EX

An adult client with good overall health has reported headaches and dizziness in recent weeks. The nurse's assessment reveals blood pressure of 158/99 mm Hg, which is unprecedented for the client. On observation, the client's skin appears reddened, though he denies feeling warm. The nurse should anticipate what further diagnostic finding?

Elevated RBC, hemoglobin, and hematocrit.

A client is prescribed the recumbent granulocyte colony-stimulating factor (CSF) filgrastim. The nurse evaluates the effectiveness by monitoring which laboratory value?

complete blood count (CBC)/differential

A client who will be undergoing a Holter monitor examination would be given which instruction?

"Keep a diary of your activities and symptoms throughout the examination."

Anticoagulant drugs prevent thromboembolic disorders. How does warfarin, one of the anticoagulant drugs, act on the body?

Alters vitamin K, reducing its ability to participate in the coagulation of the blood

Which client should most likely be assessed for orthostatic hypotension?

An older adult client who has experienced two falls since admission while attempting to ambulate to the bathroom.

A client with a history of acute coronary syndrome asks why she needs to take aspirin 81 mg every day. The most appropriate response by the nurse would be:

"Aspirin will help prevent blood clotting."

A nurse is caring for a client with an average heart rate of 56 beats/min. The client has no adverse symptoms associated with this heart rate and is receiving no treatment. Which activity modification should the nurse suggest to avoid further slowing of the heart rate?

"Avoid bearing down while having a bowel movement."

An older adult client arrives with garbled speech, unilateral facial drooping, and weakness and unfortunately dies. Laboratory work reveals hematocrit of 54% (0.54). Which complication of polycythemia could most likely be associated with this client's death?

Cerebral thrombosis

A client who has just been diagnosed with mitral valve stenosis tells the nurse that he has heard of the disease but he does not know anything about it. What would be the nurse's best response?

- It is a defect of the mitral valve which causes obstruction of blood flow.

The nurse suspects a client has stage 2 systolic hypertension. What systolic pressure would confirm the nurse's suspicion?

140 mm Hg or higher

The nurse knows that the main objective of the management of hypertension is to achieve a sustainable level of blood pressure below:

140/90

A client with a gastrointestinal bleed has been prescribed a transfusion of packed red blood cells. The client possesses type B antibodies but lacks D antigens. The nurse ensures which blood type is transfused to prevent a transfusion reaction?

A-

The nurse is caring for a client who has a low level of T lymphocytes. The nurse plans care for a client with:

Decreased immune response

From which one of the following sites is a fatal pulmonary thromboembolism most likely to originate?

Deep vein thrombophlebitis of the leg

Most common uncomplicated urinary tract infections are caused by ____ that enter through the urethra.

Escherichia coli

What is the most common cause of a lower urinary tract infection?

Escherichia coli

Which procedure is a nonsurgical method of treatment for renal calculi (kidney stones)?

Extracorporeal shock wave lithotripsy (ESWL)

Unilateral obstruction of the urinary tract may result in renin secretion, thereby leading to which manifestation?

Increased blood pressure

The nurse is counseling a client regarding a high cholesterol level. The nurse teaches the client that which lipoprotein is the main carrier of cholesterol?

LDL

A client's bone marrow study report reveals the findings of blast cells in the bone marrow. What does the nurse interpret this as indicating?

Leukemia

If a client is in the early phases of nephrotic syndrome, which area of the body will likely have the initial presence of edema?

Lower extremities

A young adult client presents with an enlarged, firm cervical lymph node on the right side of the neck. Palpation of the node is painless. The nurse should document this assessment finding and anticipate preparing the client for which diagnostic procedure to confirm diagnosis?

Lymph node biopsy

Which of the following clients is at greatest risk for developing a urinary tract infection (UTI)?

Older adult female client admitted with an indwelling Foley catheter that has been in place for 1 month

A client is admitted with a suspected diagnosis of Hodgkin lymphoma (HL). Which diagnostic test would the nurse look for to confirm the diagnosis?

Presence of Reed-Sternberg cells

A 26-year-old client has an absolute neutrophil count of less than 500 cells/mm^3 (0.50 x 10^9/L) Which interpretation of this lab value is accurate?

Severe neutropenia

An obese client with a history of gout and a sedentary lifestyle has been advised by the primary health care provider to avoid organ meats, certain fish, and other foods that are high in purines. This treatment would be advised for which type of kidney stones?

