NUR 240 EAQ - Physiological Adaptation

Which statements regarding the involution process are correct? Select all that apply. One, some, or all responses may be correct.

1.) Involution begins immediately after expulsion of the placenta. 2.) Involution progresses rapidly during the next few days after birth. 3.) Involution is the return of the uterus to a nonpregnant state after birth.

Which clinical manifestations are consistent with Sjögren syndrome? Select all that apply. One, some, or all responses may be correct.

1.) Xerostomia 2.) Keratoconjunctivitis sicca

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

Amenorrhea

Which catecholamine receptor is responsible for increased heart rate?

Beta-1 receptor

A client's breath has a sweet, fruity odor. Which condition is affecting this client?

Diabetic acidosis

Which musculoskeletal condition is illustrated in the figure?

Scoliosis

Which is a comparison between blood plasma and interstitial fluid?

They both contain the same kinds of ions.

When a client with intermittent claudication asks what causes the associated symptoms, which response would the nurse make?

"Inadequate circulation to the legs causes pain when walking."

While assessing a client's vascular system, the nurse finds that pulse strength is diminished and barely palpable. Which documentation is correct in this situation?

1+

The nurse is assessing the body temperature of four febrile clients over 4 days. Which client is suffering from remittent fever?

Client C

Which autoimmune disease affects the central nervous system?

Multiple sclerosis

A client at 28 weeks' gestation visits the clinic for a routine examination. Which finding is of greatest concern to the nurse?

Puffy fingers

The nurse observes elevated superficial lesions filled with purulent fluid on a client's skin. Which type of lesion would the nurse document in the health record?

Pustule

Which electrolyte deficiency triggers the secretion of renin?

Sodium

The nurse is caring for an infant with a myelomeningocele. Which clinical manifestation helps distinguish a myelomeningocele from a meningocele?

Affected lower extremities.

Which intervention would the nurse implement when caring for a client 24 hours after thyroidectomy?

Check the sides of the operative site dressing and the back of neck.

During an annual physical assessment, a client reports not being able to smell coffee and most foods. Which cranial nerve function would the nurse assess?

I

Which finding would the nurse document as normal for a second, post abdominoperineal resection stoma?

Moist, red, and raised above the skin surface.

Which physical skin finding indicates opioid abuse?

Needle marks

Which synovial joint movement is involved in turning a client's palm downward?

Pronation

The nurse is providing postoperative care to a client who is being weaned from mechanical ventilation. Which is a priority nursing action?

Remaining with the client to assess responses.

A client experiencing chills and fever is admitted to the hospital. After assessing the client's vitals and medical history, the nurse concludes that the client's fever pattern is remittent. Which assessment finding led to this conclusion?

The client's fever spikes and falls without a return to normal temperature levels.

Which glands secrete hormones that regulate metabolism of carbohydrates, proteins, and fats? Select all that apply. One, some, or all responses may be correct.

1.) Pancreas 2.) Thyroid gland 3.) Adrenal cortex

Which term would the nurse use to document observing the characteristic gait associated with Parkinson disease?

Shuffling

A young adult is unconscious after an accident. As part of the assessment, the nurse applies a painful stimulus to the client's left lower leg. Which response is expected in a healthy adult?

Withdrawing the leg.

The nurse is assessing a client's degree of edema and finds 8 mm of depth. Which would be correct to document this condition?

4+

Which assessment finding would the nurse recognize as common in infants with Down syndrome?

Abnormal heart sounds

Which condition results in visual distortion?

Astigmatism

Which virus is responsible for causing infectious mononucleosis in clients?

Epstein-Barr virus

The nurse is caring for a client who is prescribed desmopressin acetate. Which is the expected outcome in the client?

Urine output: 3 L/day

A client with a history of pancreatitis is scheduled for surgery to excise a pseudocyst of the pancreas. The client asks, "What is a pseudocyst?" Which information would the nurse include in a response to this question?

Walled off space of pancreatic enzymes and exudate.

Which statement is true regarding primary dysmenorrhea? Select all that apply. One, some, or all responses may be correct.

1.) During the luteal phase, F2-alpha is secreted. 2.) Pain usually begins at the onset of menstruation and lasts for 8 to 48 hours.

Which hormones are most commonly produced in excess with hyperpituitarism? Select all that apply. One, some, or all responses may be correct.

1.) Prolactin 2.) Growth hormone

The nurse suspects acute akathisia in a client receiving antipsychotic therapy for treatment of schizophrenia. Which symptoms in the client support the nurse's suspicion? Select all that apply. One, some, or all responses may be correct.

