Med-Surg HESI Evolve Questions
Which skin infection would cause facial paralysis? Candidiasis Herpes zoster Herpes simplex Dermatophytosis
Herpes zoster Facial paralysis is the clinical sign of Bell's palsy, a complication of the herpes zoster infection. This is seen when the trigeminal nerve is infected by the varicella-zoster virus. Candidiasis is a fungal infection not associated with Bell's palsy. Herpes simplex is a viral infection and may not cause Bell's palsy. Dermatophytosis is also a fungal infection not associated with Bell's palsy.
Which skin infection is caused by bacteria? Folliculitis Candidiasis Herpes zoster Dermatophytosis
Folliculitis Folliculitis is caused by bacteria. Candidiasis is a skin infection caused by a fungus. Herpes zoster is caused by a virus. Dermatophytosis is caused by a fungus.
The nurse is preparing to administer a nasogastric tube feeding to a client via infusion pump. What is the most important assessment the nurse needs to perform before beginning the pump? Checking for the last bowel movement Checking for residual stomach contents Checking to determine time of last medication for nausea Checking to make sure the head of bed is elevated at least 15 degrees
Checking for residual stomach contents Checking for any residual feeding not absorbed in the client's stomach must be done before introducing any more feeding. Aspiration can occur if a feeding is started with excessive residual. Checking for last bowel movement is important but not as crucial as checking for gastric residual. Knowledge of last nausea medication is not necessary at this time. Clients receiving nasogastric tube feedings must have the head of their bed elevated to at least 30 degrees.
Which pulmonary function test provides a more sensitive index of obstruction in smaller airways? Forced vital capacity Functional residual capacity Forced expiratory volume in 1 second Forced expiratory flow over the 25% to 75% volume of the forced vital capacity
Forced expiratory flow over the 25% to 75% volume of the forced vital capacity Forced expiratory flow over the 25% to 75% volume of the forced vital capacity is the measure that provides a more sensitive index of obstruction in smaller airways. Forced vital capacity indicates respiratory muscle strength and ventilator reserve. Functional residual capacity is normal or decreased in restrictive pulmonary diseases and increased in obstructive pulmonary diseases. Forced expiratory volume in 1 second is reduced in certain obstructive and restrictive disorders.
Which hormones are involved in building and maintaining healthy bone tissue? Select all that apply. Insulin Thyroxine Glucocorticoids Growth hormone Parathyroid hormone
Insulin, Growth hormone Insulin works together with growth hormone to increase bone length, which helps to build and maintain healthy bone tissue. Thyroxine increases the rate of protein synthesis in all types of tissues. Glucocorticoids regulate protein metabolism to reduce or intensify the organic matrix of bone. Parathyroid hormone secretion stimulates bones to promote osteoclastic activity and release calcium into the blood when serum calcium levels are lowered.
A nurse educates the client about the relationship between the kidneys and blood pressure. Which term should the nurse use to describe the part of the kidney that senses changes in blood pressure? Calices Glomerulus Macula densa Juxtaglomerular cells
Macula densa The macula densa, a part of the distal convoluted tubule, consists of cells that sense changes in the volume and pressure of blood. Calices are cup-like structures, present at the end of each papilla that collect urine. The glomerulus is the initial part of the nephron, which filters blood to make urine. Juxtaglomerular cells secrete renin. Renin is produced when sensing cells in the macula densa sense changes in blood volume and pressure.
The serum ammonia level of a client with hepatic cirrhosis and ascites is elevated. What nursing intervention is the priority? Weigh the client daily. Restrict the client's oral fluid intake. Measure the client's urine specific gravity. Observe the client for increasing confusion.
Observe the client for increasing confusion. An increased serum ammonia level impairs the central nervous system, causing an altered level of consciousness. Increasing ammonia levels are not related to weight. An alteration in fluid intake will not affect the serum ammonia level. Measuring the client's urine specific gravity is not the priority; the priority is to monitor the client's neurological status.