Uric acid stones

Which dysrhythmia is considered to be the most fatal and requires immediate treatment?

Ventricular fibrillation

A client with a history of angina presents with uncharacteristic chest pain. The subsequent electrocardiogram (ECG) reveals T-wave elevation. This finding suggests an abnormality with which aspects of the cardiac cycle?

Ventricular repolarization

A 45-year-old client is undergoing exercise stress testing. At which point will the test be halted and not allowed to continue?

When the client experiences chest pain

Which client will the nurse prioritize to assess first?

client with sinus arrest

A client asks the nurse if it is possible to contract influenza by being exposed to wound secretions. On what knowledge should the nurse base her response to the client?

Influenza transmission occurs by inhalation of droplet nuclei.

The nurse is planning care for a client with a urinary tract obstruction. The nurse includes assessment for which possible complication?

Increased blood pressure

The nurse evaluating a client's blood work determines that a client has an increased risk for infection based on which lab result?

Absolute neutrophil count of 800/μL (0.80 x 10^9/L)

The nurse is reviewing laboratory results for a client who is experiencing angina. Which finding might be expected in a client with dyslipidemia?

Elevated total cholesterol

A client has been experiencing anemia and thrombocytopenia. Subsequent diagnostic testing has revealed the presence of immature granulocyte types and the Philadelphia chromosome. This client is likely to experience:

a prolonged chronic phase of leukemia.

The health care team is developing a plan of care for a client diagnosed with congestive heart failure (CHF). The primary treatment goal would be:

improving quality of life by relieving symptoms.

Which is the second step of hemostasis?

platelet plug

The health care provider is discussing major risk factors for coronary artery disease (CAD) with a client. The most important information for the provider to include would be:

History of cigarette smoking and elevated blood pressure

An 86-year-old client is disappointed to learn that he or she has class II heart failure despite a lifelong commitment to exercise and healthy eating. Which age-related change predisposes older adults to the development of heart failure?

Increased vascular stiffness

A cytotechnologist is performing genetic testing on a series of tissues. One tissue comes back with the WT1 mutation, and it's mapped to chromosome 11. What disease will the client most likely develop?

Wilms tumor

A parent has brought her 2-week-old infant to the emergency department due to the infant's persistent and increasing jaundice. Laboratory testing reveals indirect bilirubin level is 28 mg/dL (479 µmol/L), but otherwise a normal physical assessment. Which intervention will most likely be prescribed for this infant?

Phototherapy

The nurse is conducting a staff in-service program on non-Hodgkin lymphomas. The nurse should include that essentially all people with Burkitt lymphoma have evidence of infection with:

EBV

A client who developed a deep vein thrombosis during a prolonged period of bed rest has deteriorated as the clot has dislodged, resulting in a pulmonary embolism. Which type of shock is this client at risk of experiencing?

Obstructive shock

Considering the PQRST complex of an electrocardiogram (ECG), which letter designation represents atrial depolarization?

P wave

A client has been diagnosed with a dissecting aortic aneurysm. It is most important for the nurse to assess the client for:

Tearing or ripping-type pain in the chest or back

A client newly diagnosed with lung cancer asks the nurse why the health care provider has ordered a positron emission tomography (PET) scan. Which response by the nurse is best?

"This diagnostic procedure will let the doctor know if you have any metastatic lesions in your body."

After birth, red blood cells are normally made in which location?

Bone marrow

The nurse caring for a client in the early stage of multiple myeloma would anticipate the client to report which symptom?

Bone pain

Which factor differentiates chronic leukemias from acute leukemias?

Leukemic cells are more fully differentiated in chronic than in acute leukemias.

During chronic blood loss, iron deficiency anemia occurs. Most clients are asymptomatic until their hemoglobin falls below 8 g/dL (80 g/L). The red blood cells that the body does produce have too little hemoglobin. What is the term for the resulting anemia?

Microcytic hypochromic

The nurse assesses the electrocardiogram for depolarization of the atria. What portion of the ECG will the nurse be assessing?

P wave above the baseline

A 75-year-old client with a history of heart valve replacement arrives at the outpatient clinic with multiple red pinpoint lesions. The nurse identifies the lesions as:

Petechiae

A client experiencing a sinus arrest would demonstrate which symptom or finding?

