Physiological Adaptations Quiz

A nurse is caring for a client who has reported difficulty sleeping. Which statement made by the client requires further assessment? Select one: a. "I have been really stressed out at work lately." b. "I drink a cup of chamomile tea to help relax at bedtime." c. "I make a point of getting to bed at the same time every night." d. "I try not to nap during the day, even though I'm tired."

a. "I have been really stressed out at work lately." Assessment of the related factor or probable cause of the sleep disturbance is a key step in caring for a client who has difficulty sleeping. These causes become the focus of interventions for minimizing or eliminating the problem. Therefore, the client's statement about increased stress requires further investigation so that appropriate interventions for treating the cause of the sleep disturbance can be implemented

A nurse is caring for a client who is experiencing a sodium level of 119 mEq/L. Which nursing action would be most appropriate at this time? Select one: a. Administer 0.9% Normal Saline. b. Provide oral hygiene and comfort measures. c. Monitor for diminished breath sounds. d. Encourage water and other fluids.

a. Administer 0.9% Normal Saline. Administering of isotonic IV therapy would be appropriate at this time for restoration of normal ECF volume.

A client with chronic obstructive pulmonary disease (COPD) has oxygen therapy ordered. Which principle should guide the nurse in managing the delivery of oxygen to this client? Select one: a. Clients with COPD should receive low concentrations (2-3 L) of oxygen since the stimulus to breathe is their low PaO2. b. Clients with COPD require higher concentrations (6-8 L) of oxygen since hypoxemia is their stimulus to breathe. c. The concentration of oxygen should be low since the stimulus to breathe in clients with COPD is an elevated PaCO2. d. The concentration of oxygen should be high since the stimulus to breathe in clients with COPD is an elevated PaCO2.

a. Clients with COPD should receive low concentrations (2-3 L) of oxygen since the stimulus to breathe is their low PaO2. Clients with COPD should receive low concentrations (2-3 L) of oxygen since the stimulus to breathe is their low PO2.

A client is admitted to the hospital for treatment of an acute asthma attack. The client is receiving an aminophylline infusion. Which of the following assessment findings indicate the client is experiencing the desired effect of aminophylline? Select one: a. Decreased wheezing b. Decreased heart rate c. Increased blood pressure d. Increased mucous production

a. Decreased wheezing This indicates increased bronchial dilation and improved air movement.

A nurse is caring for a client with a partial hearing impairment. The nurse understands which of the following is the best way to communicate with this client? Select one: a. Speak slowly in a low-pitched voice. b. Have a family member present. c. Conduct only the physical assessment at this time. d. Provide assessment questions in a written format.

a. Speak slowly in a low-pitched voice. Speaking slowly in a low-pitched voice and facing the client promotes understanding for a client with a partial hearing impairment.

Which of the following should the nurse use to determine the neurological status of a client with a head injury? Select one: a. The Glasgow Coma Scale b. Manifestations of seizure activity c. Client's reported pain scale d. Respiratory rate

a. The Glasgow Coma Scale The Glasgow Coma Scale (GCS) is used to determine the client's level of consciousness (LOC). This is done with a head injury client at regular intervals, because LOC changes precede all other changes in vital and neurological signs. Each response is scored to predetermined criteria. The score is calculated numerically and the higher the score the higher the functioning.

A nurse is teaching lifestyle modifications to a client diagnosed with hypertension. Which of the following statements made by the client indicates a need for further teaching? Select one: a. "We have a glass of wine a couple of times a week with dinner." b. "I will substitute mushrooms for the bacon in my daily omelets." c. "Losing weight is so hard, but so far I am losing 2 pounds a week." d. "I don't like to walk, but I do aerobics and work out at the gym during the week."

b. "I will substitute mushrooms for the bacon in my daily omelets."

A nurse is caring for a client diagnosed with diabetes. The nurse notes that the client has a mild tremor, slight diaphoresis and is fully oriented. Which of the following nursing actions should have the highest priority? Select one: a. Administer 50% Dextrose via IV push. b. Assess the client's blood glucose level. c. Give the client 4 ounces of orange juice. d. Call the lab for a stat glucose level.

b. Assess the client's blood glucose level. Check the patient's blood glucose. Although it is most likely that this patient is experiencing hypoglycemia, the blood glucose must be checked to confirm the problem and also to document HOW LOW the blood glucose is, which further helps determine the best treatment. Most facilities have protocols to treat hypoglycemia based on the blood glucose results. In addition, we can better evaluate how our interventions work when we compare later blood glucoses with the first blood glucose taken while the patient had symptoms.

