Pathophysiology Test 3

Closed angle glaucoma is caused by A. Abnormal drainage of the aqueous humor through the trabecular meshwork that controls the flow of aqueous humor into the canal of Schlemm B. Narrow anterior chamber angle that interferes with outflow of aqueous humor from the anterior chamber C. Increased production of aqeous humor D. Decrease production of aqueous humor

B. Narrow anterior chamber angle that interferes with outflow of aqueous humor from the anterior chamber

In taking the history of a patient suspected of having bacterial meningitis, which question is most important for the nurse to ask? A. "Do you live in a crowded residence? B. "When was your last tetanus vaccination?" C. "Have you had any viral infections recently?" D. "Have you traveled out of the country in the last month?"

A. "Do you live in a crowded residence?

During discharge teaching for a patient who experienced a mild stroke, you are providing details on how to eliminate risk factors for experiencing another stroke. Which risk factors below for stroke are modifiable? A. Obesity B. Sedentary Lifestyle C. Family History D. Advanced Age E. Smoking

A. Obesity B. Sedentary Lifestyle E. Smoking

While positioning a patient in bed with increased ICP, it important to? A. Placing the HOB at 30-35 degrees B. Flex the neck C. Place the patient's head to the side D. Flex the hips

A. Placing the HOB at 30-35 degrees

A patient who experienced a cerebral hemorrhage is at risk for developing increased ICP. Which sign and symptom below is the EARLIEST indicator the patient is having this complication? A. Restlessness B. Bradycardia C. Unequal pupil size D. Posturing

A. Restlessness

Which is the priority nursing diagnosis for a patient who has severe visual impairment? A. Risk for injury B. Chronic confusion C. Risk for loneliness D. Disturbed body image

A. Risk for injury

A nurse in the emergency department is observing a 4 year old child for signs of increased intracranial pressure after a fall from a bicycle which resulted in a head trauma. Which of the following signs or symptoms would be cause for concern? A. repeated vomiting B. inability to read short words at a distance of 18 inches C. bulging anterior fontanel D. signs of sleepiness at 10 pm

A. repeated vomiting

Your patient has entered the post ictus stage for seizures. The patient's seizure presented with an aura followed by body stiffening and then recurrent jerking. The patient had incontinence and bleeding in the mouth from injury to the tongue. What is an expected finding in this stage based on the type of seizure this patient experienced? A. Crying and anxiety B. Sleepy, headache, and soreness C. Immediate return to baseline behavior D. Unconsciousness

B. Sleepy, headache, and soreness

The nurse monitors for which complication in the patient with large renal calculi? A) Chronic hypertension B) Hydronephrosis C) Polyuria D) Dysuria

B) Hydronephrosis

Examination of a patient's bladder stones reveal that they are primarily composed of uric acid. The nurse would expect to provide the patient with which type of diet? A) Low calcium B) Low purine C) High protein D) High oxalate

B) Low purine

Which patient below is at most risk for a hemorrhagic stroke? A. 65 year old male patient with carotid stenosis B. A 88 year old male with uncontrolled hypertension and a history of brain aneurysm repair 2 years ago C. A 55 year old female with atrial flutter D. A 89 year old female with atherosclerosis

B. A 88 year old male with uncontrolled hypertension and a history of brain aneurysm repair 2 years ago

I'm planning care for a patient with detached retina, which of the following nursing diagnosis should receive priority? A. Alteration in comfort B. Alteration in mobility C. Alteration in skin integrity D. Alteration in tissue perfusion

B. Alteration in mobility

The nurse has interviewed these patients in the emergency department triage area. Which one warrants immediate medical evaluation? A. The 30-year-old with nausea after a scleral buckling procedure yesterday B. The 35-year-old who has sudden-onset eye pain and decreased vision C. The 18-year-old with periorbital ecchymosis acquired during an altercation D. The 24-year-old who has a foreign body sensation in the right eye after gardening

B. The 35-year-old who has sudden-onset eye pain and decreased vision

An adult client is brought to the emergency department due to a motor vehicle accident. While monitoring the client, the nurse begins to suspect increased intracranial pressure, ICP, when: A. The BP decreased from 160/90 to 110/70 B. the client is orientated when aroused from sleep, and goes back to sleep immediately C. the client refuses dinner due to anorexia D. the pulse is increased from 88 to 96 with occasional skipped beats.

B. the client is orientated when aroused from sleep, and goes back to sleep immediately

Which statement indicates that the patient need additional teaching about ear hygiene? A. "I will wash my hands before I put in my earplugs at work" B. " I will clean my ears with plain warm water and a washcloth every day" C. "I will use a cotton swab to get the extra water out of my ears after I swim" D. "I can rinse my ears with lukewarm sterile water if ear wax builds up."