Prolonged periods of asystole demonstrated on an electrocardiogram

A 3-year-old child has been admitted to the pediatric unit for the treatment of croup. The nurse should include which action in the child's plan of care?

Providing cool, moist air for the child to breathe

Select the first stage of hemostasis.

Vessel spasm

A client is admitted to the hospital with a diagnosis of deep vein thrombosis and started on intravenous heparin therapy. Seven days later, the client's lab values identify a rapid decrease in platelets. The health care provider recognizes this as:

Drug-induced thrombocytopenia

A client has been given the diagnosis of diffuse glomerulonephritis. The client asks the nurse what diffuse means. The nurse responds:

"All glomeruli and all parts of the glomeruli are involved."

A client from Texas is suspected of being infected with coccidioidomycosis and has been admitted to the hospital with fever, cough, pleuritic chest pain, and skin lesions. When performing a health history, which question would be most valuable to assist with diagnosis?

"Do you work in construction and dig soil?"

A client is newly diagnosed with impaired platelet function, thrombocytopathia. Which question is most appropriate for the nurse to ask in order to determine the possible cause of this problem?

"Have you been taking aspirin or any nonsteroidal anti-inflammatory drugs (NSAIDs)?"

The neonate displays a yellow discoloration of her skin on the second day of life. The neonatologist explains this condition to the parents. Which statement is most accurate?

"The increase in bilirubin, which causes the jaundice, is related to the increased red blood cell breakdown."

A child has been home from camp for 2 weeks and reports a sore throat, low-grade fever, and enlarged cervical lymph nodes. After testing, it is determined the child has Epstein-Barr virus (EBV)-associated infectious mononucleosis. The parent asks, "How did my child acquire this type of infection?" Which is the best response by the nurse?

"The infection is acquired primarily through contact with infected oral secretions."

A client asks the purpose of an exercise stress test. What is the nurse's best response?

"The test is used to measure functional status during stress."

What should the nurse teach the client prior to ergometry?

"This test evaluates cardiac function."

A client diagnosed with tuberculosis asks the nurse how long the antitubercular medication will need to be taken. What is the best response?

"You can take drug therapy for as long as 24 months or until all tubercle bacilli are eliminated."

A nurse is caring for an older adult client with a urinary tract infection (UTI). The nurse understands which information about UTI's in the older adult population? Select all that apply.

- Client may have no symptoms. - The UTI may be reflected in a change in the client's mental state. - UTI is relatively common in older adults.

A nurse is providing care for a client with a history of severe atherosclerosis. Which clinical manifestations should the nurse anticipate and assess in the client? Select all that apply

- Cognitive deficits due to ischemia or thrombosis. - Aneurysm formation due to weakening of blood vessel walls.

A nurse is planning a community education program on lifestyle modification to manage hypertension. Which topic should be included in the teaching plan? Select all that apply.

- Consume a diet rich in fruits, vegetables, and low-fat dairy products. - Reduce dietary sodium intake. - Stop smoking. - Limit alcohol consumption.

The nurse is studying hemostasis. She knows that which statements are true? Select all that apply

- Hemostasis refers to the body's ability to control bleeding. - Vessel constriction or spasm is a factor in effective hemostasis. - Hemostasis results in the formation of a platelet plug. - Hemostasis occurs in established stages.

The nurse is assessing a client newly diagnosed with Hodgkin lymphoma. Where should the nurse anticipate finding enlarged lymph nodes? Select all that apply.

- Neck - Axilla - Supraclavicular area

The nurse knows that which statements regarding sodium and hypertension are correct? Select all that apply.

- Sodium may increase the responsiveness of the cardiovascular system to adrenergic (sympathetic) stimulation. - Reduction in sodium intake often produces a reduction in blood pressure. - In the INTERSALT study, urinary sodium excretion and systolic blood pressure are closely correlated.

The nurse is admitting a 90-year-old client with a history of heart failure, coronary artery disease, prostate cancer, diabetes, and hypercholesterolemia. Which condition(s) in this client's history places the client at higher risk for thrombotic events related to atherosclerotic plaque formation and rupture? Select all that apply.

- diabetes - coronary artery disease - hypercholesterolemia

The nurse assesses a client in an ambulatory care facility. Which manifestation(s) leads the nurse to advocate for investigation of possible acute pyelonephritis? Select all that apply.

