Patho Hesi Quizzes (For Review)

Which hormone is released from the posterior pituitary gland? 1) Oxytocin 2) Prolactin 3) Growth hormone 4) Luteinizing hormone

Answer: 1) Oxytocin Rationale: Oxytocin is released from the posterior pituitary gland, which acts on the uterus and mammary glands. Prolactin, growth hormone, and luteinizing hormone are produced by the anterior pituitary gland.

Which term should the nurse use to describe bone loss greater than normal but less than that caused by osteoporosis? 1) Osteopenia 2) Osteomyelitis 3) Osteomalacia 4) Osteoarthritis

Answer: 1) Osteopenia Rationale: Osteopenia is defined as bone loss that is more than normal but not yet at the level for a diagnosis of osteoporosis. Osteomyelitis is infection of bone or bone marrow. Osteomalacia is softening of bones due to calcium or vitamin D deficiency. Osteoarthritis is cartilage deterioration in the joints.

A client with a history of alcoholism and cirrhosis is admitted with severe dyspnea as a result of ascites. Which process that most likely caused the ascites should the nurse consider when planning care? 1) Increased secretion of bile salts 2) Increased pressure in the portal vein 3) Increased interstitial osmotic pressure 4) Increased production of serum albumin

Answer: 2) Increased pressure in the portal vein Rationale: The enlarged cirrhotic liver impinges on the portal system, causing increased hydrostatic pressure from increased pressure in the portal vein, resulting in ascites. Bile salts are not responsible for fluid shifts; increased serum bile results from biliary obstruction, not increased secretion of bile. Interstitial osmotic pressure is unchanged; decreased intravascular osmotic pressure accounts for fluid movement into interstitial spaces. The liver's production of serum albumin is decreased with cirrhosis of the liver.

A 13-year-old adolescent is found to have idiopathic scoliosis. Because exercise and avoidance of fatigue are essential components of care, which sport should the nurse suggest as the most therapeutic for this preadolescent? 1) Golf 2) Bowling 3) Swimming 4) Badminton

Answer: 3) Swimming Rationale: The hyperextension required in swimming helps strengthen back muscles and necessitates deeper respirations, both of which are necessary before surgery and before wearing a brace or cast. The other options involve twisting the back muscles, which is not therapeutic for a child with this condition.

A client has chronic obstructive pulmonary disease (COPD). To decrease the risk of CO 2 intoxication (CO 2 narcosis), what should the nurse do? 1) Initiate pulmonary hygiene to clear air passages of trapped mucus 2) Instruct to deep breathe slowly with inhalation longer than exhalation 3) Encourage continuous rapid panting to promote respiratory exchange 4) Administer oxygen at a low concentration to maintain respiratory drive

Answer: 4) Administer oxygen at a low concentration to maintain respiratory drive Rationale: With chronically high levels of carbon dioxide it is believed that decreased oxygen levels become the stimulus to breathe; high oxygen administration negates this mechanism. Initiating pulmonary hygiene to clear air passages of trapped mucus is an appropriate intervention, but is not directly related to CO 2 intoxication (CO 2 narcosis). Encouraging continuous rapid panting to promote respiratory exchange will not bring oxygen into the alveoli for exchange; nor will it adequately remove carbon dioxide because it will increase bronchiolar obstruction. Inhalation should be of regular depth, and expiration should be prolonged to prevent carbon dioxide trapping (air trapping).

Which secondary skin lesion may include athlete's foot as an example? 1) Scar 2) Scale 3) Ulcer 4) Fissure

Answer: 4) Fissure Rationale: An example of a fissure-type secondary lesion is athlete's foot. Surgical incisions and healed wounds are examples of scar-type secondary lesions. A scale-type secondary lesion would include flaking of the skin following a drug reaction or sunburn. Ulcer-type lesions may include pressure ulcers or chancres.

The client is in atrial fibrillation. Which information should the nurse consider about atrial fibrillation when planning care for this client? 1) A loss of atrial kick 2) No physiologic changes 3) Increased cardiac output 4) Decreased risk of pulmonary embolism

Answer: 1) A loss of atrial kick Rationale: Atrial fibrillation arises from multiple ectopic foci in the atria, causing chaotic quivering of the atria and ineffectual atrial contraction. The atrioventricular (AV) node is bombarded with hundreds of atrial impulses and conducts these impulses in an unpredictable manner to the ventricles. This irregularity is called "irregularly irregular." The ineffectual contraction of the atria results in loss of "atrial kick." If too many impulses conduct to the ventricles, atrial fibrillation with rapid ventricular response may result and compromise cardiac output. One complication of atrial fibrillation is thromboembolism. The blood that collects in the atria is agitated by fibrillation, and normal clotting is accelerated. Small thrombi, called mural thrombi, begin to form along the walls of the atria. These clots may dislodge, resulting in pulmonary embolism or stroke. The client may or may not be aware of the atrial fibrillation. If the ventricular response is rapid, the client may show signs of decreased cardiac output or worsening of heart failure symptoms.

The nurse is caring for a 76-year-old obese client with a history of epigastric distress, esophageal burning, binge drinking, and frequent episodes of bronchitis. A diagnosis of hiatal hernia is made. Which health problems most likely contributed to the development of the hiatal hernia? Select all that apply. 1) Aging 2) Obesity 3) Bronchitis 4) Esophagitis 5) Binge drinking

Answer: 1) Aging && 2) Obesity Rationale: Muscle weakness consistent with the aging process is associated with the development of a hiatal hernia. Obesity causes stress on the diaphragmatic musculature, which weakens and allows the stomach to protrude into the thoracic cavity. Inflammation of the bronchi will not weaken the diaphragm. Esophagitis does not cause a hiatal hernia. Alcoholism can cause relaxation of the lower esophageal sphincter (LES), causing risk for aspiration and gastroesophageal reflux disease.

A client's laboratory report shows altered serum calcium concentration. Which hormones are responsible for this condition? Select all that apply. 1) Calcitonin 2) Thyroxine 3) Glucocorticoids 4) Growth hormone 5) Parathyroid hormone

Answer: 1) Calcitonin & 5) Parathyroid hormone Rationale: Produced by the thyroid gland, calcitonin decreases the serum calcium concentration if it increases above the normal level. Parathyroid hormones increase and stimulate bones to promote osteoclastic activity and release calcium into the blood in response to low serum calcium levels. Thyroxine increases the rate of protein synthesis in all types of tissues. Glucocorticoids regulate protein metabolism to maintain the organic matrix of bone. Growth hormone helps to increase bone length and determine the amount of bone matrix formed before puberty.

The nurse is assessing a client with mumps and orchitis. Which organ will be affected?

Answer: Testes Rationale: Mumps is a viral infection that may cause orchitis in males. Painful inflammation and swelling of the testes (the organ indicated by choice D) indicates orchitis. Choice A indicates the seminal vesicles. Choice B indicates the prostate gland. Choice C indicates the epididymis.

When planning discharge teaching for the parents of a child with asthma, what information should the nurse include? 1) Avoid foods high in fat. 2) Stay at home for 2 weeks. 3) Increase protein and calorie intake. 4) Minimize exertion and exposure to cold.

Answer: 4) Minimize exertion and exposure to cold. Rationale: Cold and exercise can precipitate bronchospasm, and increased exercise depletes oxygen. Treatment of asthma does not involve a low-fat diet. Asthma is a chronic condition. A return to usual activities after the acute stage is essential for growth and development. Although increased protein and calories may be needed to support the child during a coexisting bacterial infection in the acute stage, a return to usual eating habits is indicated by the time of discharge.

Which gastrointestinal (GI) change may be found in the client with burn injuries? 1) Abdominal distention 2) Increased peristalsis 3) Activation of GI motility 4) Increased blood flow to the GI area

Answer: 1) Abdominal distention Rationale: The client with burn injuries may have abdominal distention due to loss of peristalsis. Gastrointestinal motility may be inhibited with burn injuries. Blood flow may be reduced and mucosal damage might have occurred.

