LP10 LP11 LP12

The nurse's assessment of a client suggests that the client's chronic constipation may be the result of overactivity of the somatointestinal reflex. What assessment question should the nurse ask to confirm this or rule it out?

"Do you often wear clothing that is constraining?"

The nurse is caring for a client with a malignant brain tumor. The client asks the nurse why the tumor is being treated with radiation instead of chemotherapy. The nurse's explanation involves what important information?

"Medications have difficulty crossing the blood-brain barrier."

What client is likely to be experiencing a heightened ability to learn?

A client who gave birth 12 hours ago

What client should the nurse monitor most closely for signs and symptoms of respiratory distress syndrome?

A premature neonate

A client sought care because of the presence of fat in stool. What assessment should the care team prioritize?

Assess the client's synthesis and release of bile

What does the liver produce that is important in the digestive process?

Bile

A client presents to the clinic with a temperature of 38.6°C (101.5°F); malaise, myalgia, arthralgia, and a purulent, productive cough. The client states "The fever just started today but I have had this cough for many, many months." What would the nurse suspect the client has?

Bronchiectasis

The nurse is developing the teaching portion of a care plan for a client with asthma. What would be an important component for the nurse to emphasize?

Chronic inhalation of nonallergic inhaled irritants can trigger an attack.

When the nurse administers a medication that stimulates the parasympathetic nervous system, the drug will have what impact on the GI system?

Decreases sphincter tone

When a person learns, this action begins as an electrical circuit called what?

Engram

The intensive care nurse is caring for a client with acute respiratory distress syndrome (ARDS). What is the nurse's best intervention?

Establishing mechanical ventilation, as prescribed

The nurse is caring for a client with pneumonia. The nurse would expect to see which symptoms? Select all that apply.

Fever Difficulty breathing Oxygen saturation of 88%

A client has experienced a seizure. A deficiency in what neurotransmitter may have caused the client's seizure activity?

Gamma-aminobutyric acid (GABA)

What is the major inhibitory neurotransmitter in the CNS?

Gamma-aminobutyric acid (GABA)

The nurse is caring for a client who is having difficulty swallowing tablets. What action will the nurse implement to help the client swallow his or her medication?

Have the client suck on a Popsicle

A nurse is caring for an 80-year-old client with pneumonia. The most appropriate nursing diagnosis for this client would be what?

Impaired gas exchange

What is a unique characteristic of the gastrointestinal (GI) system?

It is the only system open to the external environment.

The client is diagnosed with myasthenia gravis, a condition in which antibodies block, alter, or destroy the receptors for acetylcholine. What symptom would the nurse expect this client to display?

Muscle dysfunction

The nurse is preparing to perform a neurologic assessment of a new client. The nurse should be aware that the energy required by the nerves is provided by what? Select all that apply.

Oxygen Glucose

The nurse is caring for a client who does not produce adequate mucus in the stomach. This creates a risk for what health problem?

Peptic ulcers

A nurse is caring for a client with acute respiratory distress syndrome (ARDS). The nurse is aware that this disease is characterized by what?

Progressive loss of lung compliance and increasing hypoxia

The nurse is caring for a client who has sustained damage to his omenta. What nursing diagnosis should the nurse identify when planning this client's care?

Risk for infection

The nurse is providing health education for a client who is experiencing upper airway responses to mold and dust? What is the client's most likely diagnosis?

Seasonal rhinitis

The client has a seizure that causes rhythmic twitching of the left hand for 90 seconds with no loss of consciousness and then stops. The nurse notes this same action repeated many times throughout the day and documents this as what type of seizure?

Simple partial seizure

A client has a neurologic disorder that affects the structure and function of the myelin sheath and Schwann cells. What effect will this client likely experience?

Slower than normal nerve conduction

The nurse, caring for a client about to undergo gastric bypass surgery, explains that the majority of nutrients are absorbed where?

Small intestine

A client's neuron is stimulated, and depolarization of the nerve has occurred. The nurse should anticipate what subsequent action?

Sodium rushes into the cell.

What is the purpose of the myelin sheath?

Speeds electrical conduction

The nurse is caring for a client whose respiratory rate has increased from 21 to 32 breaths/minute. This change in status is ultimately caused by what?

Stimulation by the medulla

The nurse recognizes the potential for stimulation of the client's chemoreceptor trigger zone (CTZ) in what circumstances? Select all that apply.

Stimulation of the back of the throat when examining the oral cavity Increased intracranial pressure Excessive stomach distention

The nursing instructor is discussing the need for lubrication of the alveoli for effective gas exchange and is produced by type II cells of the alveoli. The students know that what substance is produced by type II cells of the alveoli?

Surfactant

The nurse is preparing to provide health education to a client. The client's learning will take place in what brain region?

The areas that coordinate speech and communication

The nurse is caring for a client who is experiencing hypnosis. What assessment finding best confirms that a client is in hypnosis?