A nurse is caring for a client on the telemetry unit who is two days post coronary artery bypass grafting (CABG). The nurse recognizes a cardiac rhythm change from normal sinus rhythm to atrial fibrillation. Which of the following should be completed first? Select one: a. Prepare a diltizem drip. b. Assess the client's blood pressure. c. Notify the health care provider. d. Prepare the client for cardioversion.

b. Assess the client's blood pressure. Atrial fibrillation frequently occurs after CABG. In A-Fib the atrial kick is lost and cardiac output (C.O.) is decreased by 30%. Clients react differently to A-Fib and the decreased C.O. Some clients become hypotensive and develop shock-like symptoms: changes in LOC; cool, clammy skin; dyspnea; and chest pain. While other clients are normotensive despite the decrease in C.O., they are asymptomatic or considered stable. Treatment for A-Fib depends on the status of the client. The first action the nurse should take with a client who has converted from NSR to A-Fib is to assess the clients BP.

A nurse is caring for a client who is intubated and receiving ventilatory assistance. The high pressure alarm is sounding on the ventilator. Which of the following would have the highest priority? Select one: a. Assess the ETT cuff for proper inflation. I b. Assess the clients need for suctioning. c. Administer sedation to calm the client's fears. d. Check the endotracheal tube (ETT) to be sure there is no disconnection.

b. Assess the clients need for suctioning.

A nurse is caring for a client recovering from an abdominal aortic aneurysm (AAA) repair. Which of the following findings would have the highest priority? Select one: a. Pedal pulse amplitude 2+. b. Blood pressure 136/90 mmHg c. Urine output 28 ml/hour d. Respiratory rate 12 breaths/minute.

b. Blood pressure 136/90 mmHg Blood pressure is critically monitored to maintain a normal BP so as to protect the newly placed aortic graft. This elevated BP is the most critical assessment finding that could result in serious consequences such as rupture of the aneurysm repair if not addressed quickly.

A nurse is caring for a client following a spinal cord injury (SCI). Which of the following findings would alert the nurse to the development of neurogenic shock? Select one: a. Hyperglycemia b. Hypotension c. Hypoglycemia d. Hypertension

b. Hypotension Neurogenic shock occurs after a SCI and can cause total loss of voluntary and autonomic function for several days to weeks. Hypotension, dependent edema, and loss of temperature regulation are common symptoms.

A client is admitted to the surgical unit after sustaining a compound fracture of the left femur. The client is alert and oriented with the following vital signs: T 99.4 F, P 88, R 20, B/P 94/58. The nurse notes a 4 cm. area of bright red blood on the pressure dressing on the left lower extremity. The client is receiving intravenous fluids of normal saline at 150 ml/hr. One hour after being admitted to the unit, the nurse finds the client confused and combative. Which of the following is the most likely cause of the change in the client's condition? Select one: a. Fluid overload related to aggressive isotonic volume replacement b. Hypoxia related to fat embolism from the fractured bone. c. Infectious process related to contamination of the open wound. d. Hypovolemic shock related to hemorrhage from the open wound

b. Hypoxia related to fat embolism from the fractured bone. While it is possible for fluid overload to occur in client's receiving intravenous fluids, the most likely cause of combativeness and confusion with a long bone fracture is fat emboli.

A nurse is caring for a client who has just undergone a bone marrow transplant. Neutropenic precautions are implemented to prevent infection. Which of the following is not a precautionary neutropenic measure? Select one: a. Screen visitors b. Monitor platelets c. Restrict foods that may be contaminated with bacteria d. Frequent, thorough hand hygiene

b. Monitor platelets The monitoring of platelets is not a neutropenic precaution. Platelets are monitored to prevent injury. WBC is monitored to prevent infection.