Which statements are true regarding chondrosarcoma? Select all that apply. 1) Chondrosarcoma can arise from benign bone tumors. 2) Chondrosarcoma develops in the medullary cavity of long bones. 3) Chondrosarcoma is mostly treated by radiation and chemotherapy. 4) Chondrosarcoma occurs mostly in young males between ages 10 and 25 years. 5) Chondrosarcoma most commonly occurs in cartilage in the arm, leg, and pelvic bones.

Answer: 1) Chondrosarcoma can arise from benign bone tumors. && 5) Chondrosarcoma most commonly occurs in cartilage in the arm, leg, and pelvic bones. Rationale: Chondrosarcoma is a malignant type of bone tumor that can arise from benign bone tumors. Chrondrosarcoma most commonly occurs in cartilage in the arm, leg, and pelvic bones. Ewing's sarcoma develops in the medullary cavity of long bones. Chondrosarcoma is mostly treated by wide surgical resection. Chondrosarcoma occurs mostly in older adults between ages 50 and 70 years.

Which combination of foods should the nurse encourage a child with glomerulonephritis to choose for a meal? 1) Corn, roast chicken, peach 2) Tuna salad, cheese melt, milk 3) Hamburger, baked potato, banana 4) Bologna sandwich, salad, vanilla malted

Answer: 1) Corn, roast chicken, peach Rationale: Children with glomerulonephritis have a decreased filtration rate of plasma, which results in sodium and water retention; therefore a low-sodium diet is prescribed. With sodium and water retention stemming from a renal problem there is decreased urine output. If the child has oliguria a low-potassium diet is prescribed because the child will not be able to excrete the potassium ingested and may develop hyperkalemia, possibly life threatening. Corn, roast chicken, and peach are low-sodium, low-potassium foods. None of the other foods are permitted on a low-sodium, low-potassium diet: Tuna, cheese, and milk are high in sodium. Potatoes and bananas are high in potassium. Bologna and milk are high in sodium. Green leafy vegetables and tomatoes are high in potassium.

Which integumentary change is associated with delayed wound healing in a client? 1) Decreased cell division 2) Decreased epidermal thickness 3) Decreased immune system cells 4) Increased epidermal permeability

Answer: 1) Decreased cell division Rationale: Delayed wound healing is associated with decreased cell division. Decreased thickness of the epidermis may cause skin transparency and fragility. Decreased cells of the immune system are the reason for a decreased skin inflammatory response. Increased epidermal permeability increases the risk for irritation.

A nurse is assessing a client with a diagnosis of kidney failure for clinical indicators of metabolic acidosis. What should the nurse conclude is the reason metabolic acidosis develops with kidney failure? 1) Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate 2) Depressed respiratory rate due to metabolic wastes, causing carbon dioxide retention 3) Inability of the renal tubules to reabsorb water to dilute the acid contents of blood 4) Impaired glomerular filtration, causing retention of sodium and metabolic waste products

Answer: 1) Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate Rationale: Bicarbonate buffering is limited, hydrogen ions accumulate, and acidosis results. The rate of respirations increases in metabolic acidosis to compensate for a low pH. The fluid balance does not significantly alter the pH. The retention of sodium ions is related to fluid retention and edema rather than to acidosis.

Which hormones are involved in building and maintaining healthy bone tissue? Select all that apply. 1) Insulin 2) Thyroxine 3) Glucocorticoids 4) Growth hormone 5) Parathyroid hormone

Answer: 1) Insulin && 4) Growth hormone Rationale: 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.

The nurse is caring for a client with a body surface burn injury of 55%. Which information will the nurse consider when planning care for this client? 1) Is prone to poor healing because of a hypermetabolic state 2) Has a decreased risk of infection when in a hypermetabolic state 3) Needs a cool environment to decrease caloric need 4) Will need 20 calories/kg during the healing process

Answer: 1) Is prone to poor healing because of a hypermetabolic state Rationale: Burn injuries cause a hypermetabolic state. This results in lipid and protein catabolism, which in turn can inhibit wound healing. A hypermetabolic state increases the risk for slowed wound healing, increasing the chance for infection. Cooling the environment would cause an increase in caloric need as the body tries to warm to core temperature. Clients with burn injuries require increased calories and protein to promote wound healing. For an adult client, 20 calories/kg does not provide an adequate increase of calories or protein for the hypermetabolic state associated with burns.

The school nurse is attending to a student athlete who reports muscle pain after a practice session. Which should the nurse identify as a cause of this pain when providing instruction to the student? 1) Lactic acid 2) Acetoacetic acid 3) Hydrochloric acid 4) Beta-hydroxybutyric acid

Answer: 1) Lactic acid Rationale: The ache in muscles that have been vigorously worked without adequate oxygen supply is caused in part by the buildup of lactic acid. During rest, the lactic acid is oxidized completely to carbon dioxide and water, providing adenosine triphosphate (ATP) for further muscular contraction. Beta-hydroxybutyric acid and acetoacetic acid are not products of muscle contraction; they are ketone bodies resulting from incomplete oxidation of fatty acids. Hydrochloric acid is not a product of muscle contraction; it is present in the stomach to facilitate the digestive process.

After a lateral crushing chest injury, obvious right-sided paradoxical motion of a client's chest demonstrates multiple rib fractures, resulting in a flail chest. Which complication associated with this injury should the nurse assess in this client? 1) Mediastinal shift 2) Tracheal laceration 3) Open pneumothorax 4) Pericardial tamponade

Answer: 1) Mediastinal shift Rationale: Mediastinal structures move toward the uninjured lung, reducing oxygenation and venous return. Tracheal laceration is unlikely with a crushing injury to the chest. Flail chest is a closed chest injury; open pneumothorax results from a penetrating injury to the chest wall. Pericardial tamponade is associated with a cardiac contusion and usually occurs from a sternal, not lateral, compression injury.

The nurse is teaching the client with chronic obstructive pulmonary disease (COPD) to use pursed-lip breathing (PLB). What is the rationale for the nurse's teaching? 1) Prolonged exhalation to decrease air trapping 2) Shortened inhalation to reduce bronchial swelling 3) Increased respiratory rate to improve arterial oxygenation 4) Decreased use of diaphragm to increase amount of inspired air

Answer: 1) Prolonged exhalation to decrease air trapping Rationale: Pursed-lip breathing works to decrease dyspnea and the respiratory rate through prolonging exhalation and prevention of alveolar collapse. PLB does not increase the length of inhalation and does not increase the respiratory rate. Use of the diaphragm occurs with diaphragmatic, or abdominal, breathing.

Electrocardiography (ECG) is scheduled for an infant who has tetralogy of Fallot. The mother asks the nurse what type of test this is and why it is done. What is the best response by the nurse? 1) "It's a type of x-ray that shows us the size of the baby's heart." 2) "Electrical activity in the baby's heart is recorded, then printed on graph paper." 3) "It's an ultrasound procedure that produces images of the structures in the baby's heart." 4) "Contrast material is injected into the baby's vein to visualize the flow of blood through the heart."

Answer: 2) "Electrical activity in the baby's heart is recorded, then printed on graph paper." Rationale: An ECG not only records electrical impulses in the heart but can also reveal atrial and ventricular hypertrophy. The x-ray procedure that shows the size of a baby's heart is a chest x-ray. The ultrasound procedure that would be used to produce images of the structures in a baby's heart is the echocardiogram. The intravenous injection of contrast material to visualize the flow of blood through the heart is an angiogram.

A nurse provides education to a client about how to prevent constipation. The nurse concludes that the teaching is understood when the client makes which statements? Select all that apply. 1) "I may eat potatoes at dinner daily." 2) "I should drink at least six glasses of water every day." 3) "I must eat eggs for breakfast three times a week." 4) "I can include bran muffins in my breakfast daily." 5) "I will walk every day as part of my exercise regimen."

Answer: 2) "I should drink at least six glasses of water every day." && 4) "I can include bran muffins in my breakfast daily." && 5) "I will walk every day as part of my exercise regimen." Rationale: At least six glasses of water keeps the feces soft, which prevents constipation. Whole grains such as bran muffins are high in roughage, which prevents constipation. Walking increases intestinal motility, which helps prevent constipation. Potatoes and eggs do not contain roughage and will not prevent constipation.

