Exam 4 Biol280

The nurse cares for clients with a variety of depression disorders. Which client statements suggest the diagnosis of​ dysthymia? Select all that apply.

"Every day for over 2 years​ I've been​ sad, tired, and​ can't seem to get my act​ together.", "For the last 4​ years, I​ can't make a decision and am so worthless at work every​ day."

The nurse is about to administer lithium to a client with a bipolar disorder. Which statement by the client requires immediate follow up by the​ nurse?

"I feel like I​ can't stop moving my​ hands."

Which of the following statements made by a patient with polycythemia indicates an understanding of the​ disease?

"I have an overproduction of red cells from my bone​ marrow."

The nurse is reviewing a​ client's experience with cognitive behavioral therapy. Which statement by the client indicates the therapy has been​ effective?

"I wanted to run out of the grocery​ store, but I had no reason​ to."

Which statement by a patient with chronic heart failure indicates to the nurse that more teaching is​ needed?

"If I follow strict​ self-care, I can cure the​ disease."

Which of the following is the best response given to a patient by the nurse when a patient with heart failure asks for an explanation of his ejection​ fraction?

"It is the percentage of blood pumped by the heart with each​ beat."

Which response by the nurse is best when the mother states that she gives her​ 10-month-old baby 45​ mg/day of​ iron?

"Let's talk about safe levels of iron intake for a​ 10- month-old."

Which statement by the mother of a baby with hydrocephalus indicates that the mother understands this​ condition?

"My baby has too much fluid in his​ brain."

The nurse is providing education to a​ client's family about cardiogenic shock. Which statement should be included in the​ education?

"The body works to shunt blood to major organs."

The nurse is providing discharge instructions to a client recently diagnosed with a bipolar disorder. Which statement by the client indicates an understanding of the​ condition?

"There's no way to know for sure how I developed​ this."

Which statement made by a patient with a biventricular pacemaker indicates that more teaching is​ needed?

"This pacemaker can deliver a shock if I develop a​ life-threatening heart​ rhythm."

The nurse is providing education to a client about anxiety disorders. Which statement by the client requires further follow up by the​ nurse?

"Usually anxiety lasts for weeks after a stressor is gone."

When caring for a patient with heart​ failure, which concept about cardiac output should the nurse keep in​ mind?

A faster heart rate increases the cardiac output.

When caring for a patient with increased intracranial​ pressure, which laboratory value trend requires immediate action by the​ nurse?

A rising PaCO2 level

A patient with an ischemic stroke has a blood pressure of​ 200/110 mmHg. Which action should the nurse​ anticipate?

Administering antihypertensives if the blood pressure exceeds​ 220/120 mmHg.

When checking the orders for a patient with hemorrhagic​ stroke, which order would be a cause for concern for the​ nurse?

Administering aspirin

The nurse is counseling a couple who would like to start a family. The man has sickle cell disease and the woman does not have sickle cell disease or the sickle cell trait. Which statement by the man indicates an understanding of the transmission of the​ disease?

All our children will have the sickle cell​ trait."

Which laboratory result confirms to the nurse that therapy for pernicious anemia has been​ effective?

An increase in vitamin B12 levels

Which cardiac arrhythmia is the nurse most likely to assess in a patient with an embolic​ stroke?

Atrial fibrillation

The nurse is teaching health promotion and maintenance to a patient with aplastic anemia. Which action by the patient should be a​ priority?

Avoiding crowds during flu season

The plan of care for a patient with anemia due to alcoholism should include administration of which​ vitamin?

B vitamins

A patient with heart failure reports some shortness of breathing with​ activity, such as cleaning the house or grocery​ shopping, but no shortness of breath at rest. According to the New York Heart Association staging​ system, the nurse would classify this patient​ as:

Class II

The critical care nurse is assessing a client for clinical signs of shock. Which assessment finding does the nurse understand to be a clinical sign of​ shock?

Cold, clammy skin

The nurse is caring for a client with major depression. Which statement about this condition does the nurse know to be​ true?

Depression can be a fatal illness.

The nurse is assessing a client diagnosed with major depressive disorder​ (MDD). Which assessment findings will the nurse​ anticipate? Select all that apply.

