HESI Physio Adaptation

Which health conditions are associated with lead poisoning in a preschooler? Select all that apply. One, some, or all responses may be correct.

Brain damage Growth retardation Rationale: Exposure to excessive levels of lead affects a child's growth or causes learning and behavioral problems and brain and kidney damage. Amblyopia is an eye disorder that occurs when the brain does not receive signals from the eye. It is not caused by lead poisoning. Strabismus is an abnormal alignment of the eye, which is also not caused by lead poisoning. Hepatic steatosis or fatty liver is caused by childhood obesity, not by lead.

Which factor would elevate the oxygen saturation during an assessment?

Carbon monoxide Rationale: Carbon monoxide artificially elevates the oxygen saturation during assessment. Nail polishes interfere with the ability of the oximeter. Intravascular dyes will artificially lower the oxygen saturation. Skin pigmentation will overestimate the saturation.

An older client who is usually cheerful and cooperative demonstrates irritability and restlessness during morning hygiene. Which assessments would the nurse perform first?

Changes in mental status and cognition Rationale: Sudden changes in mental status and cognition are assessed and reported to the health care provider because there are many physical causes (e.g., delirium, electrolyte imbalances, decreased oxygenation, sepsis, increased intracranial pressure) that must be immediately treated. Once physical causes are ruled out or identified and treated, the nurse would assess for stress, mood and affect, and feelings.

A client who experienced extensive burns is receiving intravenous fluids to replace fluid loss. The nurse would monitor for which initial symptom of fluid overload?

Crackles in the lungs Rationale: Crackles, or rales, in the lungs are an early sign of pulmonary congestion and edema caused by fluid overload. Clients with fluid overload will usually demonstrate an increased heart rate and increased blood pressure. A decreased heart rate and decreased blood pressure and cyanosis in a client with fluid overload would be very late and fatal signs.

The laboratory results of a client with a pulmonary hemorrhage and glomerulonephritis reveal the presence of IgG antibodies. The nurse would be concerned about which type of hypersensitivity reaction?

Cytotoxic reaction Rationale: A client with a pulmonary hemorrhage and glomerulonephritis with deposits of IgG antibodies in the lungs and kidneys may have Goodpasture syndrome. This reaction is a type 2 cytotoxic reaction that involves the lungs and kidneys. Immediate reactions are type 1 hypersensitivity reactions that include IgE antibody reactions. Immune-complex reactions such as systemic lupus erythematosus and rheumatoid arthritis are type 3 hypersensitivity reactions that include IgG and IgM antibodies. Delayed hypersensitivity reactions are type 4 reactions that involve cytokine and cytotoxic T-cell mediated immunity.

Which is the most harmful adverse effect of lead poisoning?

Delayed development Rationale: Irreversible neurological and intellectual damage is the most serious consequence of lead poisoning, the result of cortical atrophy and encephalopathy. Although there may be a nutritional deficit, it is not the priority. Anemia and constipation, as well as renal and skeletal damage, do occur, but they are reversible.

Which nursing assessment supports a diagnosis of atelectasis in a postoperative client?

Diminished breath sounds on auscultation Rationale: Atelectasis refers to the collapse of alveoli; breath sounds over the area are diminished. A productive cough most often is associated with inflammation or infection, not atelectasis. Clubbing of the fingertips is a late sign of chronic hypoxia related to prolonged obstructive lung disease. Rhonchi are most commonly heard in clients with infectious or inflammatory diagnoses such as pneumonia or chronic bronchitis.

The nurse would monitor postoperative clients for which clinical manifestations of a pulmonary embolus? Select all that apply. One, some, or all responses may be correct.

Dyspnea Hemoptysis Feeling of impending doom Dyspnea is the most common symptom of a pulmonary embolus because of increased alveolar dead space, which impedes ventilation. With a pulmonary embolus, pulmonary blood flow is obstructed partially or completely; when infarcted areas have alveolar damage, red blood cells move into alveoli, resulting in hemoptysis. Clients with a pulmonary embolus have severe dyspnea and chest pain that precipitate a feeling of impending doom. Clients with a pulmonary embolus typically are apprehensive and hyperalert, not somnolent (the quality or state of being drowsy). Crackles, not bronchial wheezes, occur. Wheezes are associated with reactive airway disorders, such as asthma.

When assessing for hemorrhage on a client who has a total hip replacement, which is the most important nursing action to implement?

Examine the bedding under the client. Rationale: Because of the recumbent position, drainage may flow by gravity under the client and not be noticed unless the bedding is examined. Measuring the girth of the thigh is inaccurate when there is a dressing in place. In the immediate postoperative period, vital signs should be taken more frequently than every 4 hours; in addition, observation of the site is a more reliable indicator of hemorrhage. Dressings impede an accurate assessment of the site for ecchymosis.

Which event occurs in the proliferative phase of wound healing?

