Patho Quiz 2
A client with a history of acute coronary syndrome asks why she needs to take aspirin 81 mg every day. The most appropriate response by the nurse would be: "Aspirin will prevent a heart attack." "Aspirin prevents blood clotting by halting platelet production." "It will give you a steady relief of your chest pain." "Aspirin will help prevent blood clotting."
"Aspirin will help prevent blood clotting." Rationale:Aspirin (i.e., acetylsalicylic acid) is the preferred antiplatelet agent for preventing platelet aggregation in persons with ACS. Aspirin, which acts by inhibiting synthesis of the prostaglandin thromboxane A2, is thought to promote reperfusion and reduce the likelihood of rethrombosis. This dose of aspirin is not appropriate for pain relief, and the final option does not demonstrate therapeutic communication.
A 75-year-old client is being evaluated for heart failure. Which questions will the nurse ask to confirm common signs and symptoms observed in older adults experiencing heart failure? Select all that apply. "Do you easily get tired?" "Are you eating more than usual?" "Do you have swelling in your ankles?" "Do you get up often during the night to urinate?" "Are you feeling depressed?"
"Do you easily get tired?", "Do you have swelling in your ankles?", "Do you get up often during the night to urinate?", "Are you feeling depressed?" Rationale:Nocturia, depression, edema in the lower extremities, and fatigue are common symptoms and signs of heart failure in older adults. Anorexia, or decreased appetite, is also a symptom.
The nurse is caring for four clients. Select the client at risk for the development of a pulmonary embolism. A 32-year-old male with viral pneumonia A 36-year-old female smoker with an intrauterine device (IUD) An 80-year-old female client with diabetes A 62-year-old male who is postoperative for repair of a fractured femur
A 62-year-old male who is postoperative for repair of a fractured femur Rationale:A client with surgery to the lower extremities is at higher risk for the development of deep vein thrombosis that could lead to a pulmonary embolism. There is increased risk for pulmonary embolism among users of oral contraceptives, particularly in women who smoke, but not with the use of IUD.
Which client is at greatest risk for orthostatic hypotension? A 20-year-old pregnant client at 36 weeks' gestation A 70-year-old female client who has taken the same antihypertensive medication for 10 years A 66-year-old postoperative client on bed rest A 42-year-old male client with history of pulmonary embolism
A 66-year-old postoperative client on bed rest Rationale:Postoperative clients who have been immobile are at greatest risk for developing othostatic hypotension. The 70-year-old female may also be at some risk: age is a risk factor, as is administration of some antihypertensive medications.
Which clients would be considered at high risk for developing pneumonia (both community and hospital setting)? Select all that apply. A school-aged child with severe asthma controlled by steroids admitted for an exacerbation A HIV-positive client with a WBC count of 2000 who has been camping near a commercial farm raising chickens for food A young adult in motorcycle accident with head injury requiring tracheostomy and mechanical ventilation A teenager who spends a lot of time at local coffee shops using Wi-Fi to chat with friends A college female who is pregnant (unplanned) and who has been consuming alcohol prior to positive pregnancy test
A school-aged child with severe asthma controlled by steroids admitted for an exacerbation, A HIV-positive client with a WBC count of 2000 who has been camping near a commercial farm raising chickens for food, A young adult in motorcycle accident with head injury requiring tracheostomy and mechanical ventilation Rationale:Persons requiring intubation and mechanical ventilation are particularly at risk, as are those with compromised immune function, chronic lung disease (like asthma), and airway instrumentation, such as endotracheal intubation or tracheotomy. Ventilator-associated pneumonia is pneumonia that develops in mechanically ventilated clients more than 48 hours after intubation. Neutropenia and impaired granulocyte function predispose to infections caused by S. aureus, Aspergillus, gram-negative bacilli, and Candida. Pneumonia in immunocompromised persons remains a major source of morbidity and mortality. The epithelial cells of critically and chronically ill persons are more receptive to binding microorganisms that cause pneumonia.
The nurse is discussing risk factors for hypertension with a client. Which factors are nonmodifiable risk factors for development of hypertension? Select all that apply. Advanced age Low dietary potassium Excess salt consumption Obesity Ethnicity
Advanced age, Ethnicity Rationale: Constitutional risk factors are characteristics which cannot be modified, such as ethnicity and age. The other options are modifiable lifestyle risk factors.