The nurse finds that a client has reduced urinary output. Which condition would the nurse document in the client's medical record? Anuria Dysuria Oliguria Nocturia
Oliguria A reduced urinary output of less than 400 mL in a 24-hour interval is called oliguria. Anuria is the absence of urination. Painful or difficult urination is called dysuria. Frequent urination at night is called nocturia.
A client's burn wounds are scheduled to be debrided mechanically. Which equipment will the nurse prepare? Enzymatic agents Scissors and forceps Autolytic semi-occlusive dressing Continuous passive-motion device
Scissors and forceps Mechanical debridement means to physically remove dirt, damaged or dead tissue, and cellular debris from a wound or burn so that infection is prevented and healing is promoted. Scissors, forceps, or scalpels may be used along with hydrotherapy. Enzymatic preparations are used to debride chemically by dissolving and removing necrotic tissue. A mechanical device that continually moves an extremity is called continuous passive range of motion and is used for knee surgery. Autolytic debridement includes semi-occlusive or occlusive dressings to soften dry eschar by autolysis.
Which electrolyte deficiency triggers the secretion of renin? Sodium Calcium Chloride Potassium
Sodium Low sodium ion concentration causes decreased blood volume, thereby resulting in decreased perfusion. Decreased blood volume triggers the release of renin from the juxtaglomerular cells. Deficiencies of calcium, chloride, and potassium do not stimulate the secretion of renin.
Which hormonal deficiency reduces the growth of axillae and pubic hair in female clients? Growth hormone Antidiuretic hormone Thyroid-stimulating hormone Adrenocorticotropic hormone
Adrenocorticotropic hormone An adrenocorticotropic hormone deficiency causes a reduced growth of axial and pubic hair in women. A growth hormone deficiency causes decreased muscle strength and decreased bone density. An antidiuretic hormone deficiency causes excessive urine output and a low urine specific gravity. A thyroid-stimulating hormone deficiency results in hirsutism and menstrual abnormalities.
Which hormone synthesis does the nurse state is inhibited by hypokalemia? Aldosterone Somatostatin Norepinephrine Androstenedione
Aldosterone Hypokalemia inhibits synthesis of aldosterone hormone. Somatostatin inhibits the synthesis of insulin. Norepinephrine also inhibits the synthesis of insulin. Androstenedione secretion may not be inhibited by hypokalemia.
The home health nurse provides education to a client with cancer of the tongue who will begin gastrostomy feedings at home. Which statement by the client indicates teaching by the nurse is effective? "Before I start the procedure, I will don sterile gloves." "Before I start the procedure, I will obtain my body weight." "Before I start the procedure, I will measure the residual volume." "Before I start the procedure, I will instill one ounce (30 mL) of a carbonated liquid."
"Before I start the procedure, I will measure the residual volume." Measuring the residual volume establishes whether an adequate volume of the previous feeding was absorbed. If a residual exceeds the parameter identified by the healthcare provider or is over 200 mL, a feeding may be held. This prevents adding excess feeding solution that may lead to abdominal distention, nausea, vomiting, and aspiration. Clean, not sterile, gloves are necessary to protect the client from contamination with gastric secretions. Weights are taken and reported weekly or monthly depending on the client's condition and clinical goals. A carbonated beverage may be used if the tube becomes clogged; it is not used routinely.
A client suspected to have hyperpituitarism is sent by the primary healthcare provider to undergo a suppression test. Which laboratory value would indicate a positive result? 3 ng/mL 4 ng/mL 5 ng/mL 6 ng/mL
6 ng/mL When the growth hormone level in a suppression test is above 5 ng/mL, this indicates a positive result, which means the client is suffering from hyperpituitarism. Therefore, 6 ng/mL indicates a positive suppression test. When growth hormone level falls below 5 ng/mL, this indicates a negative result, which means the client is not suffering with hyperpituitarism. Therefore, 3 ng/mL, 4 ng/mL, and 5 ng/mL indicate negative results, and the client does not have hyperpituitarism.