Formation of granulation tissue Rationale: Granulation tissue is formed in the proliferative tissue. Thinning of scar tissue and strengthening of collagen fibers is seen in the maturation phase of wound healing. The increase in capillary permeability occurs in the inflammatory phase of wound healing.

Which early indicator of potential damage to the motor branch of the facial nerve would the nurse assess in a client recovering from ear surgery?

Inability to wrinkle the forehead Rationale: The motor fibers of the facial nerve innervate the superficial muscles of the face and scalp, allowing facial movement such as wrinkling the forehead. Pain behind the ear; a bitter, metallic taste; and dryness of the mouth are sensory responses that may be manifested when the injury is to the sensory, not motor, branch of the facial nerve.

Which sign related to rubeola (measles) should alert parents to seek medical help?

Macular rashes Rationale: Rubeola (measles) starts with a discrete maculopapular rash on the face and spreads downward, eventually becoming confluent. Scaly skin occurs with eczema or dermatitis. Bald patches occur with tinea capitis (ringworm). Vesicular skin lesions occur with varicella (chickenpox).

Which gland is an exocrine gland?

Salivary gland Rationale: Exocrine glands are glands with ducts that produce enzymes but not hormones. These glands secrete enzymes into ducts. The salivary gland secreting saliva is an example of an exocrine gland. Endocrine glands are ductless glands that produce hormones that are secreted into the blood. Thyroid, pituitary, and parathyroid glands are examples of endocrine glands.

A client is admitted to the hospital with Laënnec cirrhosis and chronic pancreatitis. Bile salts (bile acid factor) are prescribed, and the client asks why they are needed. How would the nurse respond?

"They aid in the absorption of fat-soluble vitamins." Rationale: Bile salts are used to aid digestion of fats and absorption of the fat-soluble vitamins A, D, E, and K. Bile salts are not involved in stimulating prothrombin production, in promoting bilirubin secretion in the urine, or in stimulating contraction of the common bile duct.

Which term would the nurse use in a report to describe the absence of menstrual periods in a 35-year-old nonpregnant client?

Amenorrhea Rationale: The absence of menstrual periods in a nonpregnant client younger than 55 years old is called amenorrhea. Rhinorrhea is an allergic state that is manifested by a runny nose. Menopause is cessation of menstruation after 55 years of age. Dyspareunia is pain during sexual intercourse.

Which hormonal deficiency causes diabetes insipidus in a client?

Antidiuretic hormone (ADH) Rationale: ADH deficiency causes diabetes insipidus. Decreased levels of prolactin may cause decreased amounts of milk secretion after birth. Decreased levels of thyrotropin cause hypothyroidism, weight gain, and lethargy. Luteinizing hormone deficiency causes menstrual abnormalities, decreased libido, and breast atrophy.

A client was admitted to a surgical unit in an unconscious state due to head trauma. Which site would be correct to obtain the client's temperature?

Axilla Rationale: The axilla would be the most appropriate site to obtain a temperature measurement in a client who is unconscious due to head trauma. The oral route is not accessible when the client is unconscious. Because the client is in a surgical unit, his or her head may be covered. Obtaining a temperature measurement through the temporal artery or tympanic membrane may not be possible.

A client is admitted with a suspected malignant melanoma on the arm. When performing the physical assessment, which would the nurse expect to find?

Brown or black mole with red, white, or blue areas Rationale: Melanomas have an irregular shape and lack uniformity in color. They may appear brown or black with red, white, or blue areas. Petechiae are pinpoint red dots that indicate areas of bleeding under the skin. A red birthmark is a vascular birthmark and often fades with time. A patchy loss of skin pigmentation indicates vitiligo.

Initially after a stroke, the client's pupils are equal and reactive to light. Four hours later, the nurse identifies that one pupil reacts more slowly than the other and the client's systolic blood pressure is increasing. For which condition would the nurse prepare to intervene?

Increased intracranial pressure Rationale: Increased intracranial pressure is manifested by a sluggish pupillary reaction and elevation of the systolic blood pressure. Spinal shock is manifested by a decreased systolic blood pressure with no pupillary changes. Brain herniation is manifested by dilated pupils and severe posturing. Hypovolemic shock is indicated by a decrease in systolic pressure and tachycardia, with no changes in pupillary reaction.

Which nursing intervention is appropriate to include in the plan of care for a client with diabetic ketoacidosis (DKA)?

Intravenous administration of regular insulin Rationale : A client admitted with DKA will have a blood glucose value greater than 250 and blood ketones. Intravenous (IV) administration of regular insulin is needed to rid the body of ketones and regulate blood glucose. Administration of insulin glargine is not going to reverse the ketoacidosis. The client will be allowed fluids to maintain hydration. Administration of 10% dextrose IV will increase the client's blood glucose.

A client arrives in the emergency department with epigastric pain and prolonged vomiting. Assessment findings include rapid and shallow respirations, dry and flushed skin, weakness, and lethargy. Which is the primary nursing concern?