A client has undergone an aortofemoral bypass for the treatment of peripheral arterial disease. Which of the following findings should be reported to the surgeon immediately? Select one: a. Redness of the incision line b. Systolic blood pressure 160 mmHg c. Systolic blood pressure 110 mmHg d. Edema of the affected limb

b. Systolic blood pressure 160 mmHg

During a home visit, a 10-day postpartum client reports pain and tenderness with redness and swelling to her right breast. A localized hard mass is also noted upon palpation. How should the nurse respond to this client? Select one: a. You will need to stop breastfeeding immediately until the swelling and redness subside. b. These symptoms suggest an inflammatory or infectious process and require immediate notification to your health care provider (HCP). c. Please mention this to your HCP at your 2-week check-up. d. This is normal breast engorgement and should subside within another week or two.

b. These symptoms suggest an inflammatory or infectious process and require immediate notification to your health care provider (HCP). These symptoms are suggestive of mastitis and should be reported to HCP. These symptoms are not signs of normal breast engorgement.

A client is prescribed warfarin daily. Which of the following statement made by the client indicates to the nurse a need for further teaching? Select one: a. "Instead of a safety razor, I have been using an electric razor to shave." b. "I have two pairs of anti-embolic stockings so that one pair can be washed each day." c. "I have been eating more salads and other green, leafy vegetables to prevent constipation." d. "I will report any sign of Purple Syndrome to my physician."

c. "I have been eating more salads and other green, leafy vegetables to prevent constipation." Warfarin inhibits the synthesis of vitamin K dependent clotting factors (factors II, VII, IX, and X). Green leafy vegetables contain vitamin K which is an antagonist to Coumadin. The patient can eat foods with vitamin K but the intake must remain consistent not "more" as stated in this answer. Foods low in vitamin K include roots, bulbs, fleshy parts of nuts, and fruit juices.

A client presents to the emergency department with an abdominal stab wound. The nurse visualizes intestines protruding through the wound. Which of the following is an appropriate action for the nurse? Select one: a. Apply pressure to the wound with wet sterile sponges. b. Irrigate the wound with a normal saline solution. c. Cover the wound with warm saline-soaked gauze. d. Place sterile gauze and an abdominal binder over the wound.

c. Cover the wound with warm saline-soaked gauze. Cover the wound with warm saline-soaked gauze. The saline soaked gauze keeps the intestine from becoming dry. The warmth helps to prevent vasoconstriction which will in turn decreases the risk of ischemia or necrosis. The gauze should then be covered by an ABD and the nurse should position the client in a low to semi-fowlers position to prevent tension on the wound and protruding organs and then notify the health care provider.

A client is admitted to the medical unit from the convalescent center for treatment of urosepsis. The client's adult daughter reports to the nurse, "I don't know what to do. I love my mom and would like to have her live in my home, but I just can't be with her every minute, and that's what she needs now." Which of the following would be the best approach to improve integration of the elderly mother into the family structure? Select one: a. Offer to refer the daughter to a counselor in an effort to better deal with her feelings of guilt. b. Assist the daughter in finding a caregiver who can assist the client in the convalescent center. c. Determine if the daughter would consider having the client visit in her home one day a week. d. Suggest that the daughter move the client into the family home on a trial basis for several weeks.

c. Determine if the daughter would consider having the client visit in her home one day a week.

A nurse is caring for a client with diabetes insipidus (DI) who has been prescribed aqueous vasopressin. Which of the following outcomes indicates that treatment has been effective? Select one: a. Blood pressure of 90/50 mm Hg b. Urine output of 200mL per hour c. Fluid intake of 2,400mL in 24 hours d. Pulse rate of 126 beats/minute

c. Fluid intake of 2,400mL in 24 hours

A client diagnosed with atrial fibrillation has a pacemaker set at a ventricular rate of 70 beats per minute. Which of the following findings should the nurse immediately report to the provider? Select one: a. HR= 96 beats /minute and regular b. HR= 76 beats/minute and irregular c. HR= 60 beats /minute and regular d. HR= 96 beats/minute and irregular

c. HR= 60 beats /minute and regular Irregular heart rate is an expected finding with atrial fibrillation. Ventricular response rates between 60 and 100 are within normal heart rate range and therefore do not require attention.