Which client is at greatest risk for the development of a venous thrombosis? A 76-year-old female with a 100-pack-per-year smoking history and hypertension A 68-year-old male on bed rest following a left hip fracture A 59-year-old male who is an intravenous drug user with hyperlipidemia A 42-year-old female with Factor V Leiden mutation on warfarin
A 68-year-old male on bed rest following a left hip fracture Venous thrombosis is the result of inflammation to a vein, hypercoagulability, venous stasis, or a combination of the three, known as Virchow triad. Bed rest and hip fracture are two major risk factors for the development of a thrombosis. While the other options present risk factors (cigarette smoking, drug abuse, and clotting disorders), the combination of the two (venous stasis and vessel injury) results in greatest risk for thrombus development.
A nurse reviews the laboratory results of a client with acute pancreatitis. Which test is most significant in determining the client's response to treatment? Platelet count Amylase level Red blood cell count Erythrocyte sedimentation rate
Amylase level In 90% of clients with acute pancreatitis, the amylase level is elevated up to three times over baseline; serum amylase usually returns to expected adult levels within three days after treatment begins. The platelet count is not an indicator of the response to treatment for pancreatitis; platelets are important in the control of bleeding. The red blood cell count is unchanged in acute pancreatitis, unless hemorrhage is present. The erythrocyte sedimentation rate is not an indicator of a response to treatment for pancreatitis.
Which drug can cause diabetes insipidus? Cabergoline Metyrapone Demeclocycline Aminoglutethimide
Demeclocycline Prolonged administration of demeclocycline may cause diabetes insipidus, as this drug decreases the production of antidiuretic hormone by the kidneys. Cabergoline inhibits the release of growth hormone and prolactin by stimulating dopamine receptors in the brain. Metyrapone and aminoglutethimide decrease cortisol production.
After multiple bee stings, a client experiences an anaphylactic reaction. The nurse determines that the symptoms the client is experiencing are caused by what processes? Respiratory depression and cardiac arrest Bronchial constriction and decreased peripheral resistance Decreased cardiac output and dilation of major blood vessels Constriction of capillaries and decreased peripheral circulation
Bronchial constriction and decreased peripheral resistance Hypersensitivity to a foreign substance can cause an anaphylactic reaction; histamine is released, causing bronchial constriction, increased capillary permeability, and dilation of arterioles. This decreased peripheral resistance is associated with hypotension and inadequate circulation to major organs. Respiratory depression and cardiac arrest are the problems that result from bronchial constriction and vascular collapse. Dilation of arterioles occurs. Arterioles dilate, capillary permeability increases, and eventually vascular collapse occurs.
What is the cup-like structure that collects a client's urine and is located at the end of each papilla? Calyx Capsule Renal cortex Renal columns
Calyx The calyx is a cup-like structure that collects urine and is located at the end of each papilla. The outer surface of the kidney consists of fibrous tissue and is called the capsule. The renal cortex is the outer tissue layer. The renal columns are the cortical tissue that dip down into the interior of the kidney and separate the pyramids.
During the first 36 hours after the insertion of chest tubes, when assessing the function of a three-chamber, closed-chest drainage system, the nurse identifies that the water in the underwater seal tube is not fluctuating. What initial action should the nurse take? Take the client's vital signs. Inform the healthcare provider. Turn the client to the unaffected side. Check the tube to ensure that it is not kinked
Check the tube to ensure that it is not kinked Once the drainage tube is patent, the fluctuation in the water column will resume; a lack of fluctuation because of lung reexpansion is unlikely 36 hours after a traumatic open chest injury. Taking the client's vital signs may be done eventually but is not the priority at this time. Informing the healthcare provider is unnecessary at this time; the chest tube is occluded, and nursing interventions should be attempted first. Turning the client to the unaffected side will compromise aeration of the unaffected lung.
Which part of the brain contains the client's "central switchboard" of the central nervous system? Cerebrum Brain stem Cerebellum Diencephalon
Diencephalon The thalamus is considered to be the major relay station or "central switchboard" for the central nervous system (CNS). The thalamus, along with the hypothalamus and epithalamus, are located in the diencephalon of the brain. The cerebrum is the largest part of the brain, which has right and left lateral ventricles deep inside and has basal ganglia at its base. The brainstem connects the rest of the brain with the CNS. It is associated with life support and basic functions, such as movement. The cerebellum is concerned with coordination of movement and works together with the brainstem to focus on the functionality of the muscles. This structure is found below the occipital lobe and adjacent to the brainstem.