C. "I will use a cotton swab to get the extra water out of my ears after I swim"

Mark was in a motor vehicle accident (MVA) and sustained a closed head injury. He hit his head on a steering wheel when his car hit a tree. The area of initial impact is called the: A. Countercoup B. Postcoup C. Coup D. Recoup

C. Coup

A patient is experiencing characteristics of a tonic-clonic seizure. The seizure started at 1402 and it is now 1408, and the patient is still experiencing a seizure. The nurse should? A. Continue to monitor the patient B. Restrain the patient to prevent further injury C. Initiate the emergency response system D. Suction the patient

C. Initiate the emergency response system

A patient has disabling attacks of vertigo. The nurse suspects that the patient has Ménière's disease. The nurse is aware that the diet of the patient must be modified. Which of the following is the best diet for the patient. A. High protein B. Low carbohydrates C. Low sodium D. Low fat

C. Low sodium

Later signs of intracranial pressure (ICP) include which of the following? A. increased pulse rate B. decreased systolic blood pressure C. projectile vomiting D. narrowed pulse pressure

C. projectile vomiting

Which patient below with ICP is experiencing Cushing's Triad? A patient with the following vitals: A. BP 90/60, HR 80, RR 22 B. BP 150/112, HR 110, RR 8 C. BP 80/40, HR 49, RR 12 D. BP 200/60, HR 50, RR 8

D. BP 200/60, HR 50, RR 8

While charting, nurse Bonnie witnesses a patient slip in the hallway landing hard on their sacrum and then lays flat in a shocked state. The nurse should first: A. Help the patient to turn on their side to open the airway B. Ask the patient how many fingers she is holding up C. Put a pillow under the patient's buttocks D. Instruct the patient not to move while she calls for help

D. Instruct the patient not to move while she calls for help

Your patient has a history of epilepsy. While helping the patient to the restroom, the patient reports having this feeling of déjà vu and seeing spots in their visual field. Your next nursing action is to? A. Assess the patient's medication history. B. Continue assisting the patient to the restroom and let them sit down. C. Initiate the emergency response system D. Lay the patient down on their side with a pillow underneath the head.

D. Lay the patient down on their side with a pillow underneath the head.

Tom as difficulty moving and controlling his legs after a motor vehicle accident (MVA). The neurons most likely involved are: A. Sensory Neurons B. Central Neurons C. Afferent Neurons D. Motor Neurons

D. Motor Neurons

A nurse is teaching family members of a client with a concussion about the early signs of increased cranial pressure, ICP. Which of the following would the nurse cite as early signs of ICP? A. dilated pupils that don't react to light B. decreased systolic BP C. inability to wake the patient with noxious stimuli D. headache and vomiting

D. headache and vomiting

You're educating a patient about transient ischemic attacks (TIAs). Select all the options that are incorrect about this condition: a. TIAs produce signs and symptoms that can last for several weeks to months. B. TIAs don't require medical treatment. C. A TIAs is a warning sign that an impending stroke may occur. D. TIAs are caused by a temporary decrease in blood flow to the brain.

a. TIAs produce signs and symptoms that can last for several weeks to months. B. TIAs don't require medical treatment.

For which clinical manifestation in the patient with a history of complex partial seizures will the nurse assess? a. automatisms b. sudden muscle stiffening c. sudden loss of muscle tone d. brief jerking of extremities

a. automatisms

What causes a gradual clouding of the lens of the eye? a. cataracts b. keratitis c. glaucoma d. macular degeneration

a. cataracts

During a neurologic assessment of a client, the nurse notes that the client's arms, wrists, and fingers have become flexed, and internal rotation and plantar flexion of the legs are evident. How does the nurse document these findings? a. decorticate posturing b. decerebrate posturing c. atypical hyperreflexia d. autonomic dysreflexia

a. decorticate posturing

During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which of the following would be most appropriate to institute? a. keep inessential noise to a minimum b. performing treatments quickly c. allowing the child to play in the bathtub d. limiting conversation with the child

a. keep inessential noise to a minimum

The nurse is assessing a client with a temporal lobe injury. Which clinical manifestations correlate with this injury? (Select all that apply.) a. memory loss b. personality changes c. loss of temperature regulation d. difficulty with sound interpretation e. speech difficulties

a. memory loss d. difficulty with sound interpretation e. speech difficulties

When interviewing the parents of a 2-year-old child, a history of which of the following illnesses would lead the nurse to suspect pneumococcal meningitis? a. middle ear infection b. fracture clavicle c. bladder infection d. septic arthritis

a. middle ear infection

The nurse would suspect the client is developing meningitis if the client exhibits: a. absence of nuchal rigidity b. a positive Brudzinkski's sign c. Glascow Coma Scale score of 15 d. a negative Kernig's sign