The nurse is explaining the physiologic reasons for taking vitamin D and calcium supplements to a client with renal failure. Which statement made by the nurse is appropriate? 1) "There will be a decrease in the inactive forms of vitamin D in your body." 2) "There will be a decrease in the active metabolite of vitamin D in your body." 3) "There will be an increase in the conversion of skin cholesterol into vitamin D." 4) "There will be an increase in the vitamin D associated intestinal absorption of calcium."

Answer: 2) "There will be a decrease in the active metabolite of vitamin D in your body." Rationale: Renal failure results in decrease in the active metabolite of vitamin D because inactive vitamin D gets activated in the liver followed by the kidneys. Food sources of vitamin D and sunlight contribute to an inactive form of the hormone in the body. Inactive vitamin D will decrease if foods rich in vitamin D are not consumed or exposure to sunlight is reduced. Conversion of skin cholesterol to vitamin D depends on the exposure to sunlight and not renal impairment. In renal failure, there is less active vitamin D and therefore less intestinal absorption of calcium.

A client is in cardiogenic shock. Which explanation of cardiogenic shock should the nurse include when responding to a family member's questions about the condition? 1) An irreversible phenomenon 2) A failure of the circulatory pump 3) Usually a fleeting reaction to tissue injury 4) Generally caused by decreased blood volume

Answer: 2) A failure of the circulatory pump Rationale: In cardiogenic shock, the failure of peripheral circulation is caused by the ineffective pumping action of the heart. Shock may have different etiologies (e.g., hypovolemic, cardiogenic, septic, anaphylactic) but always involves a drop in blood pressure and failure of the peripheral circulation because of sympathetic nervous system involvement. Shock can be reversed by the administration of fluids, plasma expanders, and vasoconstrictors. It may be a reaction to tissue injury, but there are many different etiologies (e.g., hypovolemia, sepsis, anaphylaxis); it is not fleeting. Hypovolemia will lead to hypovolemic shock; cardiogenic refers to the heart capabilities.

What is the most probable cause for Conn's syndrome in an adult client? 1) Genetic cause 2) Adrenal adenoma 3) High level of angiotensin II 4) Elevated level of plasma rennin

Answer: 2) Adrenal adenoma Rationale: Conn's syndrome is primary hyperaldosteronism. Excessive secretion of aldosterone by the adrenal glands due to an adrenal adenoma results in Conn's syndrome. Certain types of hyperaldosteronism that are diagnosed in childhood have genetic causes. High levels of angiotensin II that are stimulated by high levels of plasma rennin are a cause for secondary hyperaldosteronism.

The healthcare provider makes the diagnosis of transient ischemic attacks (TIAs). The client asks the nurse, "What causes TIAs?" When preparing a response in language the client will understand, the nurse considers that TIAs are caused by which factor? 1) Genetic valvular heart disease 2) Atherosclerotic plaques within arteries 3) Developmental defects in arterial walls 4) Multiple emboli ascending from the lower extremities

Answer: 2) Atherosclerotic plaques within arteries Rationale: Atherosclerotic plaques within arteries progressively narrow the lumens of the carotid arteries, causing TIAs. Valvular defects usually cause cerebral emboli that result in a brain attack. Brain aneurysms are developmental defects that may rupture, resulting in a brain attack. Emboli arising from the lower extremities usually result in occlusions in the pulmonary vascular system, causing a pulmonary embolus.

The nurse is preparing a blood transfusion for a client with renal failure. Why does anemia often complicate renal failure? 1) Increase in blood pressure 2) Decrease in erythropoietin 3) Increase in serum phosphate levels 4) Decrease in serum sodium concentration

Answer: 2) Decrease in erythropoietin Rationale: The hormone erythropoietin, produced by the kidneys, stimulates the bone marrow to produce red blood cells. In renal failure there is a deficiency of erythropoietin that often results in the client developing anemia. Therefore the nurse is instructed to administer blood. In renal failure, increased blood pressure is due to impairment of renal vasodilator factors and is not treated by administration of blood. Phosphate is retained in the body during renal failure, causing binding of calcium leading to done demineralization, not anemia. Increase in urinary sodium concentration and decrease in serum sodium concentration trigger the release of renin from the juxtaglomerular cells.

A client with late-stage dementia of the Alzheimer type aspirates gastric contents and develops acute respiratory distress syndrome (ARDS). Which phase characterized by signs of pulmonary edema and atelectasis should the nurse consider when planning care? 1) Fibrotic 2) Exudative 3) Reparative 4) Proliferative

Answer: 2) Exudative Rationale: Exudative (injury) phase of ARDS is the early phase. Alveoli become fluid-filled with pulmonary shunting and atelectasis. Fibrotic phase of ARDS leads to pulmonary hypertension and fibrosis. Reparative (resolution) phase starts about two weeks after injury; it is characterized by recovery. If this phase persists for a prolonged time, extensive fibrosis, death, or chronic disease may result.

A client is experiencing a myocardial infarction. What should the nurse identify as the primary cause of the pain experienced by a client with a coronary occlusion? 1) Arterial spasm 2) Heart muscle ischemia 3) Blocking of the coronary veins 4) Irritation of nerve endings in the cardiac plexus

Answer: 2) Heart muscle ischemia Rationale: Ischemia causes tissue injury and the release of chemicals, such as bradykinin, that stimulate sensory nerves and produce pain. Arterial spasm, resulting in tissue hypoxia and pain, is associated with angina pectoris. Arteries, not veins, are involved in the pathology of a myocardial infarction. Tissue injury and pain occur in the myocardium.

A nurse is preparing a teaching plan for the parents of a child with celiac disease. What information on the basic problem in celiac disease does the nurse include? 1) Green stools 2) Intolerance of gluten 3) Absence of intestinal villi 4) Susceptibility to severe dehydration

Answer: 2) Intolerance of gluten Rationale: Celiac disease is an immunological small intestine enteropathy characterized by the inability to metabolize the gliadin component of gluten found in grains such as wheat, barley, rye, and oats; this results in excessive glutamine that is toxic to the mucosal cells. The stools are fatty and yellow. The intestinal villi are present but will atrophy if exposed to foods containing gluten. Fluid balance is not the basic problem with celiac disease; however, dehydration may occur in celiac crisis.

A client has chest tubes attached to a chest tube drainage system. What should the nurse do when caring for this client? 1) Clamp the chest tubes when suctioning. 2) Palpate the surrounding area for crepitus. 3) Change the dressing daily using aseptic technique. 4) Empty the drainage chamber at the end of the shift.

Answer: 2) Palpate the surrounding area for crepitus. Rationale: Leakage of air into the subcutaneous tissue is evidenced by a crackling sound when the area is gently palpated; this is referred to as crepitus. Although hemostats should be readily available for any client with chest tubes in the event of a break in the drainage system, clamping the tube is not otherwise necessary and could cause backpressure. The dressing is not routinely changed to minimize the risk for pneumothorax. The system is kept closed to prevent the pressure of the atmosphere from causing a pneumothorax; drainage levels are marked on the drainage chamber to measure output. The chambers are not emptied; if they are filled, a new system will be attached.

The nurse is educating student nurses about the anatomy and physiology of the kidneys. What term does the nurse explain is used for the tip of the pyramid of a kidney? 1) Calyx 2) Papilla 3) Renal pelvis 4) Renal column

Answer: 2) Papilla Rationale: Pyramids are components of renal medulla, and the tip of each pyramid is called a papilla. A calyx is a structure that collects the urine at the end of each pyramid. The renal calices join together to form the renal pelvis. A renal column is a cortical tissue that separates the pyramids.

A dehydrated older adult is admitted to the hospital from a nursing home. The transfer form documents a history of liquid fecal incontinence. Which intervention by the nurse will facilitate identification of the cause of this incontinence? 1) Perform abdominal percussion. 2) Perform a digital rectal examination. 3) Collect urine culture and sensitivity test. 4) Order a pelvic and abdominal ultrasound.