Which respiratory measurement is useful in differentiating between obstructive and restrictive pulmonary dysfunction? Peak expiratory flow rate Forced vital capacity Forced mid-expiratory flow rate Forced expiratory volume/forced vital capacity ratio
Forced expiratory volume/forced vital capacity ratio Forced expiratory volume/forced vital capacity ratio is useful in differentiating between obstructive and restrictive pulmonary dysfunction. Peak expiratory flow rate aids in monitoring bronchoconstriction in asthma. Forced vital capacity is the amount of air that can be quickly and forcefully exhaled after maximum inspiration. Forced mid-expiratory flow rate is an early indicator of disease of the small airways.
The nurse is educating a couple concerning the process of fertilization. The nurse explains to the couple that which component stimulates the release of estrogen and progesterone after fertilization? Inhibin Testosterone Follicle-stimulating hormone (FSH) Human chorionic gonadotropin (hCG)
Human chorionic gonadotropin (hCG) After fertilization, human chorionic gonadotropin (hCG) stimulates the corpus luteum to produce estrogen and progesterone. Inhibin is a hormone produced by the ovarian follicles; it inhibits the secretion of follicle-stimulating hormone (FSH) and gonadotropin-releasing hormone (GnRH). Testosterone does not affect the release of estrogen and progesterone. Follicle-stimulating hormone (FSH) stimulates the growth and maturity of the ovarian follicle necessary for ovulation.
A nurse is providing postoperative care for a client one hour after an adrenalectomy. Maintenance steroid therapy has not begun yet. The nurse should monitor the client for which complication? Hypotension Hyperglycemia Sodium retention Potassium excretion
Hypotension Because of instability of the vascular system and the lability of circulating adrenal hormones after an adrenalectomy, hypotension frequently occurs until the hormonal level is controlled by replacement therapy. Hyperglycemia is a sign of excessive adrenal hormones; after an adrenalectomy, adrenal hormones are not secreted. Sodium retention is a sign of hyperadrenalism; it does not occur after the adrenals are removed. Potassium excretion is a response to excessive adrenal hormones; after an adrenalectomy is performed, adrenal hormones are lowered until replacement therapy is regulated.
Which statement does the nurse know is true regarding the effects of parathyroid hormone on bones for the maintenance of calcium balance? Increases bicarbonate and sodium excretion Enhances absorption of calcium and phosphorous Increases reabsorption of calcium and magnesium Increases net release of calcium into extracellular fluid
Increases net release of calcium into extracellular fluid Parathyroid hormone affects target tissues such as bone, kidney, and the gastrointestinal tract. The effects of parathyroid hormone on bones will be associated with the increase in the net release of calcium into extracellular fluid. Kidneys are responsible for increasing the bicarbonate and sodium excretion from the body. Action of parathyroid hormone on the gastrointestinal tract would show effects such as enhanced absorption of calcium and phosphorous. Kidneys are responsible for increased reabsorption of calcium and magnesium.
What are the functions of antidiuretic hormone (ADH)? Select all that apply. Controlling calcium balance Increasing arteriole constriction Increasing tubular permeability to water Stimulating the bone marrow to make red blood cells Promoting the reabsorption of sodium in the distal convoluted tubule (DCT)
Increasing arteriole constriction Increasing tubular permeability to water Antidiuretic hormone (ADH), also known as vasopressin, is a hormone released from the posterior pituitary gland. ADH increases arteriole constriction and tubular permeability to water. Calcium balance is controlled by blood levels of calcitonin and the parathyroid hormone (PTH). Erythropoietin stimulates the bone marrow to make red blood cells. Aldosterone promotes the reabsorption of sodium in the distal convoluted tubule (DCT).
A pathology report states that a client's urinary calculus is composed of uric acid. Which food item should the nurse instruct the client to avoid? Milk Liver Cheese Vegetables
Liver Uric acid stones are controlled by a low-purine diet. Foods high in purine, such as organ meats and extracts, should be avoided. Milk should be avoided with calcium, not uric acid, stones. Cheese or animal protein should be avoided with cystine, not uric acid, stones. Vegetables do not have to be avoided.
