIV positive." "Babies can contract HIV because of contact with maternal blood during birth."
I can contract HIV by participating in oral sex, HIV is contracted by using contaminated needles, Babies can contract HIV because of contact with maternal blood during birth
The laboratory report of a school-aged child with celiac disease reveals that the child has anemia. What does the nurse suspect as the most likely causes of the anemia? Select all that apply. Lack of gluten in the diet Inadequate caloric intake Absence of intrinsic factor Incomplete absorption of iron Incomplete absorption of folic acid
Incomplete absorption of iron, incomplete absorption of folic acid
A 3-year-old child with mild iron deficiency anemia is seen by a nurse in the clinic. In addition to weakness and fatigue, what should the nurse expect the child to exhibit? Cold, clammy skin Increased pulse rate Increased blood pressure Cyanosis of the nail beds
Increased pulse rate
An older client tells the nurse, "My legs begin to hurt after walking the dog for several blocks. The pain goes away when I stop walking, but it comes back again when I resume walking." Which condition does the nurse consider as the most likely cause of the client's pain? Spinal stenosis Buerger disease Rheumatoid arthritis Intermittent claudication
Intermittent Claudication
An 85-year-old client has a serum potassium level of 6.7 mEq/L (6.7 mmol/L). Which nursing action is the priority at this time? Monitor for cardiovascular irregularities. Inquire about changes in bowel patterns. Assess for leg muscle twitching or weakness. Assess for signs and symptoms of dehydration.
Monitor for Cardiovascular Irregularities
What does the nurse explain to a client that a positive diagnosis for human immunodeficiency virus (HIV) infection is based on? Performance of high-risk sexual behaviors Evidence of extreme weight loss and high fever Identification of an associated opportunistic infection Positive enzyme-linked immunosorbent assay (ELISA) and Western blot tests
Positive Enzyme-Linked Immunosorbent Assay (ELISA) and Western Blot
When monitoring a client for hyponatremia, which assessment findings should the nurse consider significant? Select all that apply. Thirst Seizures Erythema Confusion Constipation
Seizures, Confusion
A 3-year-old child is admitted to the pediatric unit with a hemoglobin level of 6.4 g/dL (64 mmol/L). What should the nurse's priority assessment be? Manifestations of shock Increased white cell count Presence of hemoglobinuria Signs of cardiac decompensation
Signs of Cardiac Decompensation
A client has a platelet count of 49,000/mL (40 × 10 9/L). The nurse should instruct the client to avoid which activity? - Ambulation - Blowing the nose - Visiting with children - The semi-Fowler position
Blowing the nose
A client with hypertension is starting a 2-gram sodium diet. The nurse should teach the client to avoid which foods? Select all that apply. Canned chili Ground beef Fresh salmon Luncheon meat Cooked broccoli
Canned Chili, Luncheon Meat
A nurse is assessing a client with a diagnosis of early left ventricular heart failure. Specific to this type of heart failure, what statement by the client would the nurse expect? "My ankles are swollen." "I am tired at the end of the day." "When I eat a large meal, I feel bloated." "I have trouble breathing when I walk rapidly."
"I have trouble breathing when I walk rapidly."
A nurse is taking blood pressures at a health fair. Which finding should cause the nurse to advise the client to have the blood pressure checked by a primary healthcare provider? A loud Korotkoff sound An irregular pulse of 92 beats per minute A diastolic blood pressure that remains greater than 90 mm Hg A throbbing headache over the left eye when arising in the morning
A diastolic blood pressure that remains greater than 90 mmHG
The nurse is caring for a postpartum client who has experienced an abruptio placentae. Which assessment indicates that disseminated intravascular coagulation (DIC) is occurring? Boggy uterus Hypovolemic shock Multiple vaginal clots Bleeding at the venipuncture site
Bleeding at the venipuncture site
A nurse concludes that the teaching about sickle cell anemia has been understood when an adolescent with the disorder makes which statement? - "I'll start to have symptoms when I drink less fluid." - "I'll start to have symptoms when I have fewer platelets." - "I'll start to have symptoms when I decrease the iron in my diet." - "I'll start to have symptoms when I have fewer white blood cells."
"I'll start to have symptoms when I drink less fluid."
The nurse is conducting discharge teaching with an adolescent with hemophilia. Which statement by the client indicates a need for further teaching? - "I'll use a straight razor when I start shaving." - "I plan on trying out for the swim team next year." - "If I injure a joint, I'll keep it still, elevate it, and apply ice." - "If I get a little scratch, I can apply gentle pressure for 10 to 15 minutes."
"I'll use straight razor when I start shaving."