Metabolic alkalosis Rationale: Prolonged vomiting results in fluid loss and acid (hydrochloric) loss; the client's symptoms reflect dehydration and metabolic alkalosis. Although it is important to address the client's pain, the fluid and electrolyte/acid/base imbalance must be addressed first because it can be life threatening. Although risk for injury is a potential problem, the priority is the fluid and electrolyte/acid/base problem. The ineffective breathing pattern most likely is caused by the metabolic alkalosis; the fluid and electrolyte/acid/base imbalance is a higher priority and must be addressed first.

Which assessment finding indicates hypersecretion of adrenocorticotrophic hormone?

Moon face Rationale: Hypersecretion of adrenocorticotrophic hormone results in Cushing disease, which is characterized by "moon face" appearance, an abnormal distribution of fat in the face. Protrusion of the lower jaw is a feature of acromegaly, caused by excess secretion of growth hormone. Heat intolerance is seen in clients with excess secretion of thyrotropin. In acromegaly, the client presents with "barrel-shaped" chest appearance.

Which condition is characterized by infection of a client's bone or bone marrow?

Osteomyelitis Rationale: Osteomyelitis is infection of bone or bone marrow. Osteomalacia is a condition characterized by softening of bones due to calcium or vitamin D deficiency. Herniated disc is caused by structural damage of the intervertebral discs in which the nucleus pulposus seeps through a torn or stretched annulus. Spinal stenosis is narrowing of the spinal canal.

Which finding would help confirm the nurse's suspicion that a client may have meningitis after surgery for a brain tumor?

Positive Kernig sign Rationale: Meningitis may occur secondary to surgical procedures on the brain. It is highly probable when Kernig sign is positive. The Glasgow Coma Scale is used as a reliable way of recording the conscious state of the client, but it is not used to diagnose meningitis. A meningitis diagnosis is highly probable with a positive Brudzinski sign and the presence of nuchal rigidity (e.g., stiff neck).

Which is the focus of nursing care for a laboring client when the umbilical cord suddenly prolapses and protrudes from the vagina?

Preparing the client for surgery Rationale: The fetus's life is in jeopardy, and a cesarean birth must be performed immediately. The cord is never handled because it may go into spasm and block the fetal blood supply. Neither checking the fetal heart rate every 15 minutes nor starting oxygen at 10 L/min with a tight facemask is the priority; the client must be prepared for an emergency cesarean birth.

A client at 36 weeks' gestation has gained 5 lb (2.3 kg) in the previous week and has a pronounced increase in blood pressure. Which is the initial intervention upon admission of the client to the high-risk unit?

Providing a dark, quiet room with minimal stimuli Rationale: Increasing cerebral edema may predispose the client to seizures; therefore stimuli of any kind should be minimized. It is too early to plan for a cesarean birth; other therapies will be tried first. The client will probably be given IV magnesium sulfate to prevent a seizure, not furosemide to promote diuresis. Magnesium sulfate will be used; calcium gluconate is its antidote.

The nurse is caring for a client during the emergent phase after the client sustained serious burns that involved a large surface of the skin. Which nursing intervention is the priority during this phase?

Restoring fluid volume Rationale: In the first 48 hours after a severe burn, fluid moves into the tissues surrounding the injured area. Fluid also is lost in drainage and from evaporation; this fluid loss results in a decreased circulating blood volume, which can cause hypovolemic shock. Although pain relief is an important aspect in the care of clients with burns, the immediate priority is to replace fluid losses to prevent death. If fluid losses are not replaced immediately, the client may die before the development of an infection. Blood loss usually is minimal; the loss of fluid, colloids, and electrolytes is what causes the hypovolemia.

Where would the nurse expect the fundus to be located 3 days after a cesarean birth?

Three fingerbreadths below the umbilicus Rationale: The fundus descends 1 fingerbreadth per day from the first postpartum day. So 3 days after birth, the fundus would be 3 fingerbreadths below the umbilicus. IIf the fundus is 1 or 2 fingerbreadths below the umbilicus, the nurse should suspect that involution has been delayed, and further investigation is required. Although a fundus 4 fingerbreadths below the umbilicus is not expected, it is a benign occurrence.

When performing a postoperative assessment, which parameter would alert the nurse to a common side effect of epidural anesthesia?

Decreased blood pressure Rationale: The most important side effect to monitor in a client who has received epidural anesthesia is hypotension because of autonomic nervous system blockade. In the immediate postoperative recovery period, the blood pressure would be assessed frequently. Other side effects include bradycardia, nausea, and vomiting. Increased oral temperature and unequal bilateral breath sounds are not effects associated with epidural anesthesia. Diminished peripheral pulses may result from hypotension, although they are not the most common side effects.

Which statement is true about the skeletal system of toddlers?