Answer: 2) Perform a digital rectal examination. Rationale: Fecal impaction is the primary cause of liquid fecal incontinence. A digital rectal examination will determine the presence of a fecal impaction, rectal sensation and tone; in men, it determines the size, shape, and consistency of the prostate gland. Abdominal percussion will not assist in the diagnosis of impaction. Urine culture and sensitivity test will identify urinary tract infection; urinary, not fecal, incontinence is associated with urinary tract infection. Pelvic and abdominal ultrasound might be done if earlier assessments are inconclusive and additional evaluations are required.

A nurse is caring for a client with acute pancreatitis. Which elevated laboratory test result is most indicative of acute pancreatitis? 1) Blood glucose 2) Serum lipase 3) Serum bilirubin level 4) White blood cell count

Answer: 2) Serum lipase Rationale: Lipase concentration is increased in the pancreas and is elevated in the serum when the pancreas becomes acutely inflamed; this distinguishes pancreatitis from other acute abdominal problems. An elevated blood glucose level is not indicative of pancreatitis but rather diabetes mellitus; however, hyperglycemia and glycosuria may occur in some people with acute pancreatitis if the islets of Langerhans are affected. Serum bilirubin level occurs in other disease processes, such as cholecystitis. White blood cell count is not specific to pancreatitis; white blood cells are elevated in other disease processes.

An x-ray film of a client's arm reveals a comminuted fracture of the radial bone. When determining an appropriate plan of care, the nurse considers that a comminuted fracture has what characteristics? 1) Bone protrudes through a break in the skin. 2) The bone has broken into several fragments, and the skin is intact. 3) The bone is broken into two parts, and the skin may or may not be broken. 4) Splintering has occurred on one side of the bone and bending on the other.

Answer: 2) The bone has broken into several fragments, and the skin is intact. Rationale: In a comminuted fracture, the bone is fragmented. When the bone protrudes through a break in the skin it is a compound fracture. When the bone is broken into two parts and the skin may or may not be broken it is a complete fracture. When splintering has occurred on one side of the bone and bending on the other it is a greenstick fracture.

A nurse is caring for a client with end-stage renal disease. For which clinical indicator should the nurse monitor the client? 1) Polyuria 2) Jaundice 3) Azotemia 4) Hypotension

Answer: 3) Azotemia Rationale: Azotemia is an increase in nitrogenous waste (particularly urea) in the blood, which is common with end-stage renal disease. Excessive nephron damage in end-stage renal disease causes oliguria, not polyuria; excessive urination is common in early kidney insufficiency because of the inability to concentrate urine. Jaundice is common to biliary obstruction, not to end-stage renal disease. The blood pressure may be elevated as a result of hypervolemia associated with increased total body fluid.

An adolescent comes to the school nurse complaining of a 2-day history of low-grade fever, exhaustion, and lack of energy and appetite. He has been tardy to school twice in the past week. Which assessment should the nurse use to identify the possible origin of the problem? 1) Eliciting the Kernig sign 2) Eliciting the Brudzinski sign 3) Checking for lymphadenopathy 4) Checking the pupillary response to light and accommodation

Answer: 3) Checking for lymphadenopathy Rationale: Infectious mononucleosis is caused by the Epstein-Barr virus. Mononucleosis is common in people between the age of 15 and 30 years. Signs and symptoms of mononucleosis include fever, fatigue, swollen lymph glands, and enlargement of the liver and spleen. Pupillary response to light and accommodation is checked as part of a neurologic assessment. The Kernig sign (asking the child to straighten a leg that is bent at a 90-degree angle at the knee) and Brudzinski sign (asking a child who is lying flat to bend his head and try to put his chin on his chest) are elicited as part of the assessment when meningitis is suspected.

The nurse is reviewing the urinalysis reports of four clients with renal disorders. Which client's finding signifies the presence of excessive bilirubin? 1) Client 1: amber-yellow 2) Client 2: dark, smoky color 3) Client 3: yellow- brown to olive-green 4) orange-red or orange-brown

Answer: 3) Client 3: yellow- brown to olive-green Rationale: Client 3's urinalysis reports findings of the presence of yellow-brown to olive-green-colored urine which signifies excessive bilirubin. Client 1's urinalysis report findings of the presence of amber-yellow-colored urine signifies a normal finding. Client 2's urinalysis report findings of the presence of dark, smoky-colored urine signifies hematuria. Client 4's urinalysis report findings of orange-red or orange-brown-colored urine indicates the presence of phenazopyridine in the urine.

A nurse is reviewing the assessment findings of four different clients. Which client should the nurse most likely anticipate to have defects in the spinal cord? 1) Client A: Impaired voluntary movements; paralysis on one side 2) Client B: Loss of pain sensation; Unable to recognize form of object by touch 3) Client C: Muscle tone and contractility absent; Paralysis of all extremities 4) Difficulty in swallowing; Paralysis of eye muscles

Answer: 3) Client C: Muscle tone and contractility absent; Paralysis of all extremities Rationale: Client C's assessment findings indicate absence of muscle tone and contractility as well as paralysis of all extremities. These are caused by defects in the spinal cord and are the early signs of spinal cord injury; lesions in the cervical region can cause paralysis in all extremities. Client A is showing impaired voluntary muscles and paralysis on one side; these can be due to defects in the motor system or a stroke in the brain. Client B is showing loss of pain sensation and inability to recognize the form of objects by touch; this can be due to defects in the sensory system. Client D is having difficulty swallowing and is showing paralysis of the eye muscles; this can be due to defects in the cranial nerves.

The nurse assesses the musculoskeletal system of four different clients. Which client does the nurse anticipate to be diagnosed with pes planus? 1) Client A: pain in the posterior leg from heel to knee 2) Client B: flabby appearance of the muscles 3) Client C: abnormal flatness of the sole and arch of the foot 4) Client D: general pain and tenderness in the muscles

Answer: 3) Client C: abnormal flatness of the sole and arch of the foot Rationale: Client C has pes planus; symptoms of this condition include an abnormal flatness of the sole and arch of the foot. Client A has Achilles tendonitis, which is characterized by pain in the posterior leg. Client B has atrophy, which is characterized by a flabby appearance of the muscle. Client D has myalgia, which is characterized by general pain and tenderness in the muscles.

A nurse reviews the chest examination reports of four clients with respiratory disorders. Which client's findings indicate atelectasis? 1) Client A: decreased chest wall movement; hyper-resonance; wheezes 2) Client B: increased vibrations over chest wall above effusion; dull; diminished or absent over effusion 3) Client C: decreased fremitus; dull over affected area; crackles 4) Client D: increased fremitus; dull over affected area; bronchial sounds

Answer: 3) Client C: decreased fremitus; dull over affected area; crackles Rationale: A client suffering from atelectasis may have decreased fremitus, dull percussion over the affected area, and crackle sounds upon auscultation like Client C. Decreased chest wall movements, hyperresonance, and wheezing indicate asthma in Client A. Client B with increased vibrations over the chest wall above effusion, dull percussion, and diminished or absent breath sounds over the affected area may have a pleural effusion. Client D with increased fremitus over the affected area, dull percussion over the affected area, and bronchial sounds upon auscultation may have pneumonia.

A nurse discovers lower extremity pitting edema in a client with right ventricular heart failure. Which information should the nurse consider when planning care? 1) Client has decreased plasma colloid osmotic pressure. 2) Client has increased tissue colloid osmotic pressure. 3) Client has increased plasma hydrostatic pressure. 4) Client has decreased tissue hydrostatic pressure.

Answer: 3) Client has increased plasma hydrostatic pressure. Rationale: In right ventricular heart failure, blood backs up in the systemic capillary beds; the increase in plasma hydrostatic pressure shifts fluid from the intravascular compartment to the interstitial spaces, causing edema. Increase in tissue (interstitial) colloid osmotic pressure occurs with crushing injuries or if proteins pathologically shift from the intravascular compartment to the interstitial spaces, pulling fluid and causing edema. In right ventricular heart failure, increased fluid pressure in the intravascular compartment causes fluid to shift to the tissues; the tissue hydrostatic pressure does not decrease. Although a decrease in colloid osmotic (oncotic) pressure can cause edema, it results from lack of protein intake, not increased hydrostatic pressure associated with right ventricular heart failure.

