Exam 2
A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment findings? •A) Malaise •B) Dark stools •C) Weight gain •D) Left upper quadrant discomfort
a
A student is comparing the different parts of the gastrointestinal (GI) tract. Which statement demonstrates understanding? "The esophagus is where most of the absorptive processes occur." "The mouth is the receptacle where initial digestive processes take place." "The jejunum serves as a storage channel for the elimination of waste." "The cecum is where most digestive and absorptive processes occur."
"The mouth is the receptacle where initial digestive processes take place." The GI tract can be divided into three parts: upper, middle, and lower segments. The upper part contains the mouth and esophagus and acts as a receptacle through which food passes and initial digestive processes take place. The middle portion, containing the jejunum, is where most digestive and absorptive processes occur. The lower segment, containing the cecum, serves as a storage channel for the efficient elimination of waste.
Which teaching point would be most appropriate for a group of older adults who are concerned about their cardiac health? "People with plaque in their arteries experience attacks of blood flow disruption at seemingly random times." "The plaque that builds up in your heart vessels obstructs the normal flow of blood and can even break loose and lodge itself in a vessel." "Infections of any sort are often a signal that plaque disruption is in danger of occurring." "The impaired function of the lungs that accompanies pneumonia or chronic obstructive pulmonary disease is a precursor to plaque disruption."
"The plaque that builds up in your heart vessels obstructs the normal flow of blood and can even break loose and lodge itself in a vessel."
A client with heart failure has an echocardiogram performed, revealing an ejection fraction (EF) of 40%. The nurse knows this EF is below normal and explains to the client: "This means you have a lot of pressure built up inside your heart." "This means your heart is not pumping as much blood out of the heart with each beat." "You need to increase the amount of exercise you do to get your heart muscle back in shape." "Your ventricular muscle is getting too stiff to beat normally."
"This means your heart is not pumping as much blood out of the heart with each beat."
normal basophil levels
0-2%
normal eosinophil levels
0-3%
normal platelet levels
150,000-400,000
Normal HC03 levels
22-26
normal lymphocyte levels
24-40%
Normal CO2 levels
35-45 mmHg
normal WBC count
4,800-10,800
normal monocyte levels
4-9%
normal hematocrit levels
40-50%
normal Neutrophil range
47-63%
Normal pH
7.35-7.45
Normal Oxygen levels
80-100
The nurse is planning to teach a client with gastroesophageal reflux disease about substances to avoid. Which items should the nurse include on this list? •A) Coffee •B) Chocolate •C) Peppermint •D) Nonfat milk •E) Fried chicken •F) Scrambled eggs
A b c e
A client is admitted to the cardiac unit with a diagnosis of pericarditis. The nurse is teaching the client about the anatomical location of the infection. The nurse evaluates the effectiveness of the teaching when the client correctly identifies which of the following as the location of the pericardium? The outer muscular layer of the heart The innermost lining of the heart chambers A membranous sac that encloses the heart The electrical conduction system of the heart
A membranous sac that encloses the heart
Which symptom is often observed in cases of peritonitis? Abdominal rigidity Bradycardia Decreased white blood cell count Deep, rhythmic breathing
Abdominal rigidity The abdomen is rigid and becomes boardlike because of reflex muscle guarding. The client typically becomes tachycardic, has increased WBC count, and breathes in a shallow way to avoid movement of the abdomen related to the pain.
The nursing instructor, when teaching the students about coronary artery disease (CAD), identifies which of the following as the main cause of CAD? Defect in the DNA Atherosclerosis Excessive exercise Excessive use of dairy products
Atherosclerosis
The nurse is providing care for a client in the emergency department being treated for an acute myocardial infarction. The health-care provider prescribes treatment with morphine sulfate IV push. Which is the best reason for this prescribed medication? a)Immediately alleviates pain b)Effectively treats anxiety c)Affects respiratory function d)Improves gas exchange
D- improves gas exchange bc it leads to vasodilation->overall gas exchange
When interpreting the arterial blood gas, the nurse recognizes which of these reflects the value for bicarbonate?
Bicarbonate is abbreviated as HCO3. H2CO3 is the abbreviation for carbonic acid, HCl is the abbreviation for hydrochloric acid, and H+ is the abbreviation for hydrogen.
The efficiency of the heart as a pump often is measured in the amount of blood the heart pumps per minute. Which is the correct formula to figure out the cardiac output?
CO=SVx HR
When caring for a client with hyperkalemia, the nurse prioritizes assessment of which body system? Cardiovascular Hepatic Cerebrovascular Pulmonary
Cardiovascular The most serious effect of hyperkalemia is disturbances in cardiac conduction. Peaked, narrow T waves and widening of the QRS complex occur first, followed by prolongation of the PR interval and disappearance of P waves with bradycardia. Ventricular fibrillation and cardiac arrest are terminal events.