Which physiologic dysfunction is the most common cause of hypercapnia? Alterations in carbon dioxide production Alterations in respiratory rate Disturbances in alveolar compliance Abnormalities in the function of the chest wall
Alterations in respiratory rate Rationale:Hypercapnia refers to an increase in carbon dioxide levels. In the clinical setting, four factors contribute to hypercapnia: alterations in carbon dioxide production, disturbance in the gas exchange function of the lungs, abnormalities in function of the chest wall and respiratory muscles, and changes in neural control of respiration. Alterations in respiratory function or the respiratory rate decrease minute volume, which is the most common cause of hypercapnia.
The nurse is providing instructions to a client for the treatment of a common cold. The most appropriate information would be: Antibiotics administered for 7 days Antipyretic medications and rest Antibiotics and antihistamines Complete isolation and bed rest
Antipyretic medications and rest Rationale:The common cold virus does not respond to antibiotics and should be treated with antipyretic medications and rest. Bed rest is recommended, but complete isolation is not required.
The nurse is developing a plan of care for a postsurgical client. A major goal is to prevent the formation of prevent deep vein thrombosis (DVT). The most important intervention for the nurse to implement would be: Apply ice compresses to the site of the DVT hourly. Apply sequential pneumatic compression devices to lower extremities. Massage legs to maintain blood flow. Ensure that the client remains on bed rest.
Apply sequential pneumatic compression devices to lower extremities. Rationale:The application of sequential pneumatic compression devices augments blood flow and reduces stasis. Early ambulation is encouraged. Ice applications would not be recommended due to venous constriction.
An adult client reports to the emergency department with shortness of breath. Which additional clinical finding(s) leads the health care provider to suspect the client has a moderate-sized pulmonary embolism? Select all that apply. Coughing up green-colored sputum. Apprehensive, especially when asked to lie flat Friction rub noted on both inspiration and expiration Fever higher than 103°F (39.4°C) for the past 2 days Blood-tinged sputum
Apprehensive, especially when asked to lie flat, Blood-tinged sputum Rationale:Pulmonary embolism manifestations depend on the size and location of the obstruction. Clients with moderate-sized emboli often present with breathlessness accompanied by pleuritic pain, apprehension, slight fever, and cough productive blood-tinged sputum. Sputum that is green-colored is abnormal and usually due to pneumonia. A fever higher than 103°F (39.4°C) is considered more than a "slight" fever. Pleural friction rub is an abnormal lung sound, which is caused by inflammation of the pleural layer of the lungs rubbing together. Pleural friction rub is heard on inspiration and expiration and sounds like a low-pitch harsh/grating noise.
A client presents with sinus bradycardia. What is the nurse's best action? Admit the client to the intensive care unit Increase the client's monitoring Assess the client's history Assess the client's cardiac output
Assess the client's history Rationale:The nurse needs to assess the client's history before determining if action is necessary. Sinus bradycardia is most often benign unless it is associated with a myocardial infarction, post-resuscitation, or associated with hemodynamic decompensation. It is normal in an athlete, or someone who is well conditioned. After assessing the client's history, the nurse can determine if other action is necessary.
The purpose of a cardioversion device is the treatment of which cardiac disorder? Sinus tachycardia Atrial fibrillation Symptomatic bradycardia Ventricular fibrillation
Atrial fibrillation Rationale:Synchronized cardioversion and defibrillation are two reliable methods for treating ventricular tachycardia, and cardioversion is the definitive treatment for atrial fibrillation. The discharge of electrical energy that is synchronized with the R wave of the electrocardiogram is referred to as synchronized cardioversion, and unsynchronized discharge is known as defibrillation.