- flank pain in the back - abrupt onset of fever and chills - urinary urgency and frequency

A parent brings a child into the urgent care clinic. The health care provider suspects the child has a "common cold" based on which clinical manifestation(s)? Select all that apply.

- watery, clear nasal secretions - coughing - mild fever

In which situation is blood most likely to be rapidly relocated from central circulation to the lower extremities?

A client is helped out of bed and stands up.

A client diagnosed with systemic lupus erythematosus (SLE) has been experiencing a low neutrophil count. How would this type of neutropenia be classified?

Acquired, autoimmune secondary neutropenia

A nurse is caring for a client with persistent atrial fibrillation (AF) unresponsive to antiarrhythmic therapy. Prior to an elective cardioversion, the nurse anticipates which intervention?

Administration of anticoagulants

Which individual should have priority for receiving a seasonal influenza vaccination?

An older adult resident of a long-term care facility

A client taking an antihypertensive drug for several months comes to the physician's office with a dry, persistent cough. The nurse knows that this cough is an adverse effect of which class of antihypertensive drugs?

Angiotensin-converting enzyme (ACE) inhibitors

The nurse in the emergency department is assessing a toddler suspected of epiglottitis. Which intervention is considered the priority when working with this client?

Assess if airway is compromised and call for health care provider assistance with intubation to establish an airway, if needed.

A nurse who works in a neonatal intensive care unit is providing care for an infant who was born at 26 weeks' gestation. Which initial assessment should be the nurse's priority?

Assessment of the infant's respiratory status and oxygen saturation levels

Coronary artery bypass grafting (CABG) is a treatment modality for which disorder of cardiac function?

Atherosclerosis and unstable angina

Paroxysmal supraventricular tachycardia arises from which form of reentry?

Atrioventricular (AV) nodal

In primary immune thrombocytopenia purpura (ITP), the client has which type of disorder that primarily destroys which blood component?

Autoimmune; platelets

The nurse suspects that a newborn infant who presents with bilateral flank masses, impaired lung development, and oliguria may be suffering from which disorder?

Autosomal recessive polycystic kidney disease (ARPKD)

A nurse is preparing her client for a blood transfusion. She knows that a client with type A blood is said to have which type of antibodies?

B

Pernicious anemia is thought to be an autoimmune disease that destroys the gastric mucosa. This results in chronic atrophic gastritis and the production of antibodies that interfere with which vitamin's ability to bind to intrinsic factor?

B>12

Which antiarrhythmic medication works by blunting the effect of sympathetic nervous system stimulation on the heart?

Beta-blockers, such as metoprolol

The nurse reviews the lab results of a client who has a thrombocyte count of 60 ×10^3/µL (60 ×10^9/L). The client is at risk for:

Bleeding

Clients with lung disease can develop polycythemia as a result of which condition?

Chronic hypoxia

A middle-aged client with a 30-year history of smoking was diagnosed with lung cancer. A health history revealed previous exposure to air pollution, asbestos, and radiation. Which factor mostlikely had the greatest impact on development of the lung cancer

Cigarette smoke

A client's electrocardiogram monitor begins to sound an alarm and shows sustained ventricular fibrillation. The client is unconscious and without a pulse. Which priority intervention should the nurse take?

Defibrillate the client

An expectant mother is 23 weeks into her pregnancy when she goes into labor. Regarding fetal lung development, what is of greatest concern to the attending medical team?

Development of type II alveolar cells

A nurse is caring for a client receiving heparin therapy who has developed heparin-induced thrombocytopenia. Which nursing intervention does the nurse anticipate?

Discontinuation of heparin therapy

A client is having an electrocardiogram and the nurse notes a previously undocumented prolonged QT complex suggestive of long QT syndrome. What action should the nurse take first?

Double check the placement of the electrocardiogram leads on the client.

A client has been placed on sulfamethoxazole/trimethoprim as treatment for community-acquired methicillin-resistant Staphylococcus aureus (MRSA) for 10 days. After taking the medication for 8 days, the client comes to the health care provider's office complaining of multiple nosebleeds over the past day. Laboratory work shows a platelet count of 80,000/μL. The nurse practitioner suspects which condition?

Drug-induced thrombocytopenia

A client presents to the emergency department with a sudden onset of acute pain in his left lower leg. The practitioner is unable to palpate pedal pulses and finds the client to be in atrial fibrillation. Which test will the practitioner order to find the source of the emboli?