Which parts of the nephron are the sites of action for furosemide? Select all that apply. Glomerulus Loop of Henle Distal tubule Proximal tubule Bowman capsule
Loop of Henle, Distal tubule, Proximal tubule Furosemide, known as a 'loop diuretic', inhibits sodium and chloride reabsorption from the ascending loop of Henle and proximal and distal tubules. The glomerulus is a site of glomerular filtration. The Bowman capsule (BC) is a site of the collection of glomerular filtrate.
Which hormone is crucial for ovulation and complete maturation of a client's ovarian follicles? Luteinizing hormone Follicle stimulating hormone Gonadotropin releasing hormone Human chorionic gonadotropin hormone
Luteinizing hormone Ovulation and complete maturation of ovarian follicles can only take place in the presence of luteinizing hormone. However, follicle stimulating hormone initiates maturation of the follicles. Gonadotropin releasing hormone stimulates the pituitary gland to release follicle stimulating hormone and luteinizing hormone. Human chorionic gonadotropin hormone is released after implantation and is responsible for secretion of progesterone and estrogen during pregnancy.
A client is admitted to the hospital with jaundice. After numerous diagnostic tests, the healthcare provider makes the diagnosis of cancer of the pancreas. What does the nurse conclude is the most likely cause of the client's jaundice? Necrosis of the parenchyma caused by the neoplasm Excessive serum bilirubin caused by red blood cell destruction Obstruction of the common bile duct by the pancreatic neoplasm Impaired liver function, resulting in incomplete bilirubin metabolism
Obstruction of the common bile duct by the pancreatic neoplasm The common bile duct passes through the head of the pancreas; it often is constricted or obstructed by the neoplasm, causing jaundice. Necrosis of the pancreatic parenchyma caused by the neoplasm will not cause jaundice. Excessive serum bilirubin caused by red blood cell destruction is the prehepatic cause of jaundice. Impaired liver function, resulting in incomplete bilirubin metabolism, is a hepatic cause of jaundice.
Which is the first line treatment for Paget disease? Oral alendronate 1500 mg of calcium Intravenous pamidronate Intravenous zoledronic acid
Oral alendronate Oral alendronate, a bisphosphonate, is the first line treatment for Paget disease. 1500 mg of calcium is given as a supplement to reduce the risk for hypocalcemia. When oral drugs are not effective, pamidronate and zoledronic acid are administered intravenously.
Which criteria should the primary healthcare provider use for the prescription of long-term continuous oxygen therapy? PaO2-72, SpO2- 96 PaO2-60, SpO2- 90 PaO2-55, SpO2- 88 PaO2-40, SpO2- 75
PaO2-55, SpO2- 88 The primary healthcare provider uses the criteria of PaO2-55, SpO2- 88 for the prescription of long-term continuous oxygen therapy. The values PaO2-72, SpO2-96 are adequate unless the client is hemodynamically unstable. The values PaO2-60, SpO2-90 are adequate for almost all clients. The value PaO2-40, SpO2-75 is inadequate but may be acceptable on a short-term basis if the client also has carbon dioxide retention.
A client is admitted to the hospital for an emergency cardiac catheterization. What adaptation is the client most likely to complain of after this procedure? Fear of dying Skipped heartbeats Pain at the insertion site Anxiety in response to intensive monitoring
Pain at the insertion site Pain at the arterial puncture site is attributable to entry and cannulation of the artery and is a common complaint after a cardiac catheterization. Fear of dying might occur during the precatheterization period. Although skipped heartbeats may occur during the procedure because of trauma to the conduction system, usually it does not continue after the procedure. Although some clients may be anxious, many feel safe when receiving ongoing monitoring.
The nurse assesses a client for the development of pernicious anemia after reviewing the client's history. Which condition did the nurse most likely find in the history? Acute gastritis Diabetes mellitus Partial gastrectomy Unhealthy dietary habits
Partial gastrectomy Removal of the fundus of the stomach (gastrectomy) destroys the parietal cells that secrete intrinsic factor (needed to combine with vitamin B12 preliminary to its absorption in the ileum). Hemorrhaging may cause anemia; however, pernicious anemia occurs when the intrinsic factor is not produced. The beta cells of the pancreas are not involved in secretion of intrinsic factor. Dietary intake does not affect the production of intrinsic factor.