b. a positive Brudzinkski's sign

What renal hormone is synthesized secreted by kidneys to stimulate bone marrow production of RBCs? a. renine b. erythropoietin c. creatinine d. aldosterone

b. erythropoietin

A 55 year old male presents reporting urinary retention. Tests reveal that he has a lower urinary tract obstruction. Which of the following is of most concern to the nurse a. vesicoureteral reflux and pyelonephritis b. formation of renal calculi c. glomerulonephritis d. increased bladder compliance

b. formation of renal calculi

The nurse is admitting a patient in the emergency room with a foreign body in the ear identified as an insect. Which of the following interventions is a priority for the nurse to perform? a. place a cotton plug in the affected ear b. instill diluted alcohol or mineral oil in the affected ear. c. instill a cortisone ointment into the affected ear d. instill an antibiotic ointment into the affected ear.

b. instill diluted alcohol or mineral oil in the affected ear.

The nurse assesses several patients. which one is most likely to have an open-angle glaucoma a. a patient with sudden onset eye pain b. a patient who has recently had eye surgery c. a patient who sees halos around lights d. a patient with reactive pupils and clear sclera

c. a patient who sees halos around lights

If patient is in a vegetative state and is experiencing a cerebral death what is keeping the patient alive? a. cerebral cortex b. adrenal medulla c. brain stem d. spinal cord

c. brain stem

The nurse correlates which process with the brain damage that results from increased intracranial pressure secondary to cerebral edema? a. axonal shearing and tearing from displacement of the brain in the cranium b. myelin degeneration from circulating enzymes released in areas of tissue damage c. cerebral tissue hypoxia and ischemia from compression of blood vessels d. decreased cerebral perfsuion from hypotension and blood loss

c. cerebral tissue hypoxia and ischemia from compression of blood vessels

Which teaching intervention is most appropriate for the patient with Parkinson's disease? a. universal precautions b. seizure precautions c. fall precautions d. isometric exercises

c. fall precautions

Which of the following would lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation? a. edema b. dyspnea on exertion c. hemorrhagic skin rash d. cyanosis

c. hemorrhagic skin rash

You are the charge nurse on a medical unit in an acute care hospital. Which of these interventions should you delegate to the unlicensed assistive personnel (UAP)? a. safety teaching for a patient with Parkinson's disease b. assessing the size and depth of a pressure ulcer for patient with encephalitis c. regular toileting of a patient with Alzheimer's disease d. suggesting support groups to the family of a patient with Huntington's disease

c. regular toileting of a patient with Alzheimer's disease

You are the RN triaging phone calls in a busy ophthalmology clinic. Which of these patient phone calls should you take first? a. The 32 year old patient complaining of scleral pruritus and redness b. the 32 year old patient who says "My eyes feel dry all the time" c. the 49 year old patient with blunt trauma to the left eye d. the 67 year old patient with a pustule at the right canthus

c. the 49 year old patient with blunt trauma to the left eye

While planning care for a patient who has acute pyelonephritis, a nurse recalls the most common condition associated with the development of acute pyelonephritis is a. cystitis b. renal cancer c. urinary tract obstruction d. nephrotic syndrome

c. urinary tract obstruction

A client with epilepsy develops stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How does the nurse document this seizure activity? a. Generalized Atonic seizure b. Generalized Absence seizure c. Generalized Myoclonic seizure d. Generalized Tonic-clonic seizure

d. Generalized Tonic-clonic seizure

The nurse recognizes which pathophysiological change in the patient diagnosed with myasthenia gravis? a. the myelin sheath is destroyed by the immune system, impairing nerve impulses b. autoantibodies destroy dopamine receptors, impairing transmission, of nerve impulses to the skeletal muscles c. a prion destroys central nervous system tissue, causing a global degeneration. d. autoantibodies destroy acetylcholine receptors, imapiring transmission of nerve impulses to the skeletal muscles

d. autoantibodies destroy acetylcholine receptors, imapiring transmission of nerve impulses to the skeletal muscles

A patient's chart indicates a history of meningitis. Which of the following would you not expect to see with this patient if this condition were acute? a. fever b. vomiting c. intolerance of light d. increased appetite

d. increased appetite

A nurse in the emergency department is observing a 4 year old child for signs of increased intracranial pressure after a fall from a bicycle which resulted in a head trauma. Which of the following signs or symptoms would be cause for concern? a. inability to read short words from a distance of 18 inches. b. signs of sleepiness at 10 P.M. c. bulging anterior fontanel d. repeated vomiting

d. repeated vomiting

The main source of serum bicarbonate is obtained from: a. dietary intake b. synthesis by the liver c. medicine containing sodium bicarb d. the kidneys

d. the kidneys

What puts a patient at greatest risk for hemorrhagic stroke? a. ataxia b. dysrhythmias c. migrains d. untreated high BP

d. untreated high BP