Which are primary treatment options for a client with acute venous thrombosis? Select all that apply. Bed rest Sitting Elevation of the legs with flexion at the knees Application of heat Elastic support
Bed rest, Application of heat, Elastic support Rationale:The objectives of treatment of venous thrombosis are to prevent the formation of additional thrombi, prevent extension and embolization of existing thrombi, and minimize venous valve damage. A 15- to 20-degree elevation of the legs prevents stasis. It is important that the entire lower extremity or extremities be carefully extended to avoid acute flexion of the knee or hip. Heat often is applied to the leg to relieve venospasm and to aid in the resolution of the inflammatory process. Bed rest usually is maintained until local tenderness and swelling have subsided. Gradual ambulation with elastic support is then permitted. Standing and sitting increase venous pressure and are to be avoided. Elastic support is needed for 3 to 6 months to permit recanalization and collateralization and to prevent venous insufficiency.
When CO2 levels in the blood rise, a state of hypercapnia occurs in the body. What factors contribute to hypercapnia? Select all that apply. Changes in neural control of respiration Alteration in carbon dioxide production Disturbance in gas exchange function Decrease in carbon dioxide production Abnormalities in respiratory function
Changes in neural control of respiration, Alteration in carbon dioxide production, Disturbance in gas exchange function, Abnormalities in respiratory function Rationale:Hypercapnia refers to an increase in carbon dioxide levels. In the clinical setting, four factors contribute to hypercapnia: alterations in carbon dioxide production, disturbance in the gas exchange function of the lungs, abnormalities in respiratory function of the chest wall and respiratory muscles, and changes in neural control of respiration. A decrease in carbon dioxide production does not cause hypercapnia.
Which individual is at greatest risk for developing a venous thrombosis resulting from venous stasis? Client in the terminal stage of cancer Pregnant woman Client on bed rest Dehydrated client
Client on bed rest Rationale:Bed rest or immobility causes a pooling of blood in the legs resulting in venous stasis. The other individuals are at risk for hyperreactive blood coagulation that can also result in venous thrombosis.
The nurse is assessing a client said to be in sinus rhythm. What does the nurse expect to find when evaluating the electrocardiogram? Select all that apply. Absence of T waves. Irregular rhythm Constant R to R intervals A "P" before every QRS wave A rate between 60 and 100 beats per minute
Constant R to R intervals, A "P" before every QRS wave, A rate between 60 and 100 beats per minute Rationale:In sinus rhythm, the sinus node discharges at a rate between 60 and 100 beats per minute. On the ECG, a P wave is observed before every QRS complex. R to R intervals remain constant. The rhythm is regular and T waves are present.
A client has developed chronic hypoxia and has developed pulmonary hypertension (HTN). The nurse recognizes that the most likely cause of pulmonary hypertension would be: Hardening of the pulmonary vessels due to increased fat deposits Decreased vascular resistance in the pulmonary vessels Constriction of the pulmonary vessels in response to hypoxemia Constant dilation of the pulmonary vessels in response to hypoxia
Constriction of the pulmonary vessels in response to hypoxemia Rationale:Pulmonary HTN occurs as a result of chronic hypoxia. In response to hypoxia, the pulmonary vessels constrict. The pulmonary vessels differ from the systemic circulation vessels, which dilate in response to hypoxia and hypercapnia. Smooth muscle hypertrophy and proliferation of the vessel intima occur in pulmonary HTN.
A 65-year-old male client is diagnosed with systolic hypertension. The nurse educates the client about how the aging process and development of stiff, large arteries can result in which physiologic occurence? Select all that apply. Unstable blood pressure Increased diastolic pressure Decreased diastolic pressure Widened pulse pressure Increased systolic pressure
Decreased diastolic pressure, Widened pulse pressure, Increased systolic pressure Rationale:The stiffening of the large arteries results in increased systolic pressure. Diastolic pressure may decrease or remain unchanged. The pulse pressure widens as systolic pressure rises. Stiffening of the arteries does not produce unstable blood pressure
A diagnosis of tension pneumothorax would be suspected in which physical assessment finding? Hypoxia Symmetry of chest during inspiration Deviated trachea Increased respiratory rate
Deviated trachea Rationale:Physical assessment findings of a deviated trachea and neck vein distention would indicate a tension pneumothorax. Asymmetry of the chest during inspiration would suggest a spontaneous pneumothorax. Both would need to be confirmed by radiology. The remaining options are nonspecific and occur in many conditions.