Echocardiogram

When developing the plan of care for a child with respiratory distress, what nursing intervention can the nurse provide that will facilitate respiratory movements and avoid airway compression?

Elevate the head of the bed.

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

A client has been diagnosed with inherited hypercoagulability. Select the most likely cause.

Factor V gene mutation

The nurse's plan of care for a client with multiple myeloma should include interventions to prevent:

Fractures

What is the most important factor in myocardial oxygen demand?

Heart rate

When an Rh-negative mother gives birth to an Rh-positive infant, the mother usually produces antibodies that will attack any subsequent pregnancies in which the fetus is Rh positive. When subsequent babies are Rh positive, erythroblastosis fetalis occurs. What is another name for erythroblastosis fetalis?

Hemolytic disease of the newborn

The emergency department nurse is concerned that the client's snake bite may trigger disseminated intravascular coagulation (DIC). If this should occur, which clinical manifestations would be seen?

Hemorrhage

A client with acute leukemia has developed gout and asks the nurse, "Why did this happen?" Which response is most accurate?

High uric acid levels

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

Hodgkin lymphoma

The pathologist notes that the client has Reed-Sternberg cells. He knows that these cells are a diagnostic hallmark for which disorder?

Hodgkin lymphoma

A nurse advises a client with recurring UTIs to drink large amounts of water. What normal protective action is the nurse telling the client to utilize?

Increase washout of urine

A child has developed respiratory stridor and is displaying a crowing sound. The parents ask the nurse what is causing this sound. The best response would be:

Increased turbulence of air moving through the obstructed airways

Nursing students who are studying for their upcoming cardiac exam are discussing how the heart could possibly continue to beat once removed from the body. One of the students explains that this phenomenon is directly related to automaticity. What is automaticity?

Inherent spontaneous action-potential

A nurse is assessing a 1-year-old child diagnosed with croup. Which manifestation would mostlikely be present?

Inspiratory stridor and barking cough

A client was recently diagnosed with iron deficiency anemia. The nurse anticipates which treatment to be prescribed?

Iron supplementation and dietary teaching

The student attends a health fair and has his serum cholesterol checked. He has a high lipoprotein level (LDL). He understands which of the following about LDL cholesterol?

It is believed to play an active role in the pathogenesis of the atherosclerotic lesion.

The practitioner is examining a client and notes that he has small, punctate skin hemorrhages on his abdomen and chest. This finding is suggestive of which lab result?

Low platelets

The nurse is conducting education for a client who is scheduled to undergo diagnostic testing for non-Hodgkin lymphoma (NHL). The nurse includes information on:

Lymph node biopsy

A client has been diagnosed with non-Hodgkin lymphoma (NHL), a form of malignancy that originates in which body site?

Lymph nodes

When collecting a client's history the client states that he is receiving treatment to maintain remission from leukemia. What does the nurse document that the client is receiving?

Maintenance therapy

A nurse is explaining the clinical manifestations of diabetic nephropathy (diabetic glomerulosclerosis) to a client. Which statement would be the most important information for the nurse to provide?

Microalbuminuria is a predictor of future nephropathies.

Sick sinus syndrome is suspected in the case of a child who is postoperative following cardiac surgery. Which nursing action is most appropriate?

Monitor the child's ECG for bradycardia.

The nurse working in the emergency room triages a client who comes in reporting chest pain, shortness of breath, sweating and elevated anxiety. The physician suspects a myocardial infarction. The client is given a nitrate, which does nothing for his pain. Which medication should the nurse suspect the doctor will order next for the pain?

Morphine

ECG monitoring has been found to be more sensitive than a client's report of symptoms when identifying transient ongoing myocardial ischemia. Why is this?

Most ECG-detected ischemic events are clinically silent.

The granulocyte cell lines are derived from:

Myeloid stem cells

The physician reviews a client's lab results and notes that the neutrophil count is 900/μL (0.90 x 10^9/L). This is known as:

Neutropenia

A female adolescent is reporting general malaise and lethargy. Which clinical assessment should the nurse perform in an effort to confirm or rule out infectious mononucleosis?

Palpating the client's lymph nodes

A monitored hospitalized client with a pulmonary embolism has been in atrial fibrillation (AF) for 4 days. The nurse observes the rhythm spontaneously convert to a normal sinus rhythm. Which form of AF is this?

