Nurs 4 - RN EAQ's - Client Needs: Physiological Integrity

A client is admitted with a diagnosis of preeclampsia. Which significant clinical finding does the nurse expect when reviewing the client's history? 1 Proteinuria 2 Tachycardia 3 Increased serum glucose 4 Tonic-clonic movements

1 - Proteinuria A characteristic of preeclampsia is vasospasms that cause renal injury, resulting in loss of protein in the urine. The maternal heart rate is not affected by preeclampsia. An increased serum glucose level is associated with uncontrolled diabetes, not preeclampsia. There are no data to indicate that the client had or is having a seizure. The admitting diagnosis is preeclampsia, not eclampsia.

A client is admitted to the intensive care unit with a diagnosis of acute respiratory distress syndrome. When assessing the client, what does the nurse expect to identify? 1 Hypertension 2 Tenacious sputum 3 Altered mental status 4 Slow rate of breathing

3 - Altered mental status Altered mental status is secondary to cerebral hypoxia, which accompanies acute respiratory distress syndrome (ARDS); cognition and level of consciousness are reduced. Hypotension occurs because of hypoxia. The sputum is not tenacious, but it may be frothy if pulmonary edema is present. Breathing will be fast and shallow.

The nurse is caring for a client who has a lesion in the right upper lobe. A diagnosis of tuberculosis (TB) has been made. What are the clinical manifestations of tuberculosis? 1 Frothy sputum and fever 2 Dry cough and pulmonary congestion 3 Night sweats and blood-tinged sputum 4 Productive cough and engorged neck veins

3 - Night sweats and blood-tinged sputum Blood-tinged sputum is often the presenting sign of tuberculosis (TB); diaphoresis at night is a later sign. Frothy sputum occurs with pulmonary edema. Engorged neck veins occur with right heart failure. Pulmonary congestion is characteristic of heart failure or pulmonary edema.

1 - Client A A client with an HIV infection is at risk for multiple diseases. Burning, itching and discharge from the eyes are not life-threatening and can be reported within 24 hours. Therefore client A's condition can be reported within 24 hours. All the other clients' conditions should be reported immediately.

The nurse is taking care of four clients with human immunodeficiency virus (HIV) infections. Which client's condition should the nurse report to the primary healthcare provider within 24 hours after observation? 1 Client A 2 Client B 3 Client C 4 Client D

A client is admitted to the hospital with a tentative diagnosis of Guillain-Barré syndrome. Which question by the nurse will best elicit information that supports this diagnosis? 1 "Have you experienced an infection recently?" 2 "Is there a history of this disorder in your family?" 3 "Did you receive a head injury during the past year?" 4 "What medications have you taken in the last several months?"

1 - "Have you experienced an infection recently?" Symptoms usually appear one to three weeks after an acute infection; this syndrome is linked to diseases such as viral hepatitis, the Epstein-Barr virus, and infectious mononucleosis. There is no known familial tendency that exists in the development of Guillain-Barré syndrome. This syndrome is unrelated to head trauma. Drug therapy is not implicated as a contributing factor in Guillain-Barré syndrome.

While caring for a client who had an accident, the nurse suspects injury to the frontal lobe. Which statements by the client may support the nurse's conclusion? Select all that apply. 1 "I am unable to play the piano." 2 "I am unable to hear properly." 3 "I am unable to move my eyes." 4 "I am unable to concentrate on anything." 5 "I am unable to taste any flavors in the foods I eat."

1 - "I am unable to play the piano." 3 - "I am unable to move my eyes." 4 - "I am unable to concentrate on anything." Functions of the frontal lobe include voluntary eye movements, playing musical instruments and the ability to concentrate. Therefore, injury to the frontal lobe impairs these functions. Injury to the temporal lobe causes loss of auditory function. Injury to the parietal lobe causes loss of taste sensation.