The bones of toddlers can better withstand falls than those of older adults. Rationale: The bones of toddlers can withstand falls better than those of older adults. Toddlers' bones are more pliable than those of older persons. Toddlers have greater amounts of cartilage and are highly flexible as compared with the cartilage of young adults. Older adults, especially women, are more susceptible to bone-density loss and are more prone to developing osteoporosis, which increases the risk of fractures.

A client with chronic gastritis is being treated with medication and diet. Which would the nurse teach the client when discussing the therapeutic regimen?

Avoid using analgesics that contain aspirin. Rationale: Aspirin interferes with the gastric mucosa's natural protection from pepsin and hydrochloric acid, worsening the gastritis. The client should avoid lying down after eating; sitting up for 1 hour after meals uses gravity to minimize esophageal reflux. Antacids usually are prescribed after meals. Small, frequent, bland feedings are preferred, not foods that are high in carbohydrates.

A client has a colostomy after surgery for cancer of the colon. Which postoperative nursing intervention maximizes skin integrity?

Apply stoma adhesive around the stoma and then attach the appliance. Rationale: Stoma adhesive protects the skin and helps keep the appliance attached to the skin. The appliance should be emptied when it is one-third to one-half full. Allowing one-half inch between the stoma and the appliance is too much space; the enzymes in feces can erode the skin. Initially the nurse should change the appliance; self-care usually is instituted more gradually, depending on the client's physical and emotional response to the surgery.

A child with sickle cell anemia is admitted to the unit in vasoocclusive crisis (VOC). After the child has been given the prescribed analgesic, which intervention is the priority to minimize the effects of the crisis?

Intravenous fluids Rationale: Because the kidneys of children with sickle cell anemia do not concentrate urine as well as do healthy kidneys, it is important to maintain adequate hydration. Hydration with IV fluids supplementing oral fluids can minimize the occurrence of a crisis because hemodilution helps prevent sickling. During a VOC bed rest is preferred, with the only exercise being passive range of motion. O 2 may be used if the child has respiratory distress, but it does not help resolve a VOC because it decreases erythropoiesis. Cold compresses are contraindicated because cold causes vasoconstriction. Heat usually is applied to the affected areas.

An increase in which blood component is responsible for the acidosis related to untreated diabetes mellitus?

Ketones Rationale: The ketones produced excessively in diabetes are a byproduct of the breakdown of body fats and proteins for energy; this occurs when insulin is not secreted or is unable to be used to transport glucose across the cell membrane into the cells. The major ketone, acetoacetic acid, is an alpha-ketoacid that lowers the blood pH, resulting in acidosis. Glucose does not change the pH. Lactic acid is produced as a result of muscle contraction; it is not unique to diabetes. Glutamic acid is a product of protein metabolism.

Which benign condition shows silver scaly plaques on the skin?

Psoriasis Rationale: A silver, scaly plaque on the skin is due to psoriasis and is most commonly seen on the elbows and scalp. Hyperpigmented areas that vary in form and color are due to nevi. Spontaneously occurring raised or irregular-shaped wheals of varying size are usually due to urticaria. Noninflammatory lesions, including open comedones and closed comedones, are due to acne vulgaris.

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and a partial pressure of carbon dioxide (PCO 2) of 60 mm Hg. Which complication would the nurse suspect the client is experiencing?

Respiratory acidosis Rationale: The pH indicates acidosis; the PCO 2 level is the parameter for respiratory function. The expected PCO 2 is 40 mm Hg. These results do not indicate a metabolic disorder or indicate respiratory alkalosis.

The nurse is assessing a client during the first 24 hours after a burn injury. Which sign indicates to the nurse that fluid replacement therapy is adequate?

Slowing of a previously rapid pulse Rationale: The pulse rate is one indicator of optimum vascular fluid volume; the pulse rate decreases as intravascular volume normalizes. Decreasing CVP readings indicate hypovolemia. Urinary output of 15 to 20 mL/h indicates inadequate kidney perfusion; if fluid replacement is adequate, the urinary output should be more than 30 mL/h. A hematocrit level increasing from 50% to 55% indicates hypovolemia and increased hemoconcentration.

Which electrolyte deficiency triggers the secretion of renin?

Sodium Rationale: Low sodium ion concentration causes decreased blood volume, thereby resulting in decreased perfusion. Decreased blood volume triggers the release of renin from the juxtaglomerular cells. Deficiencies of calcium, chloride, and potassium do not stimulate the secretion of renin.

The nurse is caring for a client 2 days after the client was admitted with burn injury. When performing the respiratory assessment, the nurse observes for which type of sputum?

Sooty Rationale: The mucous membranes of the respiratory tract may be charred after inhalation burns; this is evidenced by the production of sooty sputum. Frothy sputum usually is indicative of pulmonary edema. Yellow sputum or tenacious sputum usually is indicative of a respiratory infection.

Which symptom would the nurse expect the client who has a 5-year history of myasthenia gravis to report?