While playing on a jungle gym in the school playground, a school-aged child falls and sustains head trauma. The nurse suspects dysfunction of the brainstem at a low level when the child assumes the posturing depicted in the illustration. How should the nurse document this posturing in the child's hospital record? 1) Orthotonos 2) Decorticate 3) Decerebrate 4) Opisthotonos

Answer: 3) Decerebrate Rationale: Decerebrate posturing includes rigid extension and pronation of the arms and legs; it is associated with dysfunction at the level of the midbrain. Orthotonos is a tetanic spasm marked by rigidity of the body with the arms and legs in extension in a straight line; it is associated with tetanus or strychnine poisoning. Decorticate posturing consists of adduction of the arms at the shoulders, flexion of the arms on the chest with the wrists flexed and the hands fisted, and extension and adduction of the lower extremities; it is associated with dysfunction at or above the upper brainstem. Opisthotonos is a tetanic spasm in which the head and heels are bent backward and the body is bowed forward; it is associated with tetanus, strychnine poisoning, rabies, and severe meningitis.

A nurse is caring for two clients. One has Parkinson disease, and the other has myasthenia gravis. For which common complication associated with both disorders should the nurse assess these clients? 1) Cogwheel gait 2) Impaired cognition 3) Difficulty swallowing 4) Nonintention tremors

Answer: 3) Difficulty swallowing Rationale: Difficulty swallowing (dysphagia) is a manifestation of both neurologic disorders. With Parkinson disease there is a progressive loss of spontaneity of movement, including swallowing, related to degeneration of the dopamine-producing neurons in the substantia nigra of the midbrain. With myasthenia gravis there is a decreased number of acetylcholine (Ach) receptor sites at the neuromuscular junction, which interferes with muscle contraction, impairing muscles involved in chewing, swallowing, speaking, and breathing. A cogwheel gait is associated with Parkinson disease, not myasthenia gravis. Impaired cognition is associated with Parkinson disease, not myasthenia gravis. Nonintention tremors are associated with Parkinson disease, not myasthenia gravis. The nonintention tremors associated with Parkinson disease result from the loss of the inhibitory influence of dopamine in the basal ganglia, which interferes with the feedback circuit within the cerebral cortex.

After a gastrojejunostomy (Billroth II) for cancer of the stomach, a client progresses to a regular diet. After eating lunch, the client becomes diaphoretic and has palpitations. What does the nurse conclude is the probable cause of these clinical manifestations? 1) Intolerance to fatty foods 2) Dehiscence of the surgical incision 3) Extracellular fluid shift into the bowel 4) Diminished peristalsis in the small intestine

Answer: 3) Extracellular fluid shift into the bowel Rationale: Hypertonic food increases osmotic pressure and pulls fluid from the intravascular compartment into the intestine (dumping syndrome). Increased carbohydrates, not fats, are responsible for the increased osmotic pressure often associated with dumping syndrome. Dehiscence is separation of the wound edges, usually accompanied by a gush of pink-tinged fluid. Although peristalsis may be decreased because of surgery, this decrease will not account for the client's clinical manifestations.

A nurse is assessing a client for possible malabsorption syndrome. Which stool assessment finding will support this diagnosis? 1) Melena 2) Frank blood 3) Fat globules 4) Currant jelly consistency

Answer: 3) Fat globules Rationale: Undigested fat in the feces (steatorrhea) is associated with diseases of the intestinal mucosa (e.g., celiac sprue) or pancreatic enzyme deficiency. Darkening of feces by blood pigments (melena) is related to upper gastrointestinal (GI) bleeding. Bright red blood in the stool is related to lower GI bleeding (e.g., hemorrhoids). Stools containing blood and mucus (currant jelly stools) are associated with intussusception.

An infant is being admitted to a pediatric unit with bacterial meningitis. What is the priority nursing action? 1) Assessing the infant's neurologic status 2) Beginning intravenous fluids and antibiotics 3) Implementing respiratory isolation precautions 4) Teaching the parents the importance of maintaining a quiet environment

Answer: 3) Implementing respiratory isolation precautions Rationale: The infant's illness is contagious, and the nurse, as well as other clients, must first be protected with the implementation of respiratory isolation precautions. Assessment of neurologic status would be performed after implementing isolation. Parental teaching and implementation of prescribed fluids and antibiotics may be done after assessment. Also, antibiotics are usually not administered until after all cultures have been obtained.

A client with a femoral fracture associated with osteomyelitis is immobilized for 3 weeks. The nurse assesses for the development of renal calculi. What is the rationale for the nurse's assessment? 1) The client's dietary patterns have changed since admission. 2) The client has more difficulty urinating in a supine position. 3) Lack of weight-bearing activity promotes bone demineralization. 4) Fracture healing requires more calcium, which increases total calcium metabolism.

Answer: 3) Lack of weight-bearing activity promotes bone demineralization. Rationale: All clients who are confined to bed for any considerable period risk losing calcium from bones. Calcium precipitates in the urine, resulting in formation of calculi. There is no indication that the client's diet has changed. Although the client may have more difficulty urinating in a supine position because of an inability to assume the preferred anatomic position and the emotional effects of using a urinal, it usually does not predispose the client to developing renal calculi. The presence of a healing fracture does not increase total calcium metabolism; however, deposition of bone at the fracture site will be increased.

A client with cystic fibrosis asks why the percussion procedure is being performed. The nurse explains that the primary purpose of percussion is to do what? 1) Relieve bronchial spasms 2) Increase depth of respirations 3) Loosen pulmonary secretions 4) Expel carbon dioxide from the lungs

Answer: 3) Loosen pulmonary secretions Rationale: Postural drainage and percussion also known as chest physical therapy (CPT), is a way to help clients with cystic fibrosis (CF) breathe with less difficulty and stay healthy. This intervention uses gravity and clapping the chest to loosen the thick, sticky mucus in the lungs so it can be removed by coughing. Percussion does not relieve bronchial spasms. Once pulmonary secretions are loosened by percussion and the client has a clearer airway, the depth of respirations may increase and facilitate removal of carbon dioxide from the lungs.

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? 1) Calices 2) Glomerulus 3) Macula densa 4) Juxtaglomerular cells

Answer: 3) Macula densa Rationale: 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.

A client diagnosed with Bell palsy has many questions about the course of the disorder. Which information should the nurse share with the client? 1) Cool compresses decrease facial involvement. 2) Pain occurs with transient ischemic attacks (TIAs). 3) Most clients recover from the effects in several weeks. 4) Body changes should be expected with residual effects.

Answer: 3) Most clients recover from the effects in several weeks. Rationale: The client should be assured that the symptoms are not caused by a stroke; the majority of clients recover in a few weeks. Moist heat, not a cool compress, increases blood circulation to the nerve. Bell palsy is not caused by a TIA. Paresis or paralysis of cranial nerve VII occurs; pain is usually present. The majority of clients recover without residual effects; occasionally some clients are left with evidence of Bell palsy. Exercises may help to maintain muscle tone; also, surgery may be necessary.

A client has been diagnosed as brain dead. The nurse understands that this means that the client has what? 1) No spontaneous reflexes 2) Shallow and slow breathing 3) No cortical functioning with some reflex breathing 4) Deep tendon reflexes only and no independent breathing

Answer: 3) No cortical functioning with some reflex breathing Rationale: A client who is declared as being brain dead has no function of the cerebral cortex and a flat electroencephalogram (EEG). The client may have some spontaneous breathing and a heartbeat. The guidelines established by the American Association of Neurology include coma or unresponsiveness, absence of brainstem reflexes, and apnea. There are specific assessments to validate the findings. No spontaneous reflexes, shallow and slow breathing, and deep tendon reflexes only and no independent breathing do not fit the definition of brain dead.

A client with cancer of the prostate requests the urinal at frequent intervals but either does not void or voids in very small amounts. Which does the nurse conclude is most likely the causative factor? 1) Edema 2) Dysuria 3) Retention 4) Suppression

Answer: 3) Retention Rationale: An enlarged prostate constricts the urethra, interfering with urine flow and causing retention. When the bladder fills and approaches capacity, small amounts can be voided, but the bladder never empties completely. Edema does not cause the client to void frequently in small amounts. Dysuria is painful or difficult urination, which is not part of the client's responses. The urge to void is caused by stimulation of the stretch receptors as the bladder fills with urine; in suppression, little or no urine is produced.

