patho hesi

Which key feature does the nurse associate with a stage 2 pressure ulcer? A. Presence of nonintact skin B. Development of sinus tracts C. Damage to the subcutaneous tissues D. Appearance of a reddened area over a bony prominence

A. The skin is nonintact in stage 2 of pressure ulcers. Sinus tracts may develop during stage 4 of pressure ulcers. The subcutaneous tissue becomes damaged or necrotic during stage 3 of pressure ulcers. A reddened area over a bony surface occurs in stage 1 of pressure ulcers.

A newborn has just been admitted to the pediatric surgical unit from the birth hospital with a diagnosis of tracheoesophageal fistula. In what position should this child be maintained? A. Prone, to reduce risk of aspiration B. Trendelenburg, to drain stomach contents C. Semi-Fowler, to reduce the risk of chemical pneumonia D. Supine, to reduce the risk of sudden infant death syndrome

C.

A nurse in the pediatric clinic suspects that Reye syndrome is developing in a 9-year-old child. For which early signs of Reye syndrome should the nurse assess the child? Select all that apply. A. Diarrhea B. Jaundice C. Lethargy D. Vomiting E. Confusion

C, D, E

A nurse is performing the Ortolani test on a newborn. Which finding indicates a positive result? A. Dorsiflexion, then fanning B. Hypertonia and jitteriness C. An arched back and crying D. An audible click on abduction

D. As the head of the femur moves within the acetabulum, sometimes there is an audible click when there is developmental dysplasia of the hip.

The nurse assesses a patient who presents with lower back pain, impaired touch sensation at L5-S1 levels, presence of Babinski reflex, and mild weakness in the foot. Which instructions given by the nurse will help the patient manage pain? "Go on full bed rest for 3-4 days." "Perform stretching exercises daily." "Refrain from repeated lifting." "Use nonsteroidal anti-inflammatory drugs."

refrain from repeated lifting

A client has chronic obstructive pulmonary disease (COPD). To decrease the risk of CO2 intoxication (CO2 narcosis), what should the nurse do? A. Initiate pulmonary hygiene to clear air passages of trapped mucus B. Instruct to deep breathe slowly with inhalation longer than exhalation C. Encourage continuous rapid panting to promote respiratory exchange D. Administer oxygen at a low concentration to maintain respiratory drive

D.

A preschool-aged child with leukemia who is undergoing chemotherapy is susceptible to rectal ulcerations. What should the nurse recommend to the parents that will lessen the severity of this problem? A. Encourage lying on the abdomen when in bed. B. Have the child wear cotton underpants at night. C. Apply rectal ointment liberally four times a day. D. Clean the child's perianal area after each bowel movement.

D. Meticulous toilet hygiene is essential to prevent infection and promote comfort. Changing positions in bed is preferable. Underpants keep the area moist and promote bacterial growth; it is preferable to leave the area exposed to air, even if it remains under bed linens. Ointments tend to occlude and trap organisms, thus promoting infection.

A client with type 1 diabetes has morning fasting blood glucose levels between 200 and 240 mg/dl with no hypoglycemia during the night. Which acute complication of diabetes is this client experiencing? Somogyi effect Dawn phenomenon Diabetic ketoacidosis (DKA) Hyperosmolar hyperglycemic nonketotic syndrome (HHNKS)

Dawn phenomenon The dawn phenomenon is an early morning rise in blood glucose concentration with no hypoglycemia during the night. The Somogyi effect is a unique combination of hypoglycemia followed by rebound hyperglycemia.

A nurse is teaching about restrictive lung diseases. Which conditions should the nurse include? Select all that apply. Select all that apply Atelectasis Emphysema Chronic asthma Chronic bronchitis Pulmonary edema Acute respiratory distress syndrome

atelectasis, pulmonary edema, ards

A client with cancer develops thrombocytopenia from chemotherapy. Which complication should the nurse monitor for in this client? Anemia Infection Hemorrhage Granulocytopenia

hemorrhage

The mother of a 2-year-old girl expresses concern that her daughter's growth rate has slowed. What should the nurse explain to the mother about the growth of toddlers? A. "This growth pattern is typical at this age." B. "Toddlers are too busy exploring their world to eat." C. "This growth pattern can't be interpreted for another year." D. "Toddlers usually lose their taste for foods they liked when younger."

A.