A client with impaired peripheral pulses and signs of chronic hypoxia in a lower extremity is scheduled for a femoral angiogram. What would be appropriate for the nurse to include in the postprocedure plan of care? Elevate the foot of the bed. Perform urinary catheter care every 12 hours. Place in the high-Fowler position. Perform a neurovascular assessment every 2 hours.
Perform a neurovascular assessment every 2 hours. Because of the trauma associated with the insertion of the catheter during the procedure, the involved extremity should be assessed for sensation, motor ability, and arterial perfusion; hemorrhage or an arterial embolus can occur. The client has an arterial problem, and perfusion is promoted by keeping the legs at the level of or lower than the heart. A general anesthetic is not used; therefore voiding is not a concern. Keeping the client in the high-Fowler position is unsafe; this position increases pressure in the groin area, which can dislodge the clot at the catheter insertion site, resulting in bleeding. It also impedes arterial perfusion and venous return.
A client with a history of heart disease has been receiving a calcium channel blocker and morphine sulfate for pain from abdominal surgery. When getting the client out of bed, the nurse first should have the client sit on the edge of the bed with feet on the floor. What untoward client response can be prevented by this nursing action? Abdominal pain Respiratory distress Sudden hemorrhage Postural hypotension
Postural hypotension After administration of certain antihypertensives or opioids, a client's neurocirculatory reflexes may have some difficulty adjusting to the force of gravity when an upright position is assumed. Postural or orthostatic hypotension occurs, and blood supply to the brain is temporarily decreased. Abdominal pain, respiratory distress, and sudden hemorrhage will not be prevented by the intervention described.
What are the most common hormones produced in excess with hyperpituitarism? Select all that apply. Prolactin Growth hormone Luteinizing hormone Antidiuretic hormone Melanocyte-stimulating hormone
Prolactin Growth hormone The most common hormones produced in excess with hyperpituitarism are prolactin and growth hormone. Excessive stimulation of luteinizing hormone and antidiuretic hormone is also associated with hyperpituitarism, but less commonly than prolactin and growth hormone. Secretion of melanocyte-stimulating hormone stimulates adrenocorticotropic hormone, which indirectly stimulates the pituitary gland, thus leading to hyperpituitarism.
The nurse is educating a client about protease inhibitors. What statement about protease inhibitors is true? Protease inhibitors prevent viral replication. Protease inhibitors prevent the interaction between viral material and the CD4+ T-cell. Protease inhibitors prevent viral and host genetic material integration. Protease inhibitors prevent the clipping of the viral strands into small functional pieces.
Protease inhibitors prevent viral replication. Protease inhibitors act by preventing viral replication and release of viral particles. NRTIs inhibits the transformation of viral single-stranded ribonucleic acid into host double-stranded deoxyribonucleic acid (DNA) by the action of the enzyme reverse transcriptase. Entry inhibitor drugs prevent the binding of the virus to the CD4 receptors. Integrase inhibitor drugs prevent the integration of viral material into the host's DNA by the action of the enzyme integrase.
A nurse is evaluating a client's understanding of peritoneal dialysis. Which information in the client's response indicates an understanding of the purpose of the procedure? Reestablishing kidney function Cleaning the peritoneal membrane Providing fluid for intracellular spaces Removing toxins in addition to other metabolic wastes
Removing toxins in addition to other metabolic wastes Peritoneal dialysis uses the peritoneum as a selectively permeable membrane for diffusion of toxins and wastes from the blood into the dialyzing solution. Peritoneal dialysis acts as a substitute for kidney function; it does not reestablish kidney function. The dialysate does not clean the peritoneal membrane; the semipermeable membrane allows toxins and wastes to pass into the dialysate within the abdominal cavity. Fluid in the abdominal cavity does not enter the intracellular compartment.