Strength decreases with repeated muscle use Rationale: Because of the myoneural junction defect, repeated muscle contraction depletes acetylcholine, elevates cholinesterase, or exhausts acetylcholine receptor sites, resulting in decreased muscle strength as the day progresses. Hot baths tend to increase, not decrease, muscle weakness. Muscle weakness decreases, not improves, with muscle use. There is no evidence that eating meals will bring about improvement.

How are toddlers different from children of other age groups?

Toddlers sleep more during the daytime than preschoolers do. Rationale: A toddler sleeps an average of 12 hours during the day, whereas a preschooler sleeps for 12 hours during the night and less in the daytime. The growth rate of toddlers is much slower than that of infants. A toddler needs fewer kilocalories than an infant does but needs more protein relative to body weight. Dehydration and febrile seizures occur during periods of high body temperature in children between 6 months and 3 years of age.

Which newborn assessment finding will probably necessitate prolonged follow-up care?

Umbilical cord with two blood vessels Rationale: The congenital absence of a blood vessel in the umbilical cord is often associated with life-threatening congenital anomalies. There should be two arteries and one vein. An Apgar score of 8 will not require prolonged follow-up care. A weight of 3500 g is average for a full-term newborn. The expected glucose level in a healthy newborn is 40 to 69 mg/dL (1.7-3.3 mmol/L)

Which statement by the nurse is true regarding dandruff?

Which statement by the nurse is true regarding dandruff? Rationale: Dandruff is associated with excessive oil production. Hirsutism may occur as a side effect of a medication therapy. Tenderness of the scalp is associated with lice and nits. Hirsutism is a manifestation of a hormonal imbalance.

During which time period after contracting syphilis could the infection be transmitted to others?

2 years Rationale: Syphilis is contagious during the first two phases, which last a total of about 2 years. In phase 3, untreated syphilis causes complications but is not contagious.

The nurse is assessing several clients. Which client will require parenteral nutrition?

A client with severe malabsorption disorder Rationale: A client with severe malabsorption disorder requires parenteral nutrition. Clients with a brain neoplasm, anorexia nervosa, or inflammatory bowel disease will require enteral nutrition.

Which clinical finding would the nurse deem the most significant when assessing a 6-year-old child with Reye syndrome?

Altered consciousness Rationale: The severity of Reye syndrome is judged by the child's level of consciousness. Clinical stages range from alert to disoriented to coma. Although assessments for increased vomiting and for bleeding are important, neither is the priority assessment. Although fatigue does occur with Reye syndrome, level of consciousness is the priority assessment.

A client reports neck stiffness, severe headache, and a decreased level of consciousness. Which condition would the nurse suspect?

Bacterial meningitis Rationale: Bacterial meningitis is caused by a bacterium such as Streptococcus pneumonia. Fever, severe headache, neck stiffness, photophobia, and decreased levels of consciousness are symptoms that indicate bacterial meningitis. Encephalitis is the acute inflammation of the brain. Nausea and vomiting are symptoms of encephalitis. Headache, fever, nausea, and vomiting are the symptoms of brain abscess. Headache, fever, and photophobia are the symptoms of viral meningitis.

A client complains of sudden muscle weakness during times of anger or laughter that may occur at any time during the day. Which condition would be suspected in this client?

Cataplexy Rationale: Cataplexy is a condition in which muscle weakness occurs suddenly during times of intense emotion, such as anger, sadness, or laughter. A cataplexic attack may occur at any time during the day. Insomnia is a condition in which a person has chronic difficulty falling asleep. A person with narcolepsy also experiences frequent awakenings from sleep, short periods of sleep or nonrestorative sleep, or some combination thereof. Narcolepsy is a dysfunction of the mechanisms that regulate sleeping and waking states. Sleep apnea is a disorder characterized by a lack of airflow through the nose and mouth for periods of 10 seconds or longer during sleep.

When a client with chronic obstructive pulmonary disease (COPD) is receiving oxygen, which assessment findings indicate increasing carbon dioxide (CO 2) retention? Select all that apply. One, some, or all responses may be correct.

Drowsiness Irregular pulse Mental confusion Rationale: Because high oxygen saturation and high PaO 2 levels can depress respiratory drive in some (but not all) clients with COPD, the nurse will plan to assess for clinical manifestations of CO 2 retention when clients are receiving supplemental oxygen. CO 2 retention depresses the central nervous system, leading to drowsiness, confusion, and decreased respiratory depth and rate. CO 2 retention also affects cardiac function, leading to dysrhythmias. Lethargy, rather than anxiety, is seen with CO 2 retention because of central nervous system depression. Respiratory rate will decrease with CO 2 retention because of central nervous system depression.

Which clinical manifestations would the nurse observe in a client experiencing a full-blown anaphylactic shock from a type I latex allergic reaction? Select all that apply. One, some, or all responses may be correct.