Diminished ability to think or concentrate, significant weight loss

Which vital signs would the nurse expect to find in a patient with​ anemia?

Heart rate 108​ beats/minute, respirations 26​ breaths/minute

When administering​ medications, which concept pertaining to the blooddash brain barrier must the nurse​ understand?

Highly lipophilic medications cross the blooddash brain barrier directly.

The nurse is providing education to a client about recent brain​ imaging, which shows hippocampal volume loss. What is the​ nurse's understanding of this​ finding?

Hippocampal volume loss may be linked with​ depression, impaired​ learning, and memory.

When assessing a patient following an aneurysmal subarachnoid​ hemorrhage, the nurse should be alert for delayed cerebral ischemia during which time​ period?

In 3 to 14 days

The nurse is reviewing orders for a client with a diagnosis of septic shock. Which order will the nurse verify with the health care provider before​ proceeding?

Intravenous furosemide

The nursing history indicates that a patient with sickle cell disease​ (SCD) has had numerous blood transfusions in the last three months. When assessing the​ patient, the nurse should be alert for which​ condition?

Iron overload

The nurse is performing a psychosocial assessment on an adolescent client. Which special considerations should the nurse take while performing the​ assessment? Select all that apply.

It is important to differentiate between normal fears and those that interfere with normal function, Feelings of embarrassment may interfere with the assessment of adolescents.

Which information should the nurse include in a teaching care plan for a patient with moyamoya​ disease?

It may be caused by a genetic disorder.

The nurse is caring for an older adult client with a diagnosis of major depressive disorder​ (MDD). What is the​ nurse's understanding of the presentation of depression in this​ client?

It may present in the context of cardiovascular disease, dementia, or stroke.

The nurse is providing care to a client with multiple organ dysfunction syndrome​ (MODS). What does the nurse understand is occurring in the​ body's cells as a​ result?

Lactic acid production increases

The emergency department nurse is assessing a client in shock. The nurse understands that shock can be caused by which​ conditions? Select all that apply.

Low blood volume, obstruction of blood flow, failure of the heart to pump, inflammatory vascular disease

The nurse is caring for a client with a bipolar disorder. The nurse understands that the​ client's condition is characterized by which types of​ episodes? Select all that apply.

Manic, depressive, hypomanic

Which action would the intensive care nurse take to measure the preload of a patient with heart​ failure?

Measure the pulmonary artery pressure.

Which assessment data indicates to the nurse that a patient has a chronic iron​ deficiency?

Microcytic, hypochromic red blood cells

When assessing a patient with manifestations of a​ stroke, the nurse keeps in mind that embolic strokes most commonly occur in which​ artery?

Middle cerebral artery

The nurse is providing education to a client about the role of neurotransmitters in depression. Which areas of cognition does the nurse review as being mediated by​ serotonin? Select all that apply.

Optimism, impulsivity, positive mood

To increase absorption of dietary​ iron, the nurse recommends that a patient with anemia drink which beverage with​ meals?

Orange juice

The nurse should expect to assess which findings in a patient with a right anterior cerebral artery​ stroke?

Paresis and sensory loss of the left leg and foot

When assessing a​ patient, which finding by the nurse would support a diagnosis of​ left-sided heart​ failure?

Paroxysmal nocturnal dyspnea

The nurse is reviewing the plan of care for a client with hypovolemic shock. Which objectives does the nurse recognize are relevant for this​ client? Select all that apply.

Prevent further fluid loss, replace lost fluids, maximize oxygen delivery

The nurse is developing a community program about stroke risk factor reduction. Which would the nurse explain is a​ non-modifiable risk​ factor?

Prior stroke or TIA

The nurse is caring for a client presenting with​ confusion, angina, and muscular pain. The nurse understands that these findings are consistent with which stage of​ shock?

Progressive shock

The nurse is preparing to admit a client diagnosed with anaphylactic shock. The nurse understands that anaphylactic shock can have which​ triggers?

Proteins, drugs, foods

The nurse would expect to assess third nerve palsy in patient with an ischemic stroke involving which​ artery?

Proximal posterior cerebral artery

When assessing a patient with heart failure affecting only the left​ ventricle, the nurse would expect which of the following​ conditions?