The client is sedated and does not sense or react to incoming stimuli.

What organs are considered accessory digestive organs because they aid in the digestive process? Select all that apply.

The gallbladder The liver The pancreas

The nurse is caring for a client whose emotions often swing from one extreme to the other. The client's spouse tells the nurse these mood swings started when the client awoke from a coma following a serious head trauma. What area of the brain does the nurse suspect was damaged?

The limbic system

A client who nearly drowned is brought to the emergency department. The paramedics tell the nurse that the client was anoxic for approximately 5 minutes. Because of this anoxia, what might happen to the nerve cells?

The nerves might not be able to maintain the sodium-potassium pump.

A client asks the nurse what causes a cold. The nurse would tell the client that the common cold is most often caused by which type of microorganism?

Viruses

When describing the location where gas exchange takes place, the nurse should explain the function of the:

alveoli

A client has been up all night with intense coughing spasms and asks the nurse, "How is all this coughing related to my bronchitis?" The nurse tells the client that a cough is initiated by irritation to receptors in the:

bronchi

The nurse is caring for a client whose recent ultrasound of the carotids diagnosed a 90% occlusion of the right carotid artery and a 92% occlusion of the left carotid artery. The client asks the nurse, "If one of these arteries becomes completely occluded will I have a stroke?" What is the nurse's best response?

"A common vessel receiving all blood to the head called the circle of Willis will distribute blood from other arteries to the brain as needed."

The pediatric nurse practitioner is caring for a child who is diagnosed with cystic fibrosis (CF). The parents ask what the treatment is for because CF is considered a terminal illness. What would be the nurse's best response?

"Treatment is aimed at maintaining airway patency as much as possible."

The nurse in the clinic is caring for a client who has seasonal rhinitis and the client wants to know what causes this. What is the nurse's best response?

"Your upper airways are inflamed because you inhaled an antigen, causing sneezing and watery eyes."

A nurse is working on a surgical unit and has several clients who require preoperative teaching. Which client demonstrates behavior indicating this is an appropriate time to begin teaching?

A client who is clearing her throat several times while asking the nurse questions during their conversation and who appears to be slightly stressed

What client is most likely to have sustained damage to his or her limbic system?

A client whose moods are described as "volatile" and "unpredictable"

A client presents to the walk-in clinic reporting stomach pain that is relieved by eating which the nurse suspects may be caused by a peptic ulcer. How should the nurse explain the ulceration in the stomach to the client?

A mucosal lining protects the stomach from hydrochloric acid and a reduction in the mucosal lining or increase in acid production allows peptic ulcers to develop.

A client's nerve transmission has reached the end of an axon. What event will take place next?

A neurotransmitter will be released.

The nurse expects to find that the major activities of the GI tract decrease in a client experiencing what?

A stress reaction

A nurse is caring for a client who is having an adverse effects of long-term antipsychotic treatment. The client is experiencing tremors, shuffles when walking, and is having difficulty sitting up in bed. What disruption to the neurologic system should the nurse first suspect?

An interference with the extrapyramidal system

The nurse is caring for a client who is believed to be greatly deficient in serotonin. What assessment is a nursing priority?

Assessment for suicide risk

The nurse is admitting a client with an obstructive respiratory disorder. The nurse knows this includes which disorders? Select all that apply.

Asthma Cystic fibrosis

The nurse is teaching a group of adults about health promotion. What should the nurse recommend in order to minimize participants' risk of COPD?

Avoid smoking

The nurse is caring for a client who has an injured hindbrain. When assessing the client, the nurse should anticipate abnormal findings in what domain?

Basic vital functions

While assessing a new client on the unit, the nurse notes the following: productive cough, respiratory rate of 22, oxygen saturation of 90%, afebrile, and increased secretions. The client has a 20-year history of smoking 1.5 packs of cigarettes daily. What diagnosis is most likely?

Chronic obstructive pulmonary disease (COPD)

A client presents to the emergency room with an attack of acute bronchiectasis. The nurse knows that the principal pathologic finding in the diagnosis of bronchiectasis includes what?

Chronic, irreversible dilation of the bronchi and bronchioles

A client's microscopic, hair-like projections of the nasal cell membranes are transporting foreign substances toward the throat. What structures are performing this role?

Cilia

The nurse is caring for a client who has recently vomited. What physiologic change will have protected the client's lungs when vomiting?

Closing of the glottis

Water is primarily absorbed in which portion of the gastrointestinal tract?

Colon

A client has suffered damage to the thalamus as a result of a stroke. The client would exhibit deficits with what neurological function?

Conveying information about sensations to the cerebrum

A nurse is reviewing the function of the forebrain before assessing a client on the neurological unit. The nurse should identify what functions of this part of the brain? Select all that apply.