Which statement is true regarding the functions of kidney hormones? Prostaglandin increases blood flow and vascular permeability. Bradykinin regulates intrarenal blood flow via vasodilation or vasoconstriction. Renin raises blood pressure because of angiotensin and aldosterone secretion. Erythropoietin promotes the absorption of calcium in the gastrointestinal tract (GI) tract.
Renin raises blood pressure because of angiotensin and aldosterone secretion. Renin is a kidney hormone that raises blood pressure as a result of angiotensin and aldosterone secretion. Prostaglandin is a kidney hormone that regulates intrarenal blood flow via vasodilation or vasoconstriction. Bradykinin is a kidney hormone that increases blood flow and vascular permeability. Erythropoietin is a kidney hormone that stimulates the bone marrow to make red blood cells.
A client's laboratory report reveals a CD4+ T-cell count of 520 cells/mm3. According to the Centers for Disease Control and Prevention (CDC), which stage of human immunodeficiency virus (HIV) disease is present in the client? Stage 1 Stage 2 Stage 3 Stage 4
Stage 1 According to the CDC, HIV disease is divided into four stages. A client with a CD4+ T-cell count of greater than 500 cells/mm3 is in the first stage of HIV disease. A client with a CD4+ T-cell count between 200 and 499 cells/mm3 is in the second stage of HIV disease. A client with a CD4+ T-cell count of less than 200 cells/mm3 is in the third stage of HIV disease. The fourth stage of HIV disease indicates a confirmed HIV infection with no information regarding the CD4+ T-cell counts.
What type of hypersensitivity reaction is the cause of systemic lupus erythematosus? Type I Type II Type III Type IV
Type III Systemic lupus erythematosus is an example of an immune complex-mediated, or type III, hypersensitive reaction. Anaphylaxis is an example of a type I or immediate hypersensitive reaction. Cytotoxic or type II hypersensitive reactions can result in conditions such as myasthenia gravis and Goodpasture syndrome. Graft rejection and sarcoidosis are conditions that are caused by delayed or type IV hypersensitivity reactions.
The nurse is teaching a post-radiation therapy client regarding proper skin care to the radiation treatment area. Which statement made by the client indicates the nurse needs to follow up? "I will avoid wearing tight-fitting clothing." "I will avoid using adhesive bandages." "I will avoid exposing the area to cold temperatures." "I will avoid rinsing the area with the saline solution."
"I will avoid rinsing the area with the saline solution." A client who underwent radiation therapy should rinse the radiation treatment area with saline solution to prevent infection. Therefore the nurse should follow up to correct the misconception of not using saline. Tight-fitting clothing such as brassieres and belts should be avoided in the area of the treatment field. The use of adhesive bandages should be avoided and should not be used unless permitted by the radiation therapist. The radiation treatment area should not be exposed to cold temperatures.
Which client would have relatively smaller tidal volumes due to limited chest wall movement? A client with asthma A client with pneumonia A client with pulmonary fibrosis A client with phrenic nerve paralysis
A client with phrenic nerve paralysis Some respiratory conditions such as phrenic nerve paralysis may limit the diaphragm or chest wall movement and may result in smaller tidal volumes. In this condition, the lungs do not fully inflate, and the gas exchange may be impaired. Exacerbations of asthma may cause expiration to become an active labored process. Pneumonia may result in decreased lung compliance due to an accumulation of fluid in the lungs. As the lung tissue becomes less elastic or distensible, the client with pulmonary fibrosis may have decreased lung compliance.
While obtaining the client's health history, which factor does the nurse identify that predisposes the client to type 2 diabetes? Having diabetes insipidus Eating low-cholesterol foods Being 20 pounds (9 kilograms) overweight Drinking a daily alcoholic beverage
Being 20 pounds (9 kilograms) overweight Excessive body weight is a known predisposing factor to type 2 diabetes; the exact relationship is unknown. Diabetes insipidus is caused by too little antidiuretic hormone (ADH) and has no relationship to type 2 diabetes. High-cholesterol diets and atherosclerotic heart disease are associated with type 2 diabetes. Alcohol intake is not known to predispose a person to type 2 diabetes.