Pulmonary venous congestion

A child with sickle cell anemia is admitted to the pediatric unit for erythrocytapheresis. The nursing plan of care should include preparing for which of the following​ treatments?

Red blood cell exchange

Which instruction should be included in the teaching plan for a patient with​ hemochromatosis?

Reduce intake of foods high in iron.

Which laboratory assessment data indicates to the nurse that a patient has​ anemia?

Reduced erythrocytes

The nurse caring for a patient with anemia of chronic disease​ (ACD) would expect which of the following laboratory​ results?

Reduced transferrin saturation

The nurse is assisting with a client undergoing a sequential organ failure assessment​ (SOFA). Which systems will the nurse anticipate being included in the​ assessment? Select all that apply.

Respiratory, cardiovascular, neurological

Which information should the nurse include in a teaching care plan for a patient with systolic heart​ failure?

Restrict salt intake.

The nurse instructs a patient who had a TIA to take which action if he experiences symptoms of a TIA in the​ future?

Seek urgent medical care.

The critical care nurse is preparing to admit a client with suspected hypovolemic shock to the intensive care unit. Which laboratory tests does the nurse anticipate to be included in the​ client's plan of​ care? Select all that apply.

Serum lactate concentration, blood glucose level, complete blood count (CBC)

A baby has been brought to the emergency department unresponsive. The parent reports that the baby was in a motor vehicle​ accident, but the nurse notes no physical signs of trauma. A physical examination reveals retinal hemorrhages. Which diagnosis does the nurse​ suspect?

Shaken baby syndrome

A patient with heart failure reports some shortness of breathing with​ activity, such as cleaning the house or grocery​ shopping, but no shortness of breath at rest. According to the American College of Cardiology​ (ACC)/American Heart Association​ (AHA) staging, the nurse would classify this patient as:

Stage C

Which manifestation does the nurse expect a patient to exhibit in​ high-output heart​ failure?

Strong peripheral pulses

When performing an assessment of the central nervous​ system, which concept should the nurse keep in​ mind?

The brain receives about​ 15% of the cardiac output.

The nurse is caring for a client with major depression who is hospitalized for failure to thrive. The nurse understands that which body system is directly tied to emotional​ regulation?

The immune system

The nurse is caring for a client with early shock. The nurse understands that which mechanism in the body is maintaining the​ client's blood​ flow?

The kidneys respond to poor perfusion by activating the renin-angiotensin-aldosterone system.

A history and assessment of a patient with normal pressure hydrocephalus will most likely​ reveal:

an older adult

When caring for a patient who has advanced from stage C to stage D of the American College of Cardiology​ (ACC)/American Heart Association​ (AHA) heart failure classification​ system, the nurse instructs the patient and family that this stage includes the addition​ of:

interventional therapy with left ventricular assist device or heart transplantation.

During the admission history of a patient with myelodysplastic​ syndrome, the nurse should question the patient about exposure​ to:

radiation.

When assessing the patient with​ high-output heart​ failure, the nurse is most likely to​ find

validation and hypertension

When planning care for a patient with heart​ failure, which concept should the nurse keep in​ mind?

The sympathetic nervous system is activated when cardiac output drops.

What response should the nurse give when a patient with heart failure asks what the physician meant by saying his left ventricular assist device​ (LVAD) was destination​ therapy?

"Your LVAD will support your heart because you are not a candidate for heart​ transplant."

The nurse is providing dietary instructions to a pregnant patient. The nurse recommends that the daily intake of iron should​ be:

27​ mg/day

When assessing a patient with traumatic brain​ injury, which cerebral blood flow would the nurse consider​ normal?

750 millimeters of blood/minute

When a patient is suspected of having a brain arteriovenous malformation​ (AVM), which of the following may be​ auscultated?

A cerebral bruit

The emergency department nurse receives a call about an incoming client with hypovolemic shock. The nurse understands that which conditions can result in hypovolemic​ shock? Select all that apply.

Blood loss, diuresis, severe burns

The nurse is preparing to administer a​ client's medications. Which medications does the nurse recognize are used to treat the​ client's diagnosis of cardiogenic​ shock? Select all that apply.