A client is admitted to the hospital with severe diarrhea, abdominal cramps, and vomiting after eating. These symptoms have lasted 5 days. Upon further assessment, the primary healthcare provider finds that the symptoms occurred after the client ate eggs, salad dressings, and sandwich fillings. Which food borne disease would be suspected in this client? 1) Listeriosis 2) Shigellosis 3) Salmonellosis 4) Staphylococcus

Answer: 3) Salmonellosis Rationale: A client with salmonellosis will experience severe diarrhea, abdominal cramps, and vomiting; these symptoms last as long as 5 days after the intake of contaminated food. This disorder may be caused by Salmonella typhi or Salmonella paratyphi. The causative organism is usually present in such foods as eggs, salad dressings, and sandwich fillings. A client with listeriosis will experience severe diarrhea, fever, headache, pneumonia, meningitis, and endocarditis 3 to 21 days after infection. The symptoms of shigellosis range from cramps and diarrhea to a fatal dysentery that lasts for 3 to 14 days. Pain, vomiting, diarrhea, perspiration, headache, fever, and prostration lasting for 1 or 2 days are the symptoms of a Staphylococcus infection.

Which statement helps the nurse determine that a woman with genital herpes (HSV-2) understands her self-care in regards to this infection? 1) "When I have a baby, I don't want a cesarean." 2) "I can have sex as soon as the herpes sores have healed." 3) "When I finish the acyclovir prescription I will be cured." 4) "I must be careful when I have sex because herpes is a lifelong problem."

Answer: 4) "I must be careful when I have sex because herpes is a lifelong problem." Rationale: Genital herpes (HSV-2) is characterized by remissions and exacerbations; it cannot be cured. Most pregnant women with HSV-2 have cesarean deliveries to prevent their newborns from contracting the disease while passing through the vagina. Clients should abstain from sex until 10 days after the lesions heal. Herpes can be controlled, not cured.

A mother whose infant was found to have cerebral palsy at 6 months of age asks why she was not told that her baby had cerebral palsy when the infant was born. How should the nurse respond? 1) "The neurological lesions changed as your baby matured." 2) "Joint deformities don't appear until after 6 months of age." 3) "The staff members didn't want to alarm you until it was necessary." 4) "Until there's control of voluntary movement, a diagnosis can't be confirmed."

Answer: 4) "Until there's control of voluntary movement, a diagnosis can't be confirmed." Rationale: Cortical control of voluntary muscles occurs between 2 and 4 months of age. The neurological lesions are fixed and will neither progress nor regress. Cerebral palsy is not diagnosed on the basis of the presence of joint deformities; these may develop later because of spastic muscle imbalance. Parents have a right to be informed of their child's diagnosis as soon as possible.

Which client would have relatively smaller tidal volumes due to limited chest wall movement? 1) A client with asthma 2) A client with pneumonia 3) A client with pulmonary fibrosis 4) A client with phrenic nerve paralysis

Answer: 4) A client with phrenic nerve paralysis Rationale: 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.

A client reports left-sided chest pain after playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse expects to identify which finding? 1) Dull sound on percussion 2) Vocal fremitus on palpation 3) Rales with rhonchi on auscultation 4) Absence of breath sounds on auscultation

Answer: 4) Absence of breath sounds on auscultation Rationale: The left lung is collapsed; therefore, there are no breath sounds. A tympanic, not a dull, sound will be heard with a pneumothorax[1][2]. There is no vocal fremitus because there is no airflow into the left lung as a result of the pneumothorax. Rales with rhonchi will not be heard because there is no airflow into the left lung as a result of the pneumothorax.

A client comes to the emergency department reporting chest pain and difficulty breathing. A chest x-ray reveals a pneumothorax. Which finding should the nurse expect to identify when assessing the client? 1) Distended neck veins 2) Paradoxical respirations 3) Increasing amounts of purulent sputum 4) Absence of breath sounds over the affected area

Answer: 4) Absence of breath sounds over the affected area Rationale: When the lung is collapsed, air is not moving into and out of the area, and therefore breath sounds are absent. Distended neck veins are associated with failure of the right side of the heart and can occur with a mediastinal shift, but there is no evidence of either. Paradoxical respirations occur with flail chest, not pneumothorax. Purulent sputum is a sign of infection, not pneumothorax.

An adolescent with Duchenne muscular dystrophy has received care at the pediatric clinic since early childhood. Of which body system should the nurse perform a focused assessment to identify life-threatening complications as the child ages? 1) Neurologic 2) Gastrointestinal 3) Musculoskeletal 4) Cardiopulmonary

Answer: 4) Cardiopulmonary Rationale: As muscular degeneration advances in the adolescent, the diaphragm, auxiliary muscles of respiration, and heart are affected, resulting in life-threatening respiratory infections and heart failure. Central nervous system functioning is not affected by Duchenne muscular dystrophy. Nutritional problems are less of a priority than cardiopulmonary problems. Although the musculoskeletal system will exhibit marked degeneration, it is second in priority to the cardiopulmonary changes.

While assessing an immobilized client, the nurse notes that the client has shortened muscles over a joint, preventing full extension. What is this condition known as? 1) Osteoarthritis 2) Osteoporosis 3) Muscle atrophy 4) Contracture

Answer: 4) Contracture Rationale: Immobilized clients are at high risk for the development of contractures. Contractures are characterized by permanent shortening of the muscle covering a joint. Osteoarthritis is a disease process of the weight-bearing joints caused by wear and tear. Osteoporosis is a metabolic disease process in which the bones lose calcium. Muscle atrophy is a wasting and/or decrease in the strength and size of muscles because of a lack of physical activity or a neurologic or musculoskeletal disorder.

A client who has had a myocardial infarction experiences a noticeably decreased pulse pressure. What does this indicate to the nurse? 1) Increased blood volume 2) Hyperactivity of the heart 3) Increased cardiac sufficiency 4) Decreased force of contraction

Answer: 4) Decreased force of contraction Rationale: A direct relationship exists between systolic blood pressure and the force of left ventricular contraction. A decreased pulse pressure is associated with heart failure or hypovolemia. A decreased blood volume is indicated by a decreased pulse pressure. Hyperactivity of the heart is indicated by dysrhythmias and tachycardia. A decreased pulse pressure indicates decreased cardiac sufficiency.

What is the nurse's priority concern when caring for an infant born with exstrophy of the bladder? 1) Urine retention 2) Excoriation of the skin 3) Impending dehydration 4) Development of an infection

Answer: 4) Development of an infection Rationale: The constant seepage of urine from the exposed ureteral orifices makes the area susceptible to infection; infection must be prevented or controlled because it may ultimately lead to renal failure. Urine retention will not occur because of the constant seepage of urine. Although skin excoriation is a major concern, it is secondary to the development of a life-threatening infection. Although dehydration is a major concern, risk for infection is the priority for the infant at this time.

A client with emphysema experiences shortness of breath and uses pursed-lip breathing and accessory muscles of respiration. The nurse determines that the cause of the dyspnea is for which reason? 1) Spasm of the bronchi that traps the air 2) Increase in the vital capacity of the lungs 3) Too rapid expulsion of air from the bronchioles 4) Difficulty in expelling the air trapped in the alveoli

Answer: 4) Difficulty in expelling the air trapped in the alveoli Rationale: Emphysema involves destructive changes in the alveolar walls, leading to dilation of the air sacs; there is subsequent air trapping and difficulty with expiration. Bronchospasm is characteristic of asthma, not emphysema. The vital capacity is decreased because of restriction of the diaphragm and thoracic movement. Expiration is slowed by pursed-lip breathing to keep the airways open so less air is trapped.