A client has developed constrictive pericarditis and myocardial hypertrophy. Select the most likely cause. Systolic dysfunction Diastolic dysfunction Frontward failure Backward failure
Diastolic dysfunction Rationale:The conditions that cause diastolic dysfunction are those that impede expansion of the ventricles (i.e., pericarditis), those that increase ventricular wall thickness and reduce chamber size (i.e., myocardial hypertrophy), and those that delay diastolic relaxation (i.e., aging).
Which diagnosis will present the highest risk for hypercapnic/hypoxemic respiratory failure? Drug overdose Atelectasis Pulmonary edema Severe pneumonia
Drug overdose Rationale:A client diagnosed with drug overdose has the greatest risk of developing hypercapnic/hypoxemic respiratory failure. Severe pneumonia and atelectasis presents a risk for simple hypoxemic respiratory failure, whereas impaired diffusion is a possible outcome for pulmonary edema.
What manifestations would the nurse expect to find when assessing a client with a right pleural effusion? Select all that apply. Dyspnea on exertion Hypoxemia Diminished right breath sounds Elevated WBC count Stabbing chest pain with breathing
Dyspnea on exertion, Hypoxemia, Diminished right breath sounds Rationale:Pleural effusion may vary according to the cause. Classic signs include diminished breath sounds over the affected area, and dyspnea as seen with increased effort or rate of breathing. Hypoxemia may occur due to reduced surface area for gas exchange. When there is infection, the signs and symptoms can include fever and elevated white blood cell (WBC) count. Pleuritic chest pain is present with inflammation that is commonly caused by infection.
A client has been diagnosed with runs of intermittent ventricular tachycardia where the client loses consciousness and needs to be stimulated to recovery. Knowing this history, the nurse will educate the client about which treatment intervention/procedure that will depolarize the heart to allow the sinoatrial node to regain control of the heart? Immediate pacemaker implantation The benefits of ablation therapy bi-monthly Education involving automatic implantable cardioverter-defibrillators implantation The benefits of antiarrhythmic drugs and possible side effects
Education involving automatic implantable cardioverter-defibrillators implantation Rationale:Automatic implantable cardioverter-defibrillators are used to treat people with life threatening ventricular tachyarrhythmias by the use of intrathoracic electrical countershock. A cardiac pacemaker is an electronic device that delivers an electrical stimulus to the heart. It is beneficial for those with atrioventricular heart block, symptomatic bradycardia, and other cardiac arrhythmias. Leads are placed in the atria, ventricles or both. Drugs may help control heart rhythms, but they cannot stop ventricular tachycardia unless given intravenously in an intensive care setting. Ablation therapy is used to treat recurrent, life-threatening supraventricular and ventricular tacyarrhythmias. Ablation therapy is performed by catheter or surgical techniques and involves localized destruction, isolation, or excision of cardiac tissue.
Atrial fibrillation is the most common chronic dysrhythmia whose incidence increases with age. Atrial fibrillation may present as asymptomatic to severe symptomatology. What is the treatment of atrial fibrillation dependent on? Select all that apply. Etiology Size of pulse deficit Atrial rate Recency of onset Persistence of dysrhythmia
Etiology, Recency of onset, Persistence of dysrhythmia Rationale:The treatment of atrial fibrillation depends on its cause, recency of onset, and persistence of the dysrhythmia. The size of the pulse deficit and the atrial rate are not variables in treatment of atrial fibrillation.
The community health nurse is developing a program to decrease the amount of pulmonary tuberculosis that has recently risen in her area. Which populations at risk will the nurse target? Select all that apply. Foreign-born people from countries with a high incidence of tuberculosis People who have been admitted to the hospital at least twice in one year HIV-infected people Residents of high-risk congregate settings People who have high stress levels
Foreign-born people from countries with a high incidence of tuberculosis, HIV-infected people, Residents of high-risk congregate settings Rationale:Tuberculosis is a particular threat among HIV-infected people, foreign-born people from countries with a high incidence of tuberculosis, and residents of high-risk congregate settings such as correctional facilities, drug treatment facilities, and homeless shelters.
What is the most important factor in myocardial oxygen demand? Respiratory rate Degree of anxiety Heart rate Hyperthermia
Heart rate Rationale:The heart rate is the most important factor in myocardial oxygen demand since, as heart rate increases, myocardial oxygen demands increase. The degree of effect the other options have on myocardial oxygen demand is related to how much effect they have on heart rate.