Stridor Hypotension Dyspnea Rationale: Full-blown anaphylactic shock produces stridor, hypotension, and dyspnea. Fissuring and cracking of the skin occurs in individuals with a type IV contact dermatitis.

A client with chronic kidney disease selects treatment using continuous ambulatory peritoneal dialysis (CAPD). Which statement indicates the client understands the purpose of this therapy?

"The treatment uses the peritoneum as a semipermeable membrane to clear toxins by osmosis and diffusion." Rationale: Diffusion moves particles from an area of greater concentration to an area of lesser concentration. Osmosis moves fluid from an area of lesser concentration to an area of greater concentration of particles, thereby removing waste products into the dialysate, which is then drained from the abdomen. The principle of ultrafiltration involves a pressure gradient, which is associated with hemodialysis, not peritoneal dialysis. Peritoneal dialysis uses the peritoneal membrane for indirect cleansing of the blood. Dialysate does not clear toxins in a short time; exchanges may occur four or five times a day.

The nurse teaches a client about wearing thigh-high antiembolism elastic stockings. Which instruction would be correct to include?

"You will need to apply them in the morning before you lower your legs from the bed to the floor." Rationale: Applying antiembolism elastic stockings in the morning before the legs are lowered to the floor prevents excessive blood from collecting and being trapped in the lower extremities as a result of the force of gravity. Elastic stockings are worn to prevent the formation of emboli and thrombi, especially in clients who have had surgery or who have limited mobility, by applying constant compression. It is contraindicated for antiembolism elastic stockings to be applied and worn at night, rolled down, or applied after the legs are lowered to the floor.

When a client is newly diagnosed with chronic obstructive pulmonary disease (COPD), which action by the nurse has the highest priority?

Ask whether the client is interested in quitting smoking. Rationale: Smoking cessation slows the progression of COPD and is the most important action that the client can take to help maintain lung function. Although many clients may not be ready to stop smoking, the nurse will assess the client's interest in smoking cessation at every encounter. Teaching correct inhaler use is important, but inhaled medications only treat the symptoms of COPD and do not slow disease progression. The client will be educated on the progression of COPD, but education alone does not change the progression of the disease. Pulmonary rehabilitation programs are helpful in improving ability to do activities of daily living and also will assist the client with tobacco cessation, but assessment of readiness to quit smoking is done before developing a plan to quit.

A client with chronic obstructive pulmonary disease is admitted to the hospital with a tentative diagnosis of pleuritis. It is important for the nurse to perform which intervention?

Assess for signs of pneumonia. Rationale: Clients with pleuritic disease are prone to developing pneumonia because of impaired lung expansion, air exchange, and drainage. Opioids are contraindicated because opioids depress respirations. Coughing should not be suppressed; it enhances lung expansion, air exchange, and lung drainage. Oral fluids should be encouraged; pulmonary edema does not develop unless the client has severe cardiovascular disease.

When a client is diagnosed with Hodgkin disease, which lymph nodes would the nurse expect to be affected first?

Cervical Rationale: Painless enlargement of the cervical lymph nodes often is the first sign of Hodgkin disease, a malignant lymphoma of unknown etiology. Axillary node enlargement occurs after cervical lymph node enlargement. Inguinal node enlargement occurs later. Mediastinal node involvement follows the disease progresses.

When performing a focused respiratory assessment, which action would the nurse take first?

Check for any evidence of respiratory distress. Rationale: The initial action in respiratory assessment is to observe for any signs of respiratory distress. The other actions are also part of a focused respiratory assessment and would be done once the nurse is assured that no acute respiratory distress is present. Respiratory pattern would be assessed to determine whether respirations are regular and of consistent depth, but this would be done only after the nurse had determined that the client was not in respiratory distress. Changes in skin color such as cyanosis would be monitored after the nurse checked for acute respiratory distress. The shape and symmetry of the chest would be checked, but is not as important as assuring that the client is not in respiratory distress.

The nurse is examining the nails of four different clients. Which client would the nurse anticipate having a myocardial infarction?

Client A Rationale: Generalized pallor of the nail bed and white-colored nails are signs of a myocardial infarction, as noted in client A. Diffuse yellow to brown discoloration and yellow-brown nail color are signs of jaundice, as noted in client B. Dark red nails are signs of polycythemia vera, as noted in client C. Diffuse blue discoloration that blanches with pressure and blue nail color are signs of methemoglobinuria, as noted in client D.

When receiving hemodialysis, the client may develop hyponatremia. Which clinical findings related to the potential development of hyponatremia would the nurse monitor? Select all that apply. One, some, or all responses may be correct.

Diarrhea Seizures Rationale: Sodium is the most abundant cation in the extracellular fluid and functions as part of the sodium/potassium pump. In the presence of a deficit, the client will exhibit confusion, lethargy, diarrhea, and seizures. Spasm of the facial muscles after a tap over the facial nerve (Chvostek sign) indicates hypocalcemia. Cardiac dysrhythmias are associated with increases or decreases in potassium and calcium. An increase in body temperature reflects a possible infection, not an electrolyte imbalance.