An infant who has a congenital heart defect with left-to-right shunting of blood is admitted to the pediatric unit. What early sign of heart failure should the nurse identify? 1) Cyanosis 2) Restlessness 3) Decreased heart rate 4) Increased respiratory rate

Answer: 4) Increased respiratory rate Rationale: Because the lungs are stressed by pulmonary edema, a quicker respiratory rate is the first and most reliable indicator of early heart failure in infants. Cyanosis is a late sign of heart failure; with early failure there is still adequate perfusion of blood. Infants with early heart failure do not move about; they become fatigued quickly, especially when feeding, because of a decrease of oxygen to body cells. The heart rate of an infant in early heart failure increases, not decreases, in an attempt to increase oxygen to body cells.

A nurse is caring for a client with a diagnosis of acute pancreatitis and alcoholism. The client asks, "What does my drinking have to do with my diagnosis?" What effect of alcohol should the nurse include when responding? 1) Promotes the formation of calculi in the cystic duct 2) Stimulates the pancreas to secrete more insulin than it can immediately produce 3) Alters the composition of enzymes so they are capable of damaging the pancreas 4) Increases enzyme secretion and pancreatic duct pressure that causes backflow of enzymes into the pancreas

Answer: 4) Increases enzyme secretion and pancreatic duct pressure that causes backflow of enzymes into the pancreas Rationale: Alcohol stimulates pancreatic enzyme secretion and an increase in pressure in the pancreatic duct. The backflow of enzymes into the pancreatic interstitial spaces results in partial digestion and inflammation of the pancreatic tissue. Although blockage of the bile duct with calculi may precipitate pancreatitis, this is not associated with alcohol. Alcohol does not deplete insulin stores; the demand for insulin is unrelated to pancreatitis. Although the volume of secretions increases, the composition remains unchanged.

A nurse is assessing two clients. One client has ulcerative colitis, and the other client has Crohn disease. Which is more likely to be identified in the client with ulcerative colitis than in the client with Crohn disease? 1) Inclusion of transmural involvement of the small bowel wall 2) Higher occurrence of fistulas and abscesses from changes in the bowel wall 3) Pathology beginning proximally with intermittent plaques found along the colon 4) Involvement starting distally with rectal bleeding that spreads continuously up the colon

Answer: 4) Involvement starting distally with rectal bleeding that spreads continuously up the colon Rationale: Ulcerative colitis involvement starts distally with rectal bleeding that spreads continuously up the colon to the cecum. In ulcerative colitis, pathology usually is in the descending colon; in Crohn disease, it is primarily in the terminal ileum, cecum, and ascending colon. Ulcerative colitis, as the name implies, affects the colon, not the small intestine. Intermittent areas of pathology occur in Crohn. In ulcerative colitis, the pathology is in the inner layer and does not extend throughout the entire bowel wall; therefore, abscesses and fistulas are rare. Abscesses and fistulas occur more frequently in Crohn disease.

A 15-year-old adolescent is found to have type 1 diabetes. What should the nurse include when teaching the adolescent about type 1 diabetes? 1) It does not always require insulin. 2) It involves early vascular changes. 3) It occurs more often in obese adolescents. 4) It has a more rapid onset than does type 2 diabetes.

Answer: 4) It has a more rapid onset than does type 2 diabetes. Rationale: A characteristic difference between type 1 and type 2 diabetes is the rapid onset of type 1 diabetes. Type 1 diabetes often is first diagnosed during an episode of acute ketoacidosis. Children, adolescents, and adults with type 1 diabetes are insulin dependent. Vascular changes are complications associated with long-standing diabetes. Maturity-onset diabetes of the young (MODY), similar to type 2 diabetes, is more often seen in obese teenagers. Adolescents with type 1 diabetes tend to be at or below the expected weight for their height and bone structure.

The nurse is providing information about blood pressure to an unlicensed health care worker and recalls that the factor that has the greatest influence on diastolic blood pressure is what? 1) Renal function 2) Cardiac output 3) Oxygen saturation 4) Peripheral vascular resistance

Answer: 4) Peripheral vascular resistance Rationale: Peripheral vascular resistance is the impedance of blood flow, or back pressure, by the arterioles, which is the most influential component of diastolic blood pressure. Renal function through the renin-angiotensin-aldosterone system regulates fluid balance and does influence blood pressure. Cardiac output is the determinant of systolic blood pressure. Oxygen saturation does not have a direct effect on diastolic blood pressure.

Which hormone is released from the pancreas? 1) Oxytocin 2) Prolactin 3) Calcitonin 4) Somatostatin

Answer: 4) Somatostatin Rationale: Somatostatin is a hormone produced by the pancreas that inhibits the release of insulin and glucagon. Oxytocin is a hormone produced by the posterior pituitary gland that acts on the uterus and mammary glands. Prolactin is a hormone produced by the anterior pituitary gland that targets the ovaries and mammary glands in women and testes in men. Calcitonin is a hormone produced by the thyroid gland that interacts with bone tissue.

An adolescent is admitted to the burn unit with partial-thickness burns of both arms and the chest. What information about burns should guide the nurse's plan of care? 1) Burns are extremely painful and disfiguring. 2) Some grafting of the burned area is necessary. 3) Pressure dressings and prolonged hydrotherapy are required. 4) Spontaneous epithelial regeneration occurs within several weeks.

Answer: 4) Spontaneous epithelial regeneration occurs within several weeks. Rationale: If there is no subsequent infection of the burned areas, wound healing should be uneventful. Although partial-thickness burns are painful, they usually heal with little or no scarring. Regeneration will occur unless there is further insult to the burn injury, such as infection; grafting should not be necessary. Occlusive dressings may be applied to minimize the discomfort of frequent dressing changes; hydrotherapy is not required for partial-thickness burns.

A woman arrives at the women's health clinic complaining of frequency and burning pain when voiding. The diagnosis is a urinary tract infection. What is important for the nurse to encourage the client to do? 1) Void every 2 hours. 2) Record fluid intake and urinary output. 3) Pour warm water over the vulva after voiding. 4) Wash the hands thoroughly after urinating and defecating.

Answer: 4) Wash the hands thoroughly after urinating and defecating. Rationale: Hand washing is a medical aseptic technique and should limit the spread of microorganisms and help prevent future urinary tract infections if incorporated into the client's health practices. Voiding every 2 hours is unnecessary, but the client should be encouraged to void when the urge occurs. Intake and output need not be measured. Pouring warm water over the vulva after voiding is unnecessary for cystitis; it may be used as a part of perineal care for other problems.

The nurse is caring for a client with fat embolism syndrome (FES). Which anatomical part of the bone depicted in the figure is responsible for the client's condition? (1)

Answer: spongy cancellous tissue Rationale: Choice B depicts spongy cancellous tissue. Softer cancellous tissue contains large spaces or trabeculae, which are filled with red and yellow marrow. Yellow marrow contains fat cells that may be dislodged and enter the bloodstream, which can cause FES. Choice A indicates articular cartilage, which is a smooth white tissue that covers the ends of bones. Choice C indicates compact bone, which is hard due to inorganic calcium salt deposits. Choice D depicts bone cells (osteocytes) present in the deepest layer of the periosteum.

A nurse is teaching skin and basic care to the mother of a 6-month-old infant with eczema. Which statement indicates that the mother needs further teaching? 1) "I'll have to be careful not to cut my baby's nails short." 2) "I gave all of my baby's woolen blankets to my nephew." 3) "The baby can't have foods made with whole milk anymore." 4) "I'll need to buy a whole new wardrobe of cotton clothing for the baby."

Answer: 1) "I'll have to be careful not to cut my baby's nails short." Rationale: The baby's nails should be cut very short to minimize injury from scratching. Woolen and synthetic fabrics tend to further irritate the eczematous rash. Nonhuman milk can exacerbate eczema. Cotton clothing seems to be tolerated the best by infants with eczema.

Which clinical manifestation is seen in a male client due to deficiency of gonadotropin? 1) Decreased fertility 2) Increased muscle mass 3) Increased bone density 4) Decreased urine specific gravity

Answer: 1) Decreased fertility Rationale: Deficiency of gonadotropin in males results in clinical manifestation of infertility due to impotence. There is loss of muscle mass and bone density due to gonadotropin deficiency. Clients with diabetes insipidus have decreased urine specific gravity, usually less than 1.005.