A client tells the nurse about recent recurrent episodes of bleeding hemorrhoids. What should the nurse advise the client to do to help prevent future hemorrhoidal episodes? Exercise to improve circulation Eat bland foods and avoid spices Consume a high-fiber diet and drink adequate water Use laxatives to avoid constipation and the Valsalva maneuver
Consume a high-fiber diet and drink adequate water Consuming a high-fiber diet and drinking adequate water promote regular bowel function, prevents constipation, and prevent straining, which can make hemorrhoids worse; a high-fiber diet provides bulk that stimulates peristalsis, and water promotes a soft stool. Exercise is advisable, but the purpose in this instance is to increase peristalsis, not improve circulation. Bland foods and spices are unrelated to hemorrhoids; bland foods are preferred for clients with gastric or intestinal problems. Laxatives are contraindicated because they are irritating to the bowel, decrease intestinal tone, and promote dependency. The Valsalva maneuver should also be avoided.
A client is admitted to the hospital with slight jaundice and reports of pain on the left side and back. A diagnosis of acute pancreatitis is made. Which common response to acute pancreatitis should the nurse monitor in the client? Crackles Hypovolemia Gastric reflux Jugular vein distention
Hypovolemia Hypovolemia that results from a fluid shift from the intravascular compartment to the peritoneal cavity can cause circulatory collapse; this is a life-threatening event that requires immediate intervention. Crackles indicate an accumulation of fluid in the alveoli associated with hypervolemia, not hypovolemia. Gastric reflux occurs with gastroesophageal reflux disease (GERD), not with pancreatitis. Jugular vein distention indicates hypervolemia, not hypovolemia.
After an open reduction and internal fixation of a fractured hip, the nurse is helping a client to get out of bed into a chair. What should the nurse do to best accomplish this transfer? Use a transfer board to slide the client from the bed to the chair. Ask the client to put weight equally on both legs and step to the chair. Have several people assist with lifting the client from the bed to the chair. Instruct the client to bear most of the weight on the unaffected leg and pivot to the chair.
Instruct the client to bear most of the weight on the unaffected leg and pivot to the chair. Weight bearing on the unaffected leg will help maintain muscle strength; weight bearing on the affected leg may be limited initially by the primary healthcare provider's prescription or by the client's inability to tolerate weight bearing. Using a transfer board to slide the client from the bed to the chair does not involve weight bearing; weight bearing helps maintain muscle strength in the unaffected leg and independence and should be encouraged unless contraindicated by a primary healthcare provider's prescription. Asking the client to put weight equally on both legs and step to the chair may be contraindicated; weight bearing on the affected leg without a prescription can disrupt the repair, or the client may not be able to fully bear weight initially because of discomfort. Having several people assist with lifting the client from the bed to the chair does not involve weight bearing; weight bearing helps maintain muscle strength in the unaffected leg and independence and should be encouraged unless contraindicated by a primary healthcare provider's prescription.
Which disorder would the nurse state is related to the tonsils? Rhinitis Sinusitis Pharyngitis Pneumonia
Pharyngitis Pharyngitis, or sore throat, is a common inflammation of the pharyngeal mucous membranes that often occurs with rhinitis and sinusitis. Rhinitis is an inflammation of the nasal mucosa. It is a common problem of the nose and often involves the sinuses. Sinusitis is an inflammation of the mucous membranes or of one or more of the sinuses and is usually associated with rhinitis. Rhinitis and sinusitis are disorders related to the nose and sinuses. Pneumonia is excess fluid in the lungs resulting from an inflammatory process.
The nurse is teaching the client about wound healing. Which feature is associated with the "maturation phase" of normal wound healing? The scar is firm and inelastic on palpation. Fibrin strands form a scaffold or framework. White blood cells migrate into the wound. Epithelial cells are grown over the granulation tissue bed.
The scar is firm and inelastic on palpation. The maturation phase of normal wound healing involves a mature scar that is firm and inelastic when palpated. In the proliferative phase, the fibrin strands form a scaffold or framework. White blood cells migrate into the wound during the inflammatory phase. In the proliferative phase, the epithelial cells are grown over the granulation tissue bed.