Which statements about acne in adolescents are true? Select all that apply. 1 Early acne occurs in the midface region. 2 Acne is more common in girls than boys. 3 Acne usually occurs in middle to late adolescence. 4 Intake of dairy products can contribute to acne severity. 5 Acneiform eruptions are predominant in young children.

1 - Early acne occurs in the midface region. 3 - Acne usually occurs in middle to late adolescence. 4 - Intake of dairy products can contribute to acne severity. Acne occurs in more than 50% of adolescents in middle to late adolescence. Early acne occurs in the midface region, such as the chin, nose, and middle of the forehead. The intake of dairy products may contribute to acne severity. Acne is more common in boys than in girls. Acneiform eruptions occur in infants, neonates, and young children.

While instructing a community group regarding risk factors for coronary artery disease, the nurse provides a list of risk factors that cannot be modified. What should be included on the list? 1 Heredity 2 Hypertension 3 Cigarette smoking 4 Diabetes mellitus

1 - Heredity Heredity refers to genetic makeup and cannot be changed. Cigarette smoking is a lifestyle habit that involves behavior modification. Hypertension and diabetes mellitus are risk factors of coronary artery disease that can be controlled with diet, medication, and exercise.

An infant with tetralogy of Fallot becomes cyanotic and dyspneic after a crying episode. In what position should the nurse place the infant to relieve the cyanosis and dyspnea? 1 Knee-chest 2 Orthopneic 3 Lateral Sims 4 Semi-Fowler

1 - Knee-chest Flexing the hips and knees decreases venous return to the heart from the legs. When venous return to the heart is decreased, the cardiac workload is decreased. Although the orthopneic position reduces pressure of the abdominal organs on the diaphragm, it does not put enough pressure on the femoral veins and vena cava to sufficiently reduce venous return to the heart. The lateral Sims position does not reduce venous return to the heart. It does not put enough pressure on the femoral veins and vena cava to sufficiently reduce venous return to the heart. Although the semi-Fowler position reduces pressure of the abdominal organs on the diaphragm, it does not put enough pressure on the femoral veins and vena cava to sufficiently reduce venous return to the heart.

A nurse is reviewing the laboratory results of and collecting a health history from a client with a diagnosis of colitis. Which common clinical manifestation of colitis should the nurse expect? 1 Weight loss 2 Hemoptysis 3 Increased red blood cells 4 Decreased white blood cells (WBC)

1 - Weight loss The inflammatory process associated with colitis increases peristalsis, causing abdominal cramping, diarrhea, and weight loss. Coughing up blood from the respiratory tract (hemoptysis) is not associated with colitis. Anemia, not polycythemia, is associated with colitis. The WBC count may be increased, not decreased.

Which pregnant client does the nurse suspect is most likely to have placenta previa? 1 19 years old, gravida 1, para 0 2 30 years old, gravida 6, para 5 3 25 years old, gravida 2, para 1 4 40 years old, gravida 3, para 2

2 - 30 years old, gravida 6, para 5 Multiple past pregnancies can scar the endometrial lining, rendering it vulnerable to an abnormal implantation. Primigravidas are the least prone to placenta previa; the endometrium is receptive to implantation. Two pregnancies have not compromised the endometrium to the extent that an abnormal implantation is likely to occur. Age is known to be a significant factor; but, three pregnancies should not have compromised the endometrium.

A client's membranes rupture during labor. The nurse immediately assesses the electronic fetal heart rate. Variable decelerations lasting more than 90 seconds, followed by bradycardia, are observed on the monitoring strip. Which physiologic finding does the nurse suspect is the cause of this abrupt change? 1 Fetal acidosis 2 Prolapsed cord 3 Head compression 4 Uteroplacental insufficiency

2 - Prolapsed cord This variable pattern with bradycardia is an ominous sign; it is indicative of a prolapsed cord, or cord compression, which can result in fetal hypoxia. Immediate intervention is required. Fetal acidosis, not fetal heart rate changes, occurs with uteroplacental insufficiency. Early decelerations are associated with head compression and are benign. Late decelerations and tachycardia, not variable decelerations followed by bradycardia, are associated with uteroplacental insufficiency.