Which gland secretes melatonin? 1) Pineal gland 2) Thyroid gland 3) Adrenal gland 4) Parathyroid gland

Answer: 1) Pineal gland Rationale: The pineal gland secretes the hormone melatonin, which regulates the circadian rhythm and reproductive system at the onset of puberty. The thyroid gland secretes thyroid hormones. The adrenal gland secretes androgens, corticosteroids, and catecholamines. The parathyroid gland secretes the hormone calcitonin.

A 3-year-old child is admitted to the burn unit with partial- and full-thickness burns over 30% of the body. For what complication should the nurse assess the child during the first 48 hours? 1) Shock 2) Pneumonia 3) Contractures 4) Hypertension

Answer: 1) Shock Rationale: The immediate postburn period is marked by dramatic alterations in circulation because of large fluid losses through the denuded skin, vasodilation, and edema formation; the precipitous drop in cardiac output can result in shock. Pneumonia may be a later complication associated with immobility. Contractures are a later complication associated with scarring and aggravated by inadequate position changes and splinting. Hypotension, not hypertension, occurs with hypovolemic shock.

When explaining the occurrence of febrile seizures to a parents' class, what information should the nurse include? 1) They may occur in minor illnesses. 2) The cause is usually readily identified. 3) They usually do not occur during the toddler years. 4) The frequency of occurrence is greater in females than males.

Answer: 1) They may occur in minor illnesses. Rationale: Febrile seizures are usually not associated with major neurologic problems. Between 95% and 98% of these children do not experience epilepsy or other neurologic problems. The cause of febrile seizures is still uncertain. Most febrile seizures occur after 6 months of age and before age 3 years, with the average age of onset between 18 and 22 months. Boys are affected about twice as frequently as girls.

A 17-year-old adolescent was recently found to have type 2 diabetes mellitus. What information will the nurse include when providing education to the family? 1) "Your teen will need insulin injections for the rest of her life." 2) "The most important interventions are good nutrition and portion control." 3) "This is a condition where the body produces antibodies against its own cells." 4) "This condition causes weight loss and increased appetite, thirst, and urination."

Answer: 2) "The most important interventions are good nutrition and portion control." Rationale: Most children with type 2 diabetes are overweight or at risk for becoming overweight. With nutritional intervention to promote proper weight, the condition may often be managed with diet and exercise alone. A lifelong insulin regimen; the production of antibodies against the child's own cells; and weight loss with increased appetite, thirst, and urination are all typical of type 1 diabetes.

Which physiologic activity is associated with the "proliferative phase" of normal wound healing? 1) White blood cells migrate into the wound 2) Epithelial cells grow over the granulation tissue bed 3) Scar tissue gradually becomes thinner and pale in color 4) Vasodilation occurs with increased capillary permeability

Answer: 2) Epithelial cells grow over the granulation tissue bed Rationale: During the "proliferative phase" of normal wound healing, the epithelial cells grow over the granulation tissue bed. The white blood cells are migrated into the wound during the inflammatory phase. In the maturation phase, the scar tissues gradually become thinner and pale in color. The vasodilation with the increased capillary permeability may occur during the inflammatory phase.

A client with vesiculopustular lesions with honey-colored crusts on the face visits a primary healthcare provider. Which bacterial condition is suspected? 1) Cellulitis 2) Impetigo 3) Carbuncle 4) Erysipelas

Answer: 2) Impetigo Rationale: Impetigo is associated with vesiculopustular lesions that have honey-colored crusts. Impetigo usually manifests on the face. Cellulitis is a bacterial infection in which hot, tender, erythematous and edematous areas with diffuse borders are present. Carbuncle is a bacterial infection with many pustules in an erythematous area. Erysipelas is a bacterial infection with red, hot sharply demarcated plaque that is indurate and painful.

Which part of the female reproductive system produces testosterone in females? 1) Uterus 2) Ovary 3) Fallopian tube 4) Ovarian follicle

Answer: 2) Ovary Rationale: Testosterone is an androgen, and in females, androgens are produced by the ovaries and adrenal glands. The uterus holds the fetus during pregnancy. Fallopian tubes facilitate fertilization of oocyte and sperm. An ovarian follicle is a collection of oocytes in the ovary.

A nurse is planning to assess the vomitus of an infant with pyloric stenosis. Why does the nurse anticipate that the vomitus will be white rather than bile-stained? 1) The bile duct is obstructed by the pyloric sphincter. 2) There is an obstruction above the opening of the common bile duct. 3) The bile duct sphincter is connected to the hypertrophied pyloric muscle. 4) There is a constriction of the cardiac sphincter that obstructs the flow of bile.

Answer: 2) There is an obstruction above the opening of the common bile duct. Rationale: The common bile duct enters the duodenum. The pyloric sphincter is located between the end of the stomach and the beginning of the duodenum; therefore when it is hypertrophied the tight sphincter prevents any mixing of vomited formula with bile. Pyloric stenosis involves hypertrophy and hyperplasia of the muscle of the pyloric sphincter; the bile duct is intact. The bile duct enters the duodenum at a site different from the pyloric sphincter and is uninvolved in pyloric stenosis. The area affected in pyloric stenosis is the pyloric sphincter (which is between the stomach and duodenum), not the cardiac sphincter (which is between the stomach and esophagus).

A 17-year-old student with type 1 diabetes asks the nurse which hormone causes the blood glucose level to rise. When responding, the nurse should explain in language that the client can understand that liver glycogenolysis is stimulated by a hormone secreted by the islets of Langerhans. Which hormone is this? 1) Adrenocorticotropic hormone (ACTH) 2) Insulin 3) Glucagon 4) Epinephrine

Answer: 3) Glucagon Rationale: Glucagon promotes liver glycogenolysis, resulting in the release of glucose into the blood. ACTH is not directly related to glycogenolysis; it is released from the anterior pituitary. Insulin production is not directly related to glycogenolysis; in healthy individuals the level of insulin will increase as the glucose level increases. Epinephrine is not directly related to glycogenolysis; it is released from the adrenal medulla and sympathetic nerve endings.

The laboratory report of a client reveals increased serum cholesterol levels. Which other finding indicates growth hormone deficiency in the client? 1) Scalp alopecia 2) Intolerance to cold 3) Pathological fractures 4) Increased urine output

Answer: 3) Pathological fractures Rationale: Growth hormone deficiency results in thinning of bones and increases the risk for pathological fractures. Thyrotropin deficiency results in scalp alopecia and intolerance to cold. Marked increase in the volume of urine output is a sign of diabetes insipidus caused by vasopressin deficiency.

A client admitted with the diagnosis of subarachnoid hemorrhage exhibits aphasia and hemiparesis. The nurse concludes that these neurologic deficits are caused primarily by which response? 1) Blood loss 2) Tissue death 3) Vascular spasms 4) Electrolyte imbalance

Answer: 3) Vascular spasms Rationale: In an attempt to stop the bleeding, adjacent arteries constrict (vasospasm); this in turn contributes to the ischemia responsible for the neurologic deficits. The volume of blood loss is not great enough to significantly alter the oxygen-carrying capability of the remaining blood supply. Although prolonged ischemia may cause necrosis, many of the manifestations of cerebral ischemia are reversed as pressure diminishes, and there may be no permanent damage. Severe electrolyte imbalance may cause generalized weakness; however, hemiparesis and aphasia are not the result of electrolyte loss.

A nurse applies a cold pack to treat an acute musculoskeletal injury. Cold therapy decreases pain by doing what? 1) Promoting analgesia and circulation 2) Numbing the nerves and dilating the blood vessels 3) Promoting circulation and reducing muscle spasms 4) Causing local vasoconstriction, preventing edema and muscle spasms

Answer: 4) Causing local vasoconstriction, preventing edema and muscle spasms Rationale: Cold causes the blood vessels to constrict, which reduces the leakage of fluid into the tissues and prevents swelling and therefore muscle spasms. Cold does promote analgesia but not circulation. It may numb nerves but does not dilate blood vessels. Cold therapy also may numb the nerves and surrounding tissues, thus reducing pain.