Which factors increase the risk that a client will develop chronic obstructive pulmonary disease (COPD)? Select all that apply. Diabetes mellitus Obesity History of myocardial infarction History of tobacco use History of asthma
History of tobacco use, History of asthma Rationale:Smoking is the primary cause of chronic obstructive pulmonary disease (COPD). Additional causes are a hereditary deficiency of alpha1-antitrypsin and asthma. Obesity may contribute to respiratory distress, but is not a cause of COPD. Myocardial infarction (MI) and diabetes mellitus are contributing factors to heart disease, not COPD.
The health care provider is teaching a client about modifiable risk factors for atherosclerosis. The most appropriate information to provide would be: Family history of heart disease Being male Hypertension 55 years of age
Hypertension Rationale:The major risk factors that can be modified by a change in health care behaviors include cigarette smoking, obesity, hypertension, hyperlipidemia and elevated LDL cholesterol, and diabetes mellitus, all of which are traditional cardiovascular risk factors. The other options are nonmodifiable risk factors for atherosclerosis.
A client admitted to the emergency department is experiencing sinus tachycardia. What can cause this dysrhythmia that the nurse should monitor for? Select all that apply. Hyperthyroidism Insomnia Fever Pain Blood loss
Hyperthyroidism, Fever, Pain, Blood loss Rationale:Sinus tachycardia is a normal response during fever, blood loss, anxiety, pain, and exercise, and in situations that incite sympathetic stimulation. It may be associated with congestive heart failure, myocardial infarction, and hyperthyroidism. Pharmacologic agents such as atropine, isoproterenol, epinephrine, and quinidine also can cause sinus tachycardia.
The nurse is assisting a client who had a myocardial infarction 2 days ago during a bath. The client suddenly lost consciousness and the nurse was unable to feel a pulse. Cardiopulmonary resuscitation was begun and the client was connected to the monitor with a gross disorganization without identifiable waveforms or intervals observed. What is a priority intervention at this time? Administration of atropine Immediate defibrillation Applying a transcutaneous pacemaker Synchronized cardioversion
Immediate defibrillation Rationale:The classic electrocardiographic pattern of ventricular fibrillation is that of gross distortion without identifiable waveforms or or intervals. When the ventricles do not contract, there is no cardiac output, and there are no palpable or audible pulses. Immediate defibrillation using a nonsynchronized, direct-current electrical shock is mandatory for ventricular fibrillation and for ventricular flutter that has caused loss of consciousness.
When will the nurse plan to assess a client's blood pressure to confirm the possible diagnosis of orthostatic hypotension? In the morning before arising from bed In the evening just before sleep Midmorning right after taking a short walk Within a half-hour after the heaviest meal of the day
In the morning before arising from bed Rationale:To confirm orthostatic hypotension, blood pressure should be assessed while the client is supine and then after standing for 1 minute and 3 minutes. A fall of 20 mm Hg or more in systolic pressure, or 10 mm Hg or more in diastolic pressure, are considered orthostasis.
In understanding the pathology of pneumoccocal pneumonia, what occurs in the gray hepatization stage? The alveoli become filled with rich edema fluid containing numerous organisms. The alveolar exudate is removed and the lungs gradually return to normal. Capillary congestion leads to massive outpouring of polymorphonuclear leukocytes and red blood cells, leaving the lung red. Macrophages phagocytose the red blood cells and other cellular debris, leaving the lung firm and less congested.
Macrophages phagocytose the red blood cells and other cellular debris, leaving the lung firm and less congested. Rationale:In the gray hepatization stage, macrophages phagocytose the fragmented polymorphonuclear cells, RBCs, and other cellular debris. Alveolar exudate is removed in the resolution stage, while the lung becomes red during the red hepatization phase. The alveoli become filled with rich edema fluid in the edema stage.
The nurse is developing a plan of care for a client diagnosed with stable angina. Select the most important goal for this client. Preventing clotting disorders Assisting the client to return to previous lifestyle Ensuring adequate oxygenation with continuous oxygen administration Myocardial infarction prevention
Myocardial infarction prevention Rationale:Symptom reduction for quality of life and prevention of MI are treatment goals for stable angina. The other options would not be treatment goals for stable angina.