Paroxysmal

A client diagnosed with Goodpasture syndrome would require which therapy to remove proteins and autoantibodies from the system?

Plasmapheresis

A client presents to the clinic with symptoms of elevated blood pressure, dizziness, red face, pain in fingers and toes, headache, and difficulty concentrating. A blood smear reveals an increased number of erythrocytes. Based on these findings, the nurse anticipates which diagnosis?

Polycythemia vera

Which anatomical site would the nurse expect to monitor when caring for an adult client who has just had a bone marrow aspiration performed?

Posterior iliac crest

Following peripheral blood testing and a bone marrow biopsy, a client has been diagnosed with chronic myelogenous leukemia. Which abnormality is most likely to have preceded the client's diagnosis?

Presence of a Philadelphia chromosome

A client is at high risk for the development of rheumatic heart disease. The most important information for the nurse to provide would be:

Prompt diagnosis and treatment of streptococcal infections

A nurse preceptor is evaluating the skills of a new registered nurse (RN) caring for clients experiencing shock. Which action by the new RN indicates a need for more education?

Raising the head of the bed to a high Fowler's position

A female client tells the health care provider that she has recently been experiencing episodes of changes occurring 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

A client diagnosed with the common cold has been taking an over-the-counter antihistamine for the control of symptoms. What should the client be aware may occur if the drugs are used too frequently over too many days?

Rebound symptoms

What is the most common cancer of the kidney?

Renal cell carcinoma

A client is seen in the emergency department complaining of chest discomfort, productive cough, and a fever of over 101°F (38.3°C) for 3 days. The nurse performs an electrocardiogram and observes a rate of 110 beats per minute (bpm) with a normal P wave and a PR interval of 0.12 second preceding each QRS complex. What does the nurse determine the rhythm to be?

Sinus tachycardia

A client's history and physical documents the presence of an indolent lymphoma. The nurse plans care for which type of lymphoma?

Slow-growing

A client with an 80-pack-year history of tobacco smoking has presented to the clinic complaining of "bronchitis" cough for the past 5 months, weight loss, and shortness of breath. Today, this client "got scared" when he coughed up blood in his sputum. The health care provider is concerned this client may have which possible diagnosis?

Small cell lung cancer due to smoking history

The nurse is performing a history and physical on a client with diabetic nephropathy. Findings include BP 124/80; smokes two packs of cigarettes/day; diet high in saturated fats and sodium. Which intervention can help prevent the progression of the diabetic nephropathy?

Smoking cessation program

When red blood cells age, which organ is responsible for their destruction?

Spleen

An immunocompromised host is open to pneumonia from all types of organisms. There is, however, a correlation between specific types of immunologic deficits and specific invading organisms. What organism is most likely to cause pneumonia in an immunocompromised host with neutropenia and impaired granulocyte function?

Staphylococcus aureus

The nurse knows that which food is excluded from the Dietary Approaches to Stop Hypertension (DASH) diet?

Steak

Which client is at the greatest risk of developing rheumatic heart disease?

Teenager with untreated strep throat

A parent of a toddler is concerned about possible side effects of influenza immunizations. What will the nurse teach the parent regarding the influenza vaccine?

The Centers for Disease Control and Prevention recommends that all people 6 months of age and older should receive the annual influenza vaccine.

A client with iron-deficiency anemia asks, "What does this low mean corpuscular volume (MCV) level mean?" Which response by the nurse is most accurate?

The MCV is one red blood cell (RBC) index that indicates your RBCs are small cells.

The postoperative client has a catheter in his brachial artery for continuous blood pressure monitoring. Which assessment would be a concern for the nurse?

The client states his hand is numb.

A client had a tuberculin skin test (TST) performed as part of the immigration process and is surprised that the results are positive. How should the nurse best interpret this result?

The client was exposed to the tubercle bacillus at an indefinite point in the past.

A nurse observes that a client's urine is cola colored and considers which factor as a possible reason?

The client's urine contains material from the degradation of red blood cells.

The health care provider is reviewing lab results of a client diagnosed with heart failure. The provider notes that the client's ANP and BNP levels have been increasing and remain significantly elevated. These results would be interpreted as:

The condition is getting progressively worse.

The parents of a newborn are concerned because the infant's skin has a yellow color. What education should the nurse discuss with the parents?

The parents need to be taught about hyperbilirubinemia and common treatment modalities.