An older adult client present with fever, leukocytosis, left lower quadrant pain, and diarrhea alternating with constipation. The nurse concludes that these are frequently seen in clients with which health problem? Appendicitis Diverticulitis Peptic ulcer disease Irritable bowel syndrome
Diverticulitis Rationale: B is correct. Fever and diarrhea accompany diverticulitis. Fever indicates infection, which would rule out PUD and IBS. Appendicitis typically causes pain in the umbilical area or RLQ and is not accompanied by diarrhea. The diarrhea and constipation alternate since stool will get caught in the pouches and be excreted later. The pain is usually left lower quadrant since the pouchings usually occur in the descending colon (LLQ).
Which of the following is a late sign of heart failure? Shortness of breath Orthopnea Edema Frothy-blood tinged sputum
Frothy-blood tinged sputum Rationale: D is correct. This is BAD! This means our patient has fluid and blood in their lungs and they have severely impaired gas exchange. It is a late sign of HF since in early stages, you just have lung congestion with normal fluid from the impaired pumping of the left heart (fluid eventually backs up into pulmonary circulation, causing crackles and wheezes, ultimately restricting airflow)
Respiratory alkalosis can be caused by a respiratory rate in excess of that which maintains normal plasma PCO2 levels. What is a common cause of respiratory alkalosis?
Hyperventilation One of the most common causes of respiratory alkalosis is hyperventilation, which is characterized by episodes of overbreathing, often associated with anxiety.
A client asks the nurse what part of the brain regulates appetite. Which is the best response by the nurse? Hypothalamus Medulla Midbrain Cerebellum
Hypothalamus
A 20-year-old college student has a pelvic fracture and a severed leg from a motorcycle accident. She lost several units of blood. When the student arrived in the emergency department, her blood pressure was very low, her pulse was high, and her skin was pale. The nurse knows that this client has developed which type of shock? Cardiogenic Hypovolemic Distributive Obstructive
Hypovolemic Hypovolemic shock occurs when there has been extensive blood or body fluid loss. Cardiogenic shock occurs when the heart loses its ability to pump sufficient blood to meet oxygenation needs of body tissues. Distributive shock is loss of blood vessel tone, resulting in expansion of the vascular compartment. Obstructive shock is an inability of the heart to fill or empty properly.
The following lab results were returned on a client who is suspected of having pancreatitis. The nurse concludes that which result gives positive evidence of pancreatitis? Lipase 230 IU/liter Calcium 9.3 mg/dL Blood glucose 75 mg/dL White Blood cell count 5000/mm3
Lipase 230 IU/liter Rationale: A is correct. If the client is suspected of having pancreatitis, the amylase and lipase levels will be checked since these are the digestive enzymes secreted by the pancreas. If it is malfunctioning, the levels will be abnormally high. Normal amylase = 30-125 U/L and normal lipase = 10-150 U/L. When there is a problem with the pancreas, these levels can be up to 3x higher than the normal. All of the other lab values are within normal range
A client has been diagnosed with non-Hodgkin lymphoma (NHL), a form of malignancy that originates in which body site? Thymus Spleen Bone marrow Lymph nodes
Lymph nodes
A patient has the following arterial blood gases: HCO3 38, pH 7.50, PaCO2 50. What acid base imbalance is occurring and what may happen with the patient as a compensatory mechanism? Metabolic alkalosis, exhibit hypoventilation Metabolic acidosis, exhibit hyperventilation Respiratory acidosis, kidneys will excrete less bicarbonate and release more Respiratory alkalosis, kidneys will excrete more bicarbonate and release less
Metabolic alkalosis, exhibit hypoventilation Rationale: A is correct. The patient is in metabolic alkalosis since the pH and bicarbonate are both high, which is the normal relationship. The CO2 is also high, since the lungs are compensating for the alkalotic pH. This means that the pt will be hypoventilating to hold onto more CO2 to counteract the high pH and bring it down back to normal.
Acute lymphocytic leukemia (ALL) and acute myelocytic leukemia (AML) are 2 distinct disorders with similar presenting clinical features. What clinical features do ALL and AML share? Night sweats Weight gain High fever Polycythemia
Night sweats Rationale: A is correct. Although ALL and AML are distinct disorders, they typically present with similar clinical features. Both are characterized by an abrupt onset of symptoms, including fatigue resulting for anemia, low grade fever, night sweats and weight loss d.t rapid proliferation and hypermetabolism of leukemic cells; bleeding because of a decreased platelet count and bone pain and tenderness d.t bone marrow expansion. Polycythemia is an increase in RBC in the blood which is not an indication of leukemia. One of the major differences between the two is ALL usually affects kids and AML affects adults (think acute lymphocytic = little ones)
Upon admission, a client tells the nurse that he takes aspirin every 4 hours every day. The nurse determines that this client is at risk for: Peptic ulcer Cancer of the stomach Zollinger-Ellison syndrome Crohn disease
Peptic ulcer Peptic ulcers occur in the areas of the upper gastrointestinal tract and are caused by Helicobacter pylori infection and aspirin or nonsteroidal anti-inflammatory drug use. Therefore, the nurse determines that a client taking aspirin every 4 hours daily is at risk for a peptic ulcer.