Which statements concerning hypoxemia are true? Select all that apply. Normally, serum lactate levels are between 0.5-1 mmol/L (4.5-9.0 mg/dL) The brain is vulnerable to hypoxia. With hypoxemia, aerobic metabolism replaces anaerobic metabolism. The condition depends on the body's ability to adapt to lowered oxygen levels. When hypoxemia occurs, metabolic acidosis is a possible outcome.
Normally, serum lactate levels are between 0.5-1 mmol/L (4.5-9.0 mg/dL), The brain is vulnerable to hypoxia., The condition depends on the body's ability to adapt to lowered oxygen levels., When hypoxemia occurs, metabolic acidosis is a possible outcome. Rationale:Hypoxemia produces its effects through tissue hypoxia and the compensatory mechanisms that the body uses to adapt to the lowered oxygen level. Body tissues vary considerably in their vulnerability to hypoxia. Tissues with the greatest need are the brain, lungs, and heart. If the PO2 of the tissues falls below a critical level, aerobic metabolism ceases and anaerobic metabolism takes over, with formation and release of lactic acid, resulting in increased serum lactate levels and metabolic acidosis. The normal range of serum lactate levels is 1 - 0.5 mmol/L (9.0 - 4.5 mg/dL) in non-acutely ill people.
When an acute event occurs and the circulatory system can no longer provide the body with adequate perfusion of its tissues and organs, cellular hypoxia occurs and the body goes into shock. What are the causes of shock in the human body? Select all that apply. Obstruction of blood flow Hypervolemia Excessive vasoconstriction Hypovolemia Maldistribution of blood flow
Obstruction of blood flow, Hypovolemia, Maldistribution of blood flow Rationale:Shock is not a specific disease but a syndrome that can occur in the course of many life-threatening traumatic conditions or disease states. It can be caused by an alteration in cardiac function (cardiogenic shock), a decrease in blood volume (hypovolemic shock), excessive vasodilation with maldistribution of blood flow (distributive shock), or obstruction of blood flow through the circulatory system (obstructive shock). Excessive vasoconstriction and hypervolemia are not causes of shock.
Considering the PQRST complex of an electrocardiogram (ECG), which letter designation represents atrial depolarization? ST segment QRS complex P wave T wave
P wave Rationale:The P wave represents the sinoatrial node and atrial depolarization; the QRS complex depicts ventricular depolarization, and the T wave represents repolarization.
Which of the following are characteristic signs of acute arterial embolism? Pallor, pulselessness, and pain Purpura, muscle weakness, and shortness of breath Paralysis, warmth, and paranoia Pain, increased blood pressure, and warmth
Pallor, pulselessness, and pain Rationale:The presentation of acute arterial embolism is often described as that of the seven Ps: pistol shot (acute onset), pallor, polar (cold), pulselessness, pain, paresthesia, and paralysis.
Exudate in the pericardial cavity is a characteristic of which cardiac condition? Cardiac tamponade Pericardial effusion Acute pericarditis Constrictive pericarditis
Pericardial effusion Rationale:Pericardial effusion, either acute or chronic, refers to the presence of an exudate in the pericardial cavity. Acute pericarditis is characterized by chest pain, ECG changes, and pericardial friction rub. Cardiac tamponade represents a life-threatening compression of the heart resulting from excess fluid in the pericardial sac. In constrictive pericarditis, scar tissue develops between the visceral and parietal layers of the serous pericardium. In time, the scar tissue contracts and interferes with cardiac filling.
A 40-year-old male presents to the emergency department reporting chest pain and shortness of breath. The health care provider suspects a pulmonary embolism and orders several diagnostic tests. Select the test that would require further follow-up. Abnormal EKG Elevated CPK-MB Decreased white blood cells Positive D-dimer
Positive D-dimer Rationale:The D-dimer test is a good indicator that a clotting disorder has occurred. A positive result indicates a need to be further investigated for possible pulmonary embolism given the client's symptoms. The elevated CPK-MB and EKG may indicate cardiac abnormalities.