Jaundice develops in a newborn 72 hours after birth. How should the nurse best explain the probable cause of this jaundice to the parents? 1 An allergic response to the feedings 2 The physiologic destruction of fetal red blood cells 3 A temporary bile duct obstruction commonly found in newborns 4 The seepage of maternal Rh-negative blood into the neonate's bloodstream

2 - The physiologic destruction of fetal red blood cells After birth, fetal erythrocytes hemolyze, releasing bilirubin into the circulation; the immature liver cannot metabolize the bilirubin as rapidly as it is produced, resulting in physiologic jaundice. Jaundice is not an allergic response. Bile duct obstruction, which is not common in newborns, is not the cause of the jaundice. The newborn and mother have independent circulations, and Rh-negative blood does not enter the fetus's bloodstream. A problem may occur if the mother is sensitized, because her antibodies can enter the fetal circulation.

A female adolescent complains of breast pain. Which antigonadotropic herb may alleviate breast pain by decreasing prolactin levels? 1 Catnip 2 Black haw 3 Bugleweed 4 Chaste tree fruit

3 - Bugleweed Bugleweed is an herb used to decrease breast pain by decreasing prolactin levels and facilitating an antigonadotropic effect. Black haw and catnip are herbs that act as uterine antispasmodics. Chaste tree fruit also decreases breast pain by decreasing prolactin levels, but it is not antigonadotropic.

A client presents with a localized bacterial infection of mucous membranes. Which organism is most likely responsible for this condition in the client? 1 Giardia 2 Aspergillus fumigatus 3 Corynebacterium diphtheria 4 Mycobacterium tuberculosis

3 - Corynebacterium diphtheria Diphtheria is a re-emerging infection that can be characterized by localized infection of mucous membranes or skin. It is caused by Corynebacterium diphtheria. Giardia, a parasite, causes giardiasis, a diarrheal illness known as traveler's diarrhea. Aspergillosis is a lung disease caused by Aspergillus fumigatus, a fungus. Mycobacterium tuberculosis causes tuberculosis.

A nurse should plan to maintain a client who has experienced a subarachnoid hemorrhage in what position? 1 Supine 2 On the unaffected side 3 In bed with the head of the bed elevated 4 With sandbags on either side of the head

3 - In bed with the head of the bed elevated With the head of the bed elevated, the force of gravity helps prevent additional intracranial pressure [1] [2], which will intensify the ischemic manifestations of hemorrhage. The supine position will not facilitate drainage of cerebral fluid; this position promotes accumulation of fluid, which increases intracranial pressure. Lying on the unaffected side will not facilitate drainage of cerebral fluid; this position promotes accumulation of fluid, which increases intracranial pressure. Vomiting can occur with increased intracranial pressure, and placing sandbags to immobilize the head can result in aspiration.

The parents of a toddler with newly diagnosed cystic fibrosis ask a nurse what causes the problems related to this disorder. What should the nurse consider about the primary pathologic process before responding? 1 Hyperactivity of the eccrine (sweat) glands 2 Hypoactivity of the autonomic nervous system 3 Mechanical obstruction of mucus-secreting glands 4 Atrophic changes in the mucosal lining of the intestines

3 - Mechanical obstruction of mucus-secreting glands Mucous secretions increase in viscosity and precipitate or coagulate to form concentrations in glands and ducts, resulting in obstructions. Decreased amounts of pancreatic enzymes cause impairment in the digestion and absorption of nutrients. The eccrine (sweat) glands are not hyperactive, but there is an increased concentration of sweat electrolytes (e.g., sodium and chloride). The autonomic nervous system does not play a role in the pathologic process of cystic fibrosis. There is no alteration in the mucosal lining of the intestines.