A nurse is caring for a client with Addison's disease. Which of the following diets should the nurse teach the client to follow? Select one: a. High Sodium, low calcium and increased fluids. b. Low Sodium, high potassium and decreased fluids. c. High Sodium, low potassium and increased fluids. d. Low Sodium, high calcium and decreased fluids.

c. High Sodium, low potassium and increased fluids. The client with Addison's disease should have a diet high in sodium, low in potassium and increased fluids.

A nurse is caring of a client recently diagnosed with diabetes mellitus (DM). Which of the following is the physiologic basis for the polyuria manifested by individuals with untreated DM? Select one: a. Inadequate secretion of antidiuretic hormone (ADH) b. Early-stage renal failure causes a loss of urine concentrating capacity c. Hyperosmolarity of the extracellular fluids secondary to hyperglycemia d. Chronic stimulation of the detrusor muscle by the ketone bodies in the urine

c. Hyperosmolarity of the extracellular fluids secondary to hyperglycemia

The nurse is planning care for a client who is prescribed antiembolic stocking following abdominal surgery. Which of the following interventions should the nurse include? Select one: a. Remove stocking every 2 hours then reapply after 1 hour off. b. Ensure stockings are loose fitting over client's calves. c. Remove stockings one to three times per day for skin care and inspection. d. Encourage client to only wear stockings when out of bed.

c. Remove stockings one to three times per day for skin care and inspection. Antiembolic stockings should be removed one to three times per day to allow for skin care and assessment. The client's extremities should be monitored for calf pain, warmth, erythema and edema.

A client comes to the emergency department reporting epistaxis. Which of the following medications should the nurse suspect as contributing to the epistaxis? Select one: a. alprazolam b. montelukast c. ibuprofen d. furosemide

c. ibuprofen effect on clotting factors and increase the risk for bleeding.

A nurse is caring for a client who has had a gastric resection to treat peptic ulcer disease. What is the priority intervention when caring for the client in the immediate postoperative period? Select one: a. Inspect the operative site for redness or swelling. b. Monitor pain levels. c. Auscultate the lungs for adventitious sounds. d. Assess NG tube for patency.

d. Assess NG tube for patency.

A nurse is reviewing a client's lab results. Which finding would lead the nurse to suspect the client is experiencing dehydration? Select one: a. Serum sodium 130 mEq/L b. BUN 20mg/100mL c. Urine specific gravity of 1.025 d. Hematocrit 55%

d. Hematocrit 55% An increased hematocrit level (>50%) is expected with dehydration.

One hour ago, a nurse administered morphine sulfate 4 mg IVP to a client who reported pain of 9 on a scale of 10. The client now reports pain of a 7 on a scale of 10. What is the priority intervention at this time? Select one: a. Reassess pain level in 30 minutes. b. Administer antiemetic as prescribed. c. Reposition the client. d. Notify the provider of client's report.

d. Notify the provider of client's report. Nurses have a priority responsibility for the continual assessment of a client's pain level and to provide individualized interventions. Because the prescribed therapy is not effective, the nurse should notify the provider for further assistance.

A client is admitted to the emergency room after falling outside his home. The client is complaining of a severe headache with pain above his left eye. The client is restless and intermittently losses consciousness. Pupils are dilated; pulse 56 and BP 168/98. An x-ray of the head confirms a skull fracture. Which of the following is a priority assessment? Select one: a. Changes in level of consciousness b. Pupillary changes c. Blood alcohol and toxicology screening d. Respiratory Status

d. Respiratory Status Respiratory status is the priority assessment. The brain is dependent upon oxygen to maintain function and has little reserve available if oxygen is deprived. Brain function begins to diminish after 3 minutes of oxygen deprivation.

A nurse is caring for a toddler who is being treated for hypovolemia. Which of the following demonstrates to the nurse the desired response to fluid replacement? Select one: a. Central Venous Pressure 2 mm Hg b. Urine output 48 mL for the past 4 hours c. Apical heart rate 130 beats/min d. Specific Gravity 1.025

d. Specific Gravity 1.025 Specific gravity falls within normal range of 1.010-1.030 and indicates successful fluid replacement.