Diuretic therapy, nitroglycerine therapy, thrombolytic therapy

Which of the following medications would the nurse anticipate administering to a patient with systolic heart failure to reduce fluid volume and relieve​ congestion?

Diuretics

The nurse is caring for a client with generalized anxiety disorder. Which neurotransmitters does the nurse understand are tied to the pathogenesis of this​ condition? Select all that apply.

Dopamine, serotonin

Which data in a patient undergoing pulmonary heart catheterization confirms a diagnosis of systolic heart​ failure?

Elevated pulmonary artery wedge pressure

The nurse is preparing to administer paroxetine to a client with an anxiety disorder. The nurse understands which statement about this medication to be​ true?

This is often a drug of choice for anxiety treatment

The nurse is teaching a community health class about the early detection and diagnosis of bipolar disorders. Which statement will the nurse include in the​ teaching?

​"The onset of bipolar disorders may occur at any time in​ life."

Which of the following should be included in the teaching plan for a child with sickle cell​ anemia?

Encourage intake of plenty of fluids.

The effectiveness of erythropoietin therapy in the patient with renal disease can be confirmed by which laboratory​ finding?

Erythrocytes 4.4 ​million/mm3

The nurse is assessing a client for hypomania. Which findings does the nurse associate with this​ condition? Select all that apply.

Euphoria, increased energy

The nurse is caring for a client with social anxiety disorder. Which distinguishing features does the nurse understand to be associated with this​ condition? Select all that apply.

Fear of being exposed to scrutiny, avoidance of known stressors

The nurse is caring for a client with an acute myocardial infarction. The nurse understands that this condition results in cardiogenic shock by which​ mechanism?

Increased left ventricular pressure

To effectively care for patients with heart​ disease, the staff development nurse is teaching new nurses hired for the intensive care unit about the​ Frank-Starling law. Which concept will the instructor​ teach?

Increasing preload causes an increase in left ventricular contractility.

Which finding would the nurse expect when assessing a patient with a spinal subarachnoid​ hemorrhage?

Neck stiffness and photosensitivity

Which finding would the nurse expect when assessing a patient with diastolic heart​ failure?

Normal ejection fraction

The nurse is providing education about anaphylaxis to a parent at a​ well-child visit. Which agents does the nurse include when reviewing common causes of anaphylaxis in​ children? Select all that apply.

Nuts, bees stings

The nurse is providing discharge instructions to a client hospitalized with a bacterial infection. Which statement will the nurse include in the​ education?

"An unresolved infection may result in septic shock."

While assessing a​ client, the nurse notes​ stridor, tachycardia,​ edema, and hives. The nurse understands that these findings are consistent with which type of​ shock?

Anaphylactic

The nurse is providing education to a client about how the body responds to pulmonary emboli. Which statement will the nurse include in the​ teaching?

"This condition raises the risk for obstructive​ shock."

Which​ first-line medication would the nurse anticipate being in the plan of care for a patient with systolic heart failure to reduce vasoconstriction and​ afterload?

ACE inhibitor

During physical examination of a patient with sickle cell disease in a​ vaso-occlusive crisis, the nurse would be most likely to assess which hallmark​ finding?

Acute pain

Which nursing intervention should be included in the plan of care for a patient with polycythemia​ vera?

Administer anticoagulants.

A patient on warfarin fell and hit his head on an icy sidewalk and has been diagnosed with a subdural hematoma. Which intervention should be included in the nursing plan of care this​ patient?

Administer vitamin K

The nurse is reviewing medications for a client with anaphylactic shock. Which medication would the nurse anticipate to be included in the​ client's plan of​ care? Select all that apply.

Beta agonist treatment, epinephrine treatment, diphenhydramine infusion treatment

The nurse is assessing a client exhibiting a sudden sense of fear and​ dread, heart​ palpitations, and shortness of breath. The nurse understands these findings to be consistent with which​ condition?

Panic attack

While the nurse is reviewing the​ client's medication​ list, the client notes the use of an MAO inhibitor. Which medications does the nurse understand are MAO​ inhibitors?

Tranylcypromine, isocarboxazid

The nurse is caring for a client with multiple organ dysfunction syndrome​ (MODS). Which statement about this condition does the nurse know to be​ true?

Variable clinical presentations occur