Which of the following occurs during repolarization? Positively charged K+ moves outward across the cell membrane Positively charged Na+ moves outward across the cell membrane Positively charged Na+ moves into the cell membrane Positively charged K+ moves into the cell membrane
Positively charged K+ moves outward across the cell membrane Rationale:During rapid repolarization period, the slow Ca++ channels close and the influx of Ca++ and Na+ ceases. There is a sharp rise in K+ permeability, contributing to the rapid outward movement of K+ and reestablishing the resting membrane potential.
A 62-year-old female client presents to the emergency department and is diagnosed with acute heart failure syndrome. Which assessment finding would the nurse expect? Slowed breathing and dehydration. Shortness of breath and bradycardia. Productive cough with frothy sputum. Increased urination and dry skin.
Productive cough with frothy sputum. Rationale:The signs and symptoms of acute heart failure syndromes include shortness of breath and other respiratory manifestations (i.e., exertional dyspnea, orthopnea), fatigue and limited exercise tolerance, fluid retention and edema, cachexia and malnutrition, and cyanosis. Acute pulmonary edema is the most dramatic symptom of AHFS. The client would have an increased heart rate as a result of the exertional process.
A client experiencing a sinus arrest would demonstrate which symptom or finding? P-wave that occurs more frequently than expected Spontaneous persistent sinus bradycardia Prolonged periods of asystole demonstrated on an electrocardiogram Heart rate of greater than 100 beats/min
Prolonged periods of asystole demonstrated on an electrocardiogram Rationale:Sinus arrest refers to failure of the sinoatrial node to discharge and results in an irregular pulse, prolonged periods of asystole, and predisposition to other dysrhythmias. The other options do not demonstrate the symptoms demonstrated during a sinus arrest.
A client has been diagnosed with deep vein thrombosis (DVT). The nurse is planning care and recognizes that the client is most at risk for: Arterial insufficiency Polyarteritis nodosa Pulmonary embolism Vasculitis
Pulmonary embolism Rationale: Deep venous thrombosis (DVT) most commonly occurs in the lower extremities. DVT of the lower extremity is a serious disorder, complicated by pulmonary embolism, recurrent episodes of DVT, and development of chronic venous insufficiency. Isolated calf thrombi often are asymptomatic. If left untreated, they may extend to the larger, more proximal veins, with an increased risk of pulmonary emboli.
The nurse needs to assess the oxygen status of a client who is suddenly experiencing shortness of breath. The most appropriate noninvasive measurement technique would be: Arterial blood gas analysis Assessment of the rate and depth of respiration Pulse oximetry Pulmonary function tests
Pulse oximetry Rationale:Noninvasive measurements of arterial O2 saturation of hemoglobin can be obtained using an instrument called the pulse oximeter. Sensors that can be placed on the finger, toe, ear, or forehead are available. Although pulse oximetry is not as accurate as arterial blood gas measurements, it provides the means for noninvasive and continuous monitoring of O2 saturation, which is a useful indicator of respiratory and circulatory status.
A client with a known history of intravenous drug abuse has been diagnosed with infective endocarditis. Select the most likely cause of infection. Kingella kingae Eikenella corrodens Actinobacillus actinomycetemcomitans Staphylococcus aureus
Staphylococcus aureus Rationale:While all of these bacteria can cause infective endocarditis, Staphylococcus aureus is the major offender in injection drug abusers, whereas prosthetic heart valve infective endocarditis tends to be caused by coagulase-negative staphylococci (e.g., Staphylococcus epidermidis).
The nurse develops a plan to prevent atelectasis in a postsurgical client. Which intervention will be effective? Teaching the client to wear an abdominal binder Encouraging calf-pumping exercises Administering IV antibiotics Supervision of hourly deep-breathing exercises
Supervision of hourly deep-breathing exercises Rationale:Ambulation, deep-breathing exercises and changing body positions help to prevent postoperative atelectasis. An abdominal binder may restrict full diaphragmatic movement. Calf-pumping exercises and elastic stockings are designed to prevent blood clots, but do not assist in lung expansion. IV antibiotics prevent and treat infection, but do not aid lung expansion.