The nurse discovers several palpable elevated masses on a client's arms. Which term most accurately describes the assessment findings? 1 Erosions 2 Macules 3 Papules 4 Vesicles

3 - Papules Papules are superficial and elevated up to 0.5 cm. Nodules and tumors are masses similar to papules, but are elevated more than 0.5 cm and may infiltrate deeper into tissues. Erosions are characterized as loss of the epidermis layer; macules are nonpalpable, flat changes in skin color less than 1 cm in diameter; and vesicles are usually transparent, filled with serous fluid, and are a blisterlike elevation.

When assessing a client with pleural effusion, what does the nurse expect to identify? 1 Moist crackles at the posterior of the lungs 2 Deviation of the trachea toward the involved side 3 Reduced or absent breath sounds at the base of the lung 4 Increased resonance with percussion of the involved area

3 - Reduced or absent breath sounds at the base of the lung Compression of the lung by fluid that accumulates at the base of the lungs reduces lung expansion and air exchange. There is no fluid in the alveoli, so no crackles are produced. If there is tracheal deviation, it is away from the involved side. Dullness is produced on percussion of the involved area.

After surgery for repair of a myelomeningocele, the nurse places the infant in a side-lying position with the head slightly elevated. What is the main reason the nurse places the infant in this position after this particular surgery? 1 To prevent aspiration 2 To promote respiration 3 To reduce intracranial pressure 4 To maintain cleanliness of the suture site

3 - To reduce intracranial pressure The side-lying position with the head slightly elevated promotes venous return by gravity, which helps reduce intracranial pressure, a problem after myelomeningocele repair. Although preventing aspiration, promoting respiration, and maintaining cleanliness of the suture line are all important, the reason for this position that is unique with this type of surgery is that it minimizes intracranial pressure.

A client is admitted with systemic lupus erythematosus (SLE). The laboratory report shows the presence of neutrophils and monocytes as mediators of injury. Which type of hypersensitivity reaction most likely occurred in the client? 1 Type I 2 Type II 3 Type III 4 Type IV

3 - Type III Type III hypersensitivity reaction involves immunoglobulin IgG- and IgM-mediated release of neutrophils and monocytes as mediators of injury. It is an immune complex-mediated hypersensitivity reaction that occurs in SLE or rheumatoid arthritis. Allergic rhinitis and asthma may occur when mediators such as histamine and prostaglandins are involved, resulting in a type I hypersensitivity reaction. Type II hypersensitivity reaction is cytotoxic mediated, which occurs in transfusion reaction and Goodpasture syndrome. Type IV hypersensitivity reaction is a delayed hypersensitivity reaction that may occur in contact dermatitis involving T cytotoxic cells.

A child with a history of asthma is brought to the emergency department experiencing an acute exacerbation of asthma. Which nursing assessment findings support this conclusion? Select all that apply. 1 Fever 2 Stridor 3 Wheezing 4 Tachycardia 5 Hypotension

3 - Wheezing 4 - Tachycardia Bronchial constriction with mucus production causes wheezing. With the decrease in arterial oxygenation associated with asthma, the heart rate will increase. An increased temperature is characteristic of sepsis, not asthma. Stridor is due to foreign body obstruction, not asthma. Hypertension, not hypotension, may occur with asthma.

A client has a first-trimester aspiration abortion. Which statement indicates to the nurse that the client understands the discharge instructions? 1 "We can start having sex again in 4 or 5 days." 2 "My period should start again in 2 or 3 weeks." 3 "I can use tampons instead of pads after 24 hours." 4 "I'll call you if I have to change my pad more than once in 4 hours."

4 - "I'll call you if I have to change my pad more than once in 4 hours." Needing to change a sanitary pad more than once in 4 hours indicates that the bleeding is excessive and that the healthcare provider should be notified. Although instructions vary among providers, sexual intercourse may usually be resumed in 1 to 3 weeks. The menstrual period usually resumes in 4 to 6 weeks. Although instructions vary among healthcare providers, tampons should be avoided for up to 3 weeks.