Which assessment does the nurse recognize is consistent with signs and symptoms of acute pancreatitis? Groin pain Periumbilical pain Pulse of 58 beats per minute Hypertension
Periumbilical pain Abdominal pain is a cardinal manifestation of acute pancreatitis. The pain is usually located in the epigastric or periumbilical region and may radiate to the back, chest, or flank areas. Physical examination findings include fever, tachycardia, hypotension, severe abdominal tenderness, respiratory distress, and abdominal distention.
Which of the following are NOT typical signs and symptoms of right-sided heart failure? Select-all-that-apply: a. Jugular venous distention b. Persistent cough c. Weight gain d. Crackles e. Nocturia f. Orthopnea
Rationale: B, D, F are correct. Remember left = lung. The question is asking which symptoms are NOT for RIGHT sided HF. So, we need to look for s/s of left sided heart failure which manifest in the lungs, so persistent cough, crackles, orthopnea, paroxysmal nocturnal dyspnea, cyanosis, confusion, bloody sputum, tachypnea, wheezes, etc. could all be included. Right sided HF is affecting the body causing edema, ascites, JVD, weight gain, anorexia, fatigue etc. REMEMBER acronyms, drowning (left), swelling (right)
What of these would be tested by a complete blood count (CBC)? Lymphocytes and neutrophils Red blood cells and platelets Size and shape of blood cells Sodium and potassium
Red blood cells and platelets A CBC is a commonly performed screening test that determines the number of red blood cells, white blood cells, and platelets per unit of blood. Lymphocytes and neutrophils may be included in the CBC if a differential of white blood cells was also ordered. Electrolytes and size/shape of blood cells are not part of a CBC.
A patient with COPD has the following blood gases: PCO2 59, pH 7.26, HCO3 42. Which of the following conditions is presenting? Metabolic acidosis Respiratory acidosis Metabolic alkalosis Respiratory alkalosis
Respiratory acidosis Rationale: B is correct. This is respiratory acidosis since the pH is low and the CO2 is high, which is the normal relationship. The bicarbonate is also high since this is the compensatory mechanism to counteract the acidic pH in the body. So, the kidneys will hold onto more bicarbonate instead of excreting it, so more can be released into the body.
A client has had an acute myocardial infarction (MI). The brother of the client has a history of angina. The client asks how he will know if his brother's pain is angina or if the brother is actually having an MI. Which statement is correct? Chest pain with angina only occurs during the day; MI pain is more likely at night. Chest pain with angina only occurs at rest; MI pain occurs during a stressful time. Pain is more severe and lasts longer with angina than with an MI. Rest and intake of nitroglycerin relieve chest pain with angina; they do not relieve chest pain with an MI.
Rest and intake of nitroglycerin relieve chest pain with angina; they do not relieve chest pain with an MI.
The nurse assessing a client with a diagnosis of cholelithiasis will look for pain in which area? Right upper quadrant Left upper quadrant Right lower quadrant Left lower quadrant
Right upper quadrant The pain is usually located in the upper right quadrant or epigastric area and may be referred to the upper back, right shoulder, or midscapular region. Typically, the pain is abrupt in onset, increases steadily in intensity, persists for 2 to 8 hours, and is followed by soreness in the upper right quadrant.
The community health nurse is teaching about prevention of hepatitis A. Which group does the nurse suggest will benefit from this vaccine? Those who have been recently exposed to hepatitis A Homosexual women Those traveling to Third World countries Those working for the Centers for Disease Control and Prevention
Those traveling to Third World countries
Which clinical manifestation would lead the nurse to suspect a client has developed fluid volume excess? Weight gain Increased blood urea nitrogen (BUN) Decreased blood pressure Decreased urine output
Weight gain Isotonic fluid volume excess is manifested by an increase in interstitial and vascular fluids and is characterized by weight gain over a short period of time. As vascular volume increases, central venous pressure increases, leading to distended neck veins, slow-emptying peripheral veins, a full and bounding pulse, and an increase in central venous pressure. Decreased blood pressure as well as a weak, rapid pulse reflect volume deficit. BUN and hematocrit may decrease as a result of dilution due to expansion of the plasma volume.