1.) Anxiety 2.) Agitation 3.) Restless movement

Which areas are sources of stress in 4-year-old children? Select all that apply. One, some, or all responses may be correct.

1.) Attention 2.) Insecurity 3.) Activity level

A client is admitted to the hospital with severe back and abdominal pain, nausea and occasional vomiting, and an oral temperature of 101°F (38.3°C). The client reports drinking six to eight beers a day. A diagnosis of acute pancreatitis is made. Based on the data presented, which clinical finding is a primary nursing concern for this client?

Acute pain

A 90-year-old resident fell and fractured the proximal end of the right femur. The surgeon plans to reduce the fracture with an internal fixation device. Which general fact about the older adult would the nurse consider when caring for this client?

Aging reduces the physiological coping defenses.

Which physiological alteration does the nurse expect in a client's hematological system during the second trimester of pregnancy?

An increase in blood volume.

A client who underwent a physical examination reports itching after 2 days. Which condition would the nurse suspect?

Contact dermatitis

Which action would the nurse test when assessing a client's eyes to ensure formation of a single image of close objects?

Convergence

A client arrives at a health clinic reporting a recent onset of hematuria, frequency, urgency, and pain on urination. Which diagnosis will the nurse observe in the client's medical record?

Cystitis

The nurse teaching a prenatal class is asked why infants of diabetic mothers are larger than those born to women who do not have diabetes. On which information about pregnancy and diabetes would the nurse base the response?

Extra circulating glucose causes the fetus to acquire fatty deposits.

The nurse is caring for a client who is having diarrhea. Which client data would the nurse closely monitor to prevent an adverse outcome?

Fluid and electrolyte balance.

Which skin infection is caused by bacteria?

Folliculitis

Which lobe of the cerebrum includes the Broca speech center?

Frontal lobe

Which findings would be considered normal when caring for a primigravida who gave birth by vaginal delivery 24 hours ago?

Fundus firm at the umbilicus, moderate lochia rubra, voiding quantity sufficient, colostrum present.

A client measuring at 18 weeks' gestation visits the prenatal clinic stating that she is still very nauseated and vomits frequently. Physical examination reveals a brown vaginal discharge and a blood pressure of 148/90 mm Hg. There are absent fetal heart tones. Which condition does the nurse suspect the client is experiencing?

Hydatidiform mole

Which symptom indicates a client with inhalation anthrax is in the fulminant stage?

Hypoxia

A child with a history of nephrotic syndrome has a pale, muddy appearance; his appetite is poor; and he has been unusually tired after school. Which would the nurse suspect?

Impending renal failure.

Which condition is an example of a bacterial infection?

Impetigo

The day after a hysterectomy, the client asks for sanitary pads because she feels that she is about to begin menstruating. Which information would influence the nurse's response?

Menstruation will not occur because the uterus has been removed.

A client sustained minor skin injuries after an accident. Which event occurs close to the time of injury?

Migration of leukocytes to the site of injury.

Which nursing intervention would the nurse provide an infant during the immediate postoperative period after surgical repair of a cleft lip?

Minimize crying

The nurse is caring for a client with a burn injury and suspects atelectasis and hypoxia. Which age-related changes would the nurse associate with these findings?

Reduced thoracic compliance

Which condition would the infant with chordee be at risk for if surgical correction is not performed?

Sexual dysfunction

Which feature is associated with the "maturation phase" of normal wound healing?

The scar is firm and inelastic on palpation.

The nurse evaluates the condition of a client with burns of the upper body. Which assessment findings indicate potential respiratory obstruction? Select all that apply. One, some, or all responses may be correct.

1.) Brassy cough 2.) Singed nasal hair 3.) Dark mucous membranes

The client is admitted to the emergency department with burns on the anterior part of both arms, from the shoulders to the hands, and the anterior part of the head. Which percentage of total body surface area burned would the nurse document in the client's hospital record using the rule of nines?

13.5%

When caring for a client who has a blood pressure of 80/60 mm Hg and heart rate of 120 beats/minute after a motor vehicle accident, the nurse anticipates the need to rapidly implement which type of collaborative action?

Increase circulating blood volume

When a client is admitted to the emergency department with a possible spinal cord injury, the nurse would monitor for which clinical manifestations of spinal shock? Select all that apply. One, some, or all responses may be correct.

1.) Bradycardia 2.) Hypotension 3.) Urinary retention