A client has been diagnosed with a dissecting aortic aneurysm. It is most important for the nurse to assess the client for: Tonic-clonic seizures Chest pain radiating to the right arm Late hypertensive crisis Tearing or ripping-type pain in the chest or back
Tearing or ripping-type pain in the chest or back Rationale:A major symptom of a dissecting aneurysm is the abrupt presence of excruciating pain, described as tearing or ripping. Pain associated with dissection of the ascending aorta frequently is located in the anterior chest, and pain associated with dissection of the descending aorta often is located in the back. In the early stages, blood pressure typically is moderately or markedly elevated.
A client arrives in the clinic with a cough, fever, and chest discomfort and is diagnosed with community-acquired pneumonia. What education does the nurse anticipate providing prior to discharging the client from the clinic? The use of antibiotics The use of antiviral medications Limiting fluid intake until the fever is normal Maintaining bed rest for 7 days
The use of antibiotics Rationale:Treatment for community-acquired pneumonia involves the use of appropriate antibiotic therapy. Empiric antibiotic therapy, based on knowledge regarding an antibiotic's spectrum of action and ability to penetrate bronchopulmonary secretions, often is used for people with community-acquired pneumonia who do not require hospitalization.
Which serum biomarker is highly specific for myocardial tissue? Troponin C-reactive protein Creatine kinase White blood cells
Troponin Rationale:The troponin assays have high specificity for myocardial tissue and have become the primary biomarker tests for the diagnosis of myocardial infarction. Creatine kinase is specific for muscle injury but is not as focused as is troponin. White blood cells and C-reactive protein are associated with inflammation.
A client with a history of heart failure and COPD (caused by 60 pack/year smoking) presents to the clinic reporting difficulty breathing. Auscultation of breath sounds reveal absent/diminished breath sounds in the right lower lobe. Which other manifestations lead the health care provider to suspect the client may have developed atelectasis? Select all that apply. Copious amounts of thick, green sputum. Using accessory muscles to help him breathe. "Seems like I'm not making much water (decreased urine production)." "Having a hard time catching my breath." Respiratory rate—32; pulse rate—122 beats/min.
Using accessory muscles to help him breathe., "Having a hard time catching my breath.", Respiratory rate—32; pulse rate—122 beats/min. Rationale:Atelectasis is caused most commonly by airway obstruction rather than a vascular obstruction. The clinical manifestations of atelectasis include tachypnea (respiratory rate of 32), tachycardia (pulse rate of 122), dyspnea (hard time catching breath), cyanosis, signs of hypoxemia, diminished chest expansion, absence of breath sounds, and intercostal retractions (use of accessory muscles). Both chest expansion and breath sounds are decreased on the affected side. There may be intercostal retraction (pulling in of the intercostal spaces) over the involved area during inspiration. Urine production is not related to atelectasis. Copious green sputum is associated with infection.
Which dysrhythmia is considered to be the most fatal and requires immediate treatment? Premature atrial contractions Atrial flutter Ventricular fibrillation Premature ventricular contractions
Ventricular fibrillation Rationale:Ventricular fibrillation represents severe derangements of cardiac rhythms that terminate fatally within minutes unless corrective measures are taken promptly. All of the other dysrhythmias need to have further investigation into etiology, but are not immediately fatal.
The health care team is developing a plan of care for a client diagnosed with congestive heart failure (CHF). The primary treatment goal would be: placing a stent for fluid drainage from the heart. improving quality of life by relieving symptoms. eliminating CHF through curing the disease. maintaining higher oxygen levels to decrease the work of breathing.
improving quality of life by relieving symptoms. Rationale:A primary treatment goal for a client with CHF is to improve the quality of life through symptom management. CHF will not be cured, and maintaining a higher oxygen level will assist with dyspnea associated with CHF. A stent is not an option for treatment of CHF.
A preventive measure to decrease the risk of developing rheumatic heart disease includes: scheduling regular hearing examinations. prompt diagnosis of streptococcal infections with a throat culture. yearly electrocardiography after the age of 50. blood specimen assessed for rheumatoid factor.
prompt diagnosis of streptococcal infections with a throat culture. Rationale:Rheumatic heart disease is normally caused by streptococcal infections; therefore, early diagnosis of these would decrease the risk for the disease. Frequent EKG may be required after a client has a history of rheumatic heart disease. Rheumatoid factor is not related to rheumatic heart disease, and while the client may benefit from regular hearing examinations, it is not related to preventing rheumatic heart disease.