Which pathophysiological process would the nurse recognize as leading to the clinical manifestations commonly seen in cystic fibrosis?

Excessively thick mucus obstructs airways. Rationale: Dysfunction of the exocrine glands leads to the secretion of mucusthat is thicker and more tenacious than normal. The characteristics of this mucus cause it to pool in the lungs and make expectoration difficult. In addition to airway obstruction, children with cystic fibrosis are more likely to have respiratory infections. Airway irritability is associated with hyperactive airway disease. Inflamed lung parenchyma is associated with pneumonia; this a secondary complication related to the stasis of secretions. The endocrine glands are not directly affected in cystic fibrosis.

The nurse is caring for an underweight adolescent girl with a diagnosis of anorexia nervosa. Which common characteristics would the nurse recognize when obtaining a health history and performing a physical assessment? Select all that apply. One, some, or all responses may be correct.

Fatigue Secondary amenorrhea Rationale: Fatigue results because inadequate nutritional intake results in electrolyte imbalances and a decreased red blood cell count. Many of these clients have lowered body temperature and are intolerant of cold. Bulimia (not anorexia) nervosa clients will present to the clinic with metabolic alkalosis due to frequent self-induced vomiting. Amenorrheaoccurs because of endocrine imbalances resulting from starvation; it is thought that severe starvation damages the hypothalamus.

Which condition would the nurse suspect when a client has blood urea nitrogen (BUN)/creatinine ratio of 3?

Fluid volume excess Rationale: The normal range of the BUN/creatinine ratio is from 6 to 25. A decrease in the BUN/creatinine ratio indicates fluid volume excess. An increase in the BUN/creatinine ratio indicates obstructive uropathy. A decrease in the levels of BUN indicates severe hepatic damage. An increase in the levels of BUN indicates gastrointestinal bleeding.

Which organ-specific autoimmune disorder would the nurse associate with a client's kidney?

Goodpasture syndrome Rationale: Goodpasture syndrome is an autoimmune disorder associated with the client's kidney. Graves disease and Addison disease are autoimmune disorders associated with the endocrine system. Guillain-Barré syndrome is an autoimmune disorder associated with the central nervous system.

An adolescent diagnosed with new-onset type 1 diabetes mellitus has stress and reports not having a menstrual cycle for a long time. Which condition is the adolescent experiencing?

Hypogonadotropic amenorrhea Rationale: Hypogonadotropic amenorrhea may occur in type 1 diabetic adolescents experiencing stress. This condition can also result from sudden and severe weight loss, eating disorders, strenuous exercise, and mental illness. Dysmenorrhea is painful periods. Primary amenorrhea occurs for many reasons; however, no menses has occurred. The female athlete triad is eating disorders, loss of bone density, and amenorrhea.

Which initial intervention would the nurse expect the primary health care provider to order for a client admitted to the hospital with a diagnosis of diabetic ketoacidosis?

Intravenous (IV) fluids Rationale: IV fluids are given to combat dehydration in ketoacidosis and to keep an IV line open for administration of medications. After electrolyte levels are evaluated, potassium may be added along with insulin. In acidosis, potassium ions initially shift from the intracellular to extracellular compartment, resulting in hyperkalemia; as acidosis is corrected, hypokalemia may occur, and then potassium may be administered. NPH insulin is an intermediate-acting insulin; rapid-acting insulin is indicated in an emergency. Sodium polystyrene sulfonate is not indicated; abnormally high serum potassium levels will revert once dehydration is corrected.

While caring for four different clients, the nurse assesses their breathing pattern. Which client's assessment findings indicate Cheyne-Stokes respiration?

Irregular, alternating apnea and hyperventilation In Cheyne-Stokes respiration, a client's breathing pattern is characterized by progressively deeper and faster breathing, that is, hyperventilation followed by apnea. Client 3 exhibits this type of respiration. Client 1's breathing pattern indicates bradypnea, whereas client 2 exhibits tachypnea. Client 4 is exhibiting Biot respirations.

A client is admitted to the hospital with a diagnosis of Crohn disease. Which is important for the nurse to include in the teaching plan for the client?

Meeting nutritional needs Rationale: To avoid gastrointestinal pain and diarrhea, these clients often refuse to eat and become malnourished. The consumption of a high-calorie, high-protein diet is advised. Diarrhea, not constipation, is a problem with Crohn disease. Preventing an increase in weakness is a secondary concern that results from malnutrition; correcting the malnutrition will increase strength. Anticipating a sexual alteration generally is not a problem with Crohn disease.

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The client's arterial blood gases deteriorate, and respiratory failure is impending. Which clinical indicator is consistent with the client's condition?