A client has been diagnosed with pneumococcal infection. The nurse shares with the client which statement about the spread of the disease?

The spread of this bacteria, especially the antibiotic-resistant strain, is largely by healthy, colonized individuals.

A nurse is assessing a client and finds these results: - Areas of bruising (purpura) on the client's arms and legs - Pinpoint hemorrhages (petechiae) on the legs - Pinpoint hemorrhages (petechiae) in the mouth - Platelets level of 90,000/μL (90 ×109/L) What condition should the nurse suspect the client is exhibiting?

Thrombocytopenia

What is the reason why bed rest and analgesics are expected treatments for infectious mononucleosis?

To relieve fever, headache, and sore throat

Thalassemia can be classed as major or minor. If therapy for thalassemia major is not started in infants who present with this disease, severe growth retardation will occur. At 6 months of age, which therapy must be started?

Transfusion

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 client presents with uncharacteristic chest pain, and his ECG reveals T-wave elevation. This finding suggests an abnormality with which aspect of the cardiac cycle?

Ventricular repolarization

A client is pregnant for the first time and is considered to be at high risk for preeclampsia. The care team should prioritize which intervention?

Vigilant blood pressure monitoring

A nurse is caring for a client who has sustained severe trauma and has developed disseminated intravascular coagulation (DIC). The nurse will explain this complication to the family based on which physiologic principle?

Widespread coagulation and bleeding in the vascular compartment

A child has been brought to an urgent care clinic. The parents state that the child is "not making water." When taking a history, the nurse learns the child had a sore throat about 1 week ago but seems to have gotten over it. "We [parents] only had to give antibiotics for 3 days for the throat to be better." The nurse should suspect the child has developed:

acute postinfectious glomerulonephritis.

The nursing caring for a 62-year-old client with diffuse large B-cell lymphoma plans care based on the knowledge that this client's lymphoma is:

aggressive

The nurse is developing a plan of care for a postsurgical client. A major goal is to prevent the formation of deep vein thrombosis (DVT). Which nursing intervention should the nurse implement?

apply sequential pneumatic compression devices to lower extremities

A 10-month-old infant has begun to take his first steps and his mother has brought him for assessment because of swelling in his ankles and knees. The mother also states that he was eager to walk but has now regressed and cries when she tries to encourage it. The clinician should:

assess the child for signs and symptoms of hemophilia A.

Which disease is caused by calcified scar tissue that develops between the visceral and parietal layers of the serous pericardium?

constrictive pericarditis

A client has been prescribed a thiazide diuretic, hydrochlorothiazide (HCTZ), for the initial treatment of hypertension. The nurse teaches the client that this medication lowers blood pressure through what effect?

decreasing vascular volume

A client has just returned from his surgical procedure. During initial vital sign measurements, the nurse notes that the client's heart rate is 111 beats/minute and the BP is 100/78 (borderline low). In this early postoperative period, the nurse should be diligently monitoring the client for the development of:

hypovolemic shock due to acute intravascular volume loss.

A female client comes to the clinic with symptoms of fatigue and heavy menses over the past 6 months. Laboratory tests reveal a microcytic hypochromic anemia. Based on these results, the nurse anticipates teaching the client about which type of anemia?

iron-deficiency anemia

Assessment of an older adult client reveals bilateral pitting edema of the client's feet and ankles; difficult to palpate pedal pulses; breath sounds clear on auscultation; oxygen saturation level of 93% (0.93); and vital signs normal. What is this client's most likely health problem?

right-sided heart failure

A client arrives at the emergency room with dizziness and a near syncopal episode. Vital signs include a heart rate of 46 beats/min and blood pressure of 86/50 mm Hg. The cardiac monitors show regular rhythm as above. The client states the health care provider has been running blood work to rule out hypothyroidism. Based on the rhythm, what does the nurse report the client has?

symptomatic bradyarrhythmia

A client who is being treated for small-cell lung cancer has been placed in protective isolation due to neutropenia. The most likely cause of this client's neutropenia is

the effects of chemotherapy on white blood cell development.

A 42-year-old male client recently diagnosed with liver cancer is noted as at high risk for bleeding abnormalities. The nurse recognizes this risk as a result of:

the reduction of clotting factors synthesized in the liver.

Many different proteins, enzymes, and hormones are involved in maintaining hemostasis. Which protein is required for platelet adhesion?

von Willebrand factor