An older adult client presents with complaints of crushing pain on the left side of the chest. After the client is examined, it is found that the client has unstable angina. Which intervention to reduce the pain is appropriate for the client? a)Administering nitroglycerin b)Changing the position of the client c)Encouraging the client to take deep breaths d)Administering antianxiety medication
a
The registered nurse is reviewing cardiac output with nursing staff. Which statement by an attending nurse indicates understanding? a)"Cardiac output is the amount of blood that the heart pumps out of the left ventricle." b)"Cardiac output is increased in heart failure." c)"Cardiac output is unvaried by body size." d)"Adrenergic stimulation slows heart rate, and cholinergic stimulation raises heart rate."
a
The registered nurse is reviewing information with coronary staff nurses about the renin-angiotensin-aldosterone system (RAAS). Which statement made by an attending nurse indicates understanding? a)"RAAS is a mechanism that regulates arterial blood pressure." b)"RAAS is a mechanism that decreases blood pressure." c)"RAAS is a mechanism that increases blood volume in response to increased renal perfusion." d)"RAAS is a mechanism with detrimental effects that decrease workload for the left ventricle."
a
When listening to heart sounds, you can best hear S1 at the: base of the heart. apex of the heart. aortic area. second intercostal space to the right of the sternum.
apex of the heart. Rationale: B is correct. S1 is best heard at the apex of the heart. S1 is the closing of the atrioventricular valves which is the first sound heard (so S1) and the AV valves are lower than the SL valves. S2 is the closing of the SL valves. This is heard second (so S2) and the SL valves are higher than the AV valves. Remember, the base in the top of the heart and the apex is the point at the bottom!! The pulmonary semilunar valve sounds (pulmonic valve) can be heard in the 2nd ICS to the right of the sternum; the aortic SL valve can be heard in 2nd ICS to the left of the sternum. Remember your cardiac assessment for fundamentals, this will help you
Which statement best differentiates cardiac afterload from cardiac preload? a)Cardiac afterload is the volume of blood in the heart at the end of diastole. b)Cardiac afterload is the amount of resistance that the ventricle must overcome. c)Cardiac afterload is the factor that affects cardiac output. d)Cardiac afterload is the amount of blood that enters the right atrium.
b
The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Where should the nurse anticipate the location of the pain? •A) Right lower quadrant, radiating to the back •B) Left lower quadrant •C) Right groin pain •D) Right upper quadrant, radiating to the right scapula and shoulder
d
Which wave in the electrocardiogram represents ventricular repolarization? a)P wave b)Q wave c)S wave d)T wave
d
Preload is increased in: hypervolemia, heart failure dehydration, decreased blood pressure vasoconstriction and increased blood pressure abundance of calcium ions
hypervolemia, heart failure Rationale: A is correct. Preload is the amount of volume in the ventricles after diastole (end diastolic pressure). When we have an increased fluid volume in the body, such as with hypervolemia (or fluid volume excess) or heart failure, the preload is going to be increased. Dehydration would decrease preload and decreased BP would decrease afterload. Vasoconstriction and increased BP would cause increased afterload. An abundance of calcium ions would increase contractility of the heart.
normal hemoglobin levels
male: 14-16.5 female: 12-15
normal RBC count
male: 4.2-5.4 million female: 3.6-5 million
Discomfort when breathing while lying down flat; common in people with some types of heart or lung conditions.
orthopnea
Venous thrombosis most commonly occurs in the lower extremities, Risk factors for venous thrombosis include which of the following? stasis of blood, hypercoagulability, inflammation hypocoagulability, vessel wall injury, increased pressure on deep veins vessel wall injury, hypocoagulability, decreased venous blood flow stasis of blood, hypercoagulability, vessel wall injury
stasis of blood, hypercoagulability, vessel wall injury Rationale: D is correct. Virchow's Triad is associated with venous thrombosis: stasis of blood, increased blood coagulability, and vessel wall injury. Inflammation is a symptom of venous thrombosis, not a risk factor. Decreased venous return can result from venous thrombosis, if the thrombus does not completely obstruct the vein, so it is not a risk factor. Hypocoagulability would not cause a thrombus to form.
The nurse is reviewing the record of a client with Crohn's disease. Which stool characteristic should the nurse expect to note documented in the client's record? •A) Diarrhea •B) Chronic constipation •C) Constipation alternating with diarrhea •D) Stool constantly oozing from the rectum
•A) Diarrhea
A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery? •A) Folate deficiency •B) Malabsorption of fat •C) Intestinal obstruction •D) Fluid and electrolyte imbalance
•D) Fluid and electrolyte imbalance