Mental confusion Rationale: Decreased oxygen to the vital centers in the brain results in restlessness and confusion. Cyanosis is a late sign of respiratory failure. Tachycardia, not bradycardia, will occur as a compensatory mechanism to help increase oxygen to body cells. Distended neck veins occur with fluid volume excess (e.g., pulmonary edema).

When a client develops internal bleeding after abdominal surgery, which clinical manifestations would the nurse expect the client to exhibit? Select all that apply. One, some, or all responses may be correct.

Pallor Tachycardia Rationale:Pallor occurs with hemorrhage as the peripheral blood vessels constrict in an effort to shunt blood to the vital organs in the center of the body. Heart rate accelerates (tachycardia) in hemorrhage as the body attempts to increase blood flow and oxygen to body tissues. Urinary output decreases (the opposite of polyuria) with hemorrhage because of a lowered glomerular filtration rate secondary to hypovolemia. Respirations increase (the opposite of bradypnea) and become shallow with hemorrhage as the body attempts to take in more oxygen. Hypotension, not hypertension, occurs in response to hemorrhage as the person experiences hypovolemia.

After a cerebrovascular accident (CVA, also known as "brain attack"), a client is unable to differentiate between heat or cold and sharp or dull sensory stimulation. The nurse would conclude the CVA affected which lobe of the brain?

Parietal Rationale: Sensory impulses from temperature, touch, and pain travel via the spinothalamic pathway to the thalamus and then to the postcentral gyrus of the parietal lobe, the somatosensory area. The frontal area is the area of abstract thinking and muscular movements. The occipital area of the brain is where nerve impulses translate into sight. The temporal area is the area where nerve impulses translate into sound.

The nurse reviews the principles of oxygen administration. Which is the primary consideration when determining which method of oxygen delivery will be the most effective for a client?

Pathological condition Rationale: Several modes are used for administration of oxygen; selection is based on the disease and the client's status. Although the other factors such as activity level, facial anatomy, and mental capacity will be taken into consideration, the ultimate decision is based on the pathological condition and therapeutic needs.

Which clinical findings are commonly associated with hyperglycemia? Select all that apply. One, some, or all responses may be correct.

Polyuria Polydipsia Polyphagia Rationale: Polyuria is excessive urination associated with osmotic diuresis. Polydipsia is excessive thirst associated with hyperglycemia; thirst is the response to osmotic diuresis and glycosuria. Polyphagia is associated with the catabolic state induced by insulin deficiency. Polyphrasia is excessive talking associated with mental illness, not hyperglycemia. Polydysplasia is related to multiple developmental abnormalities and is unrelated to hyperglycemia.

Which action by the nurse is best when a client who had a myocardial infarction 2 days previously has a temperature of 100.2°F (37.9°C)?

Record the temperature reading and continue to monitor it. Rationale: Myocardial necrosis causes a rise in body temperature within the first 24 hours after a myocardial infarction. This increase in temperature gradually returns to the usual range for an adult after several days. A temperature of 100.2°F (37.9°C) is an expected response to myocardial necrosis, not a respiratory infection. Auscultating lung sounds and encouraging coughing and deep breathing are not necessary for the temperature elevation. A temperature of 100.2°F (37.9°C) is an expected response and is not an emergency requiring notification of the primary health care provider.

A client's treponema-specific test indicates a positive antibody for syphilis; however, the client does not exhibit any clinical manifestations of the infection. Which would the nurse infer from this finding?

The client is in the latent stage of syphilis. Rationale: A positive treponema-specific antibody test indicates the client has syphilis. In the latent stage of syphilis, the signs and symptoms are absent and it is a noninfectious stage. Chronic destructive lesions are present in the late stage of syphilis. Painless, indurated lesions are present in the primary stage of syphilis. Flulike symptoms are present in secondary syphilis.

A client with a skin infection on the hand reports itching near the site of infection. Upon assessment, the nurse notices serpiginous patches with elevated borders. The nurse would teach the client about which condition?

Tinea manus Rationale: A serpiginous patch with an elevated border is a clinical feature of dermatophytosis; tinea is the common term used to describe dermatophytoses. If this lesion is seen on the hand, it is termed tinea manus. If the dermatophytoses is seen on the foot, it is termed tinea pedis. Tinea capitis describes the involvement of the head. Similarly, tinea corporis describes involvement of the rest of the body.

When evaluating for response to treatment for a client with pharyngitis, which action will the nurse take?

Use a tongue blade to inspect the tonsils for swelling. Rationale: Pharyngitis is an inflammation of the throat and the nurse will inspect the tonsils for improvement in enlargement and exudates. A nasal speculum would be used to inspect the nares for a client with rhinitis. Improvement in a client with sinusitis is assessed by palpating over the sinuses for improvement in tenderness or warmth. Improvement in lower respiratory infections such as pneumonia is evaluated by auscultation of lung sounds.