Coordination of speech and communication Learning Housing of the extrapyramidal motor system

The nurse is assessing a postoperative client whom the nurse suspects may have developed atelectasis. What assessment finding by the nurse best supports this suspicion?

Crackles on lung auscultation

Information is being carried into a client's neuron from other neurons. What component of the neurologic system will perform this function?

Dendrite

The nurse is caring for a client who experienced damage to the midbrain during neurologic surgery. The nurse caring for the client will expect the client to exhibit what sign?

Difficulty in distinguishing hot and cold

When describing gas exchange, the nurse should teach a client that oxygen and carbon dioxide enter and leave the body by what method?

Diffusion

A nurse is discussing cystic fibrosis (CF) with a couple who have just given birth to an infant with this disorder. The nurse explains that the respiratory component of this disease is caused by what?

Excessive respiratory tract secretions

A client reports frequent acid indigestion. The nurse instructs the client to increase intake of what to reduce stimulation of acid production?

Fiber

The perioperative nurse is caring for a postsurgical client and the nurse has identified a risk for atelectasis. What are the nurse's best actions to prevent the development of atelectasis? Select all that apply.

Help the client to ambulate as soon as possible Encourage deep breathing and coughing

What is the purpose of the peritoneum?

Helps keep the GI tract in place and prevent friction with movement

A client's dysphagia has been attributed to damage to the client's swallowing center? This client has dysfunction in what part of the brain?

Hindbrain

A client is admitted with an asthma attack caused by an allergic reaction to a medication. The nurse is aware that this severe allergic response is triggered by the immediate release of what?

Histamine

A female client has experienced a stroke affecting the right side of her brain. What assessment finding is most likely attributable to this health problem?

Inability to distinguish a spoon from a fork

The nurse is caring for a child diagnosed with cystic fibrosis whose body does not produce pancreatic enzymes appropriately. When planning the client's care, the nurse should address what consequence of this?

Incomplete digestion of carbohydrates

A client is reporting an inability to breathe nasally because of severe rhinitis. The nurse should identify what important role in breathing that is disrupted when the nasal passages are blocked?

Inspired air is warmed and humidified.

The nurse is caring for a client admitted with a suspected malabsorption disorder as the result of pancreatic damage. The client may require supplements of what digestive enzymes? Select all that apply.

Lipase Amylase Trypsin

A client sustained a closed-head injury 4 hours ago and now presents to the emergency department with difficulty breathing. The nurse should suspect damage to what part of the brain?

Medulla oblongata

A nurse in a rehab facility recognizes the client with damage to what area of the brain will affect the client's ability to swallow?

Medulla oblongata

The nurse is caring for a client who suffered a head injury and is now having difficulty breathing. The client should be assessed for damage to what part of the central nervous system?

Medulla oblongata

A client has pheochromocytoma, which causes hypertension due to excessive hormone release from the adrenal medulla. This client's symptoms are due to disruptions in the level of what hormone?

Norepinephrine

What is the basic type of movement that occurs in the esophagus?

Peristalsis

Nutrients absorbed in the small intestine travel directly to the liver via what system?

Portal system

A nurse is caring for a client with chronic bronchiectasis. The nurse should assess the client for what clinical manifestations?

Purulent cough

While bathing the noncommunicative client, the nurse notices the client is swallowing vigorously and repeatedly. What should the nurse do in response?

Ready the emesis basin

The nurse is aware that clients with bronchiectasis often have an underlying medical condition that increases the chance for infection. What are some of these medical conditions? Select all that apply.

Recent organ transplant AIDS Rheumatoid arthritis

The nurse is caring for a client whose unpredictable emotions are due to an infarct in the limbic system. The nurse should be aware that this part of the brain contains high levels of what neurotransmitters? Select all that apply.

Serotonin Epinephrine Norepinephrine

The nurse is caring for a client with meningitis who is not responding to the prescribed antibiotic and whose condition continues to deteriorate. What rationale will the nurse give the family to explain why the antibiotic is not as effective as it was hoped?

The blood-brain barrier prevents the antibiotics from crossing into the brain.

The nurse is caring for a child who has been brought to the emergency department with decreased level of consciousness after a bicycle crash with the client has begun projectile vomiting. How should the nurse best interpret this behavior?

The child's intracranial pressure may be elevated.

The nurse collects a nursing history from a client who admits that she keeps herself so busy that she ignores the need to defecate. The nurse should explain what unintended consequence of this behavior?

The client's external sphincter will require more distention to stimulate a defecation reflex.

The nurse is caring for a client who has Parkinson's disease. This client most likely has:

deficient levels of dopamine.

The nurse is caring for a client who has developed severe constipation. The nurse observes that the client's food intake for the past 24 hours has been minimal as a result of the:

ileogastric reflex.

A client has been diagnosed with stenosis of the pulmonary artery that inhibits the flow of unoxygenated blood between the right ventricle and the alveoli. This client will experience impaired:

perfusion