A nurse expects that a client with right-sided heart failure will exhibit which of these signs or symptoms? 1 Oliguria 2 Pallor 3 Cool extremities 4 Distended neck veins

4 - Distended neck veins Veins are distended because of the systemic venous pressure and congestion that are associated with right-sided heart failure. Oliguria, pallor, and cool extremities are key features of left-sided heart failure.

A nurse is caring for a client with a diagnosis of chronic kidney failure who has just been told by the primary healthcare provider that hemodialysis is necessary. Which clinical manifestation indicates the need for hemodialysis? 1 Ascites 2 Acidosis 3 Hypertension 4 Hyperkalemia

4 - Hyperkalemia Protein breakdown liberates cellular potassium ions, leading to hyperkalemia, which can cause a cardiac dysrhythmia and standstill. The failure of the kidneys to maintain a balance of potassium is one of the main indications for dialysis. Ascites occurs in liver disease and is not an indication for dialysis. Dialysis is not the usual treatment for acidosis; usually this responds to administration of alkaline drugs. Dialysis is not a treatment for hypertension; this is usually controlled by antihypertensive medication and diet.

After a resection of the colon, a client returns to the surgical unit from the postanesthesia care unit with a nasogastric tube to negative pressure. What does the nurse explain is the purpose of this tube? 1 Monitoring the acidity of gastric secretions 2 Providing a route for liquid tube feedings when possible 3 Permitting continuous decompression of the large intestine 4 Removing fluids and gas from the upper gastrointestinal tract

4 - Removing fluids and gas from the upper gastrointestinal tract A nasogastric tube removes fluids and gas from the upper gastrointestinal tract, which improves healing of the surgical area and minimizes nausea. Monitoring the acidity of gastric secretions is not the purpose of a nasogastric tube in this situation. Tube feedings are contraindicated after gastrointestinal surgery. The tube decompresses the stomach, not the large bowel.

A male newborn has been exposed to human immunodeficiency virus (HIV) in utero. Which assessment supports the diagnosis of HIV infection in the newborn? 1 Delay in temperature regulation 2 Continued bleeding after circumcision 3 Hypoglycemia within the first day of birth 4 Thrush that does not respond readily to treatment

4 - Thrush that does not respond readily to treatment Thrush, an oral infection caused by Candida albicans, is an opportunistic infection that may be indicative of underlying HIV infection. A delay in temperature regulation is more commonly associated with immaturity of the hypothalamus. Bleeding after a circumcision is associated with a bleeding disorder such as hemophilia. Hypoglycemia is usually associated with the infant of a diabetic mother.

A nurse is assessing a client who presents with a circumscribed, hypertrophic, flesh-colored papule on the skin. The client reports pain upon lateral compression. What should the nurse suspect in the client? 1 Plantar warts 2 Herpes zoster 3 Tinea corporis 4 Verruca vulgaris

4 - Verruca vulgaris A client with a painful, circumscribed, hypertrophic, and flesh-colored papule on the skin may have verruca vulgaris. Plantar warts are usually located on the foot and occur due to pressure by walking or prolong standing. Herpes zoster is caused by the varicella zoster virus and may cause grouped vesicles and pustules on the trunk, face, and lumbosacral areas. Tinea corporis is a ringworm infection with a scaly and erythematous appearance on the skin.

2 - Psoriasis The image depicts psoriasis. This condition is a chronic autoimmune dermatitis that involves the excessively rapid turnover of epidermal cells. Characteristic scaling and inflammation are present on the skin. Lentigo is a condition in which hyperpigmented, brown-to-black macules or patches are present on the skin. Acne vulgaris includes papules and pustules on the face, neck, and upper back. Seborrheic keratoses are irregularly round or oval papules or plaques on the skin.

Which condition is depicted in the image?