The healthcare provider makes the diagnosis of transient ischemic attacks (TIAs). The client asks the nurse, "What causes TIAs?" When preparing a response in language the client will understand, the nurse considers that TIAs are caused by which factor? Genetic valvular heart disease Atherosclerotic plaques within arteries Developmental defects in arterial walls Multiple emboli ascending from the lower extremities
Atherosclerotic plaques within arteries
A nurse is collecting a health history from a client with thromboangiitis obliterans (Buerger disease). What symptoms are most likely to be associated with this disorder? General blanching of skin Easy fatigue of extremities Burning pain after exposure to cold Presence of Homans sign when ambulating
Burning pain after exposure to cold
A nurse is caring for a client with a diagnosis of polycythemia vera. The client asks, "Why do I have an increased tendency to develop blood clots?" Which effect of the polycythemia vera should the nurse include in the teaching session? Elevated blood pressure Increased blood viscosity Fragility of the blood cells Immaturity of red blood cells
Increased Blood Viscosity
A client's laboratory report indicates hyperkalemia. Which responses should the nurse expect the client to exhibit? Select all that apply. Anorexia Vomiting Constipation Muscle weakness Irregular heart rate
Muscle Weakness, Irregular Heart Rate, Vomiting
A nurse is monitoring a client admitted with a diagnosis of myocardial infarction (MI) for dysrhythmias. Which reason for increased incidence of dysrhythmias in this client should the nurse monitor? Metabolic alkalosis Myocardial hypoxia Decreased catecholamine secretion Increased parasympathetic nervous system stimulation
Myocardial Hypoxia
Which statement is true regarding the functions of kidney hormones? Prostaglandin increases blood flow and vascular permeability. Bradykinin regulates intrarenal blood flow via vasodilation or vasoconstriction. Renin raises blood pressure because of angiotensin and aldosterone secretion. Erythropoietin promotes the absorption of calcium in the gastrointestinal tract (GI) tract.
Renin raises blood pressure because of angiotensin and aldosterone secretion
A client's laboratory report reveals a CD4+ T-cell count of 520 cells/mm 3. According to the Centers for Disease Control and Prevention (CDC), which stage of human immunodeficiency virus (HIV) disease is present in the client? Stage 1 Stage 2 Stage 3 Stage 4
Stage 1
A client has surgery to replace a prolapsed mitral valve. What should the nurse teach the client? The signs and symptoms of pericarditis The signs and symptoms of heart failure That cardiac surgery will have to be done eventually for the other valves That cardiac surgery will have to be done every six months to replace the valve
The signs and symptoms of heart failure
To prepare a client for surgery, which explanation by a nurse would be accurate related to pneumatic compression devices? They help the venous blood return to the heart. They will not cause discomfort, but gently massage the legs. They are used instead of anticoagulant therapy. They must be worn until the first time the client gets out of bed.
They help the venous blood return to the heart
Serum cardiac marker studies are prescribed for a client after a myocardial infarction. Which laboratory test is most important for the nurse to monitor? Troponin Myoglobin Homocysteine Creatine kinase (CK)
Troponin
A nurse is teaching a group of clients about risk factors for heart disease. Which factors will the nurse include that increase a client's risk for a myocardial infarction (MI)? Select all that apply. Obesity Hypertension Diabetes insipidus Asian-American ancestry Increased high-density lipoprotein (HDL)
Obesity, Hypertension
While the nurse moves a client from a lying to standing position, the client experiences a rapid drop in blood pressure. The nurse would report this finding as what? Malignant hypotension Orthostatic dehydration Orthostatic hypotension Vasomotor instability
Orthostatic Hypotension
A client is admitted to the hospital with a long history of hypertension. The nurse should assess the client for which complication? Cataracts Esophagitis Kidney failure Diabetes mellitus
Kidney Failure
The healthcare provider prescribes a low-fat, 2-gram sodium diet for a client with hypertension. The nurse should explain that the purpose of restricting sodium is to do what? Chemically stimulate the loop of Henle Diminish the thirst response of the client Prevent reabsorption of water in the distal tubules Cause fluid to move toward the interstitial compartment
Prevent the reabsorption of water in the distal tubules
During a client's routine physical examination, an abdominal aortic aneurysm is diagnosed. The client is admitted to the hospital immediately, and surgery is scheduled for the next morning. Which clinical finding should the nurse expect when completing the admission assessment? Signs of shock Visible peristaltic waves Radiating abdominal pain Pulsating abdominal mass
Pulsating Abdominal Mass
Parents of a child with sickle cell anemia ask about their child taking iron supplements to help treat the anemia. What would be the best response? Taking supplements will not help with this condition. It is advised that iron be taken with orange juice to aid in absorption. An over-the-counter multivitamin with iron should meet the needs of the child. It is advised that liquid iron supplements be given through a straw to prevent staining the teeth.
Taking supplements will not help with this condition
The nurse instructs the client admitted for an acute exacerbation of chronic obstructive pulmonary disease (COPD) about the importance of assessing for right-sided heart failure after discharge. What does the nurse instruct the client to assess for? Increased appetite Clubbing of the nail beds Hypertension Weight gain
Weight Gain