A 10-year-old child is admitted to the pediatric unit in vaso-occlusive sickle cell crisis. The nurse manager is planning to assign a room. Which child is the best roommate option for this client? A. Child with thalassemia B. Child with osteomyelitis C. Child with viral pneumonia D. Child with acute pharyngitis

A. all other diseases are infectious

Which symptoms present in a child indicate Turner syndrome? Select all that apply. A. Webbed neck B. Impaired language C. Tall stature with long legs D. Low position of posterior hairline E. Shield-shaped chest with wide space between the nipples

A, D, E. Turner syndrome is a chromosomal abnormality seen in females in which an X chromosome is partly or completely absent. The clinical manifestations of Turner syndrome include a webbed neck, low posterior hairline, and shield-shaped chest with wide space between the nipples. Impaired language skills are seen in clients with triple X or superfemale syndrome. The client with Turner syndrome has short stature. Tall stature with long legs is a finding in Klinefelter syndrome.

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

A, E

A nurse who is caring for a 7-year-old child with acute glomerulonephritis assesses the child for cerebral complications. What signs and symptoms indicate cerebral involvement? A. Headache, drowsiness, and vomiting B. Generalized edema, anorexia, and restlessness C. Anuria, temperature higher than 103° F (39.4° C), and confusion D. Cardiac decompensation, heart rate of 114 beats/min, and vomiting

A.

Spinal fusion is performed in an adolescent with scoliosis. What postoperative nursing intervention is specifically related to surgery for scoliosis? A. Log-rolling every 2 hours B. Checking the dressing frequently C. Supervising deep-breathing exercises D. Maintaining the adolescent in the supine position for 3 days

A.

A child undergoes tonsillectomy and adenoidectomy for numerous recurrent respiratory tract infections. After the surgery, what should the nurse teach the parents to do? A. Offer crushed ice chips. B. Encourage the intake of ice cream. C. Keep the child in the supine position. D. Gargle with a diluted mouthwash solution.

A. Ice chips are soothing and promote vasoconstriction. Cool water, flavored ice pop, or diluted fruit juice may be given but fluids with a red or brown color should be avoided to distinguish fresh or old blood in emesis from the ingested liquid. Milk and milk products coat the mouth, causing the child to clear the throat, which may precipitate bleeding.

The nurse is measuring the body temperature of four neonates born at term in a pediatric health setting. Which neonate has normal body temperature? A. Neonate 1- 35.5 C B. Neonate 2- 36.9 C C. Neonate 3- 37.1 C D. Neonate 4- 38.5 C

C. The normal body temperature of term neonates is in the range of 36.5° C to 37.5° C. Therefore a body temperature of 37.1° C is a normal finding. The body temperatures of 35.5° C and 36.0° C in neonates 1 and 2 indicate hypothermia. The body temperature of 38.5° C in neonate 4 indicates hyperthermia.

The laboratory report of a client reveals increased serum cholesterol levels. Which other finding indicates growth hormone deficiency in the client? A. Scalp alopecia B. Intolerance to cold C. Pathological fractures D. Increased urine output

C. 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 reports a cold and a whooping sound with the cough. Which organism is responsible for this condition? A. Yersinia pestis B. Bordetella pertussis C. Corynebacterium diphtheria D. Mycobacterium tuberculosis

B.

A nurse is teaching parents about growth and development in preadolescent girls, and a mother asks at what age her daughter will have her first period. What is the most accurate response by the nurse? A. Before the pubic hair appears B. At the end of the growth spurt C. Near the age when their mothers did D. Around the time when the breasts develop

B.

An 11-year-old boy who has stepped on a rusty nail is given tetanus immune globulin in the emergency department. The nurse knows that the immune globulin injection will confer what type of immunity? A. Longer-lasting active immunity B. Temporary passive acquired immunity C. Passive immunity throughout the child's life D. Active natural immunity throughout the child's life

B.

The neonate has a protruding tongue and a crease that transverses the entire width of each palm. The nurse recognizes that these findings are characteristic of what congenital condition? A. Hypothyroidism B. Down syndrome C. Turner syndrome D. Fetal alcohol syndrome

B. Dysmorphic features that are characteristic of Down syndrome include a protruding tongue and simian creases across the palms. A protruding tongue but not the transverse palmar creases may also occur with hypothyroidism. Turner syndrome is characterized by a webbed neck and peripheral edema. Children with fetal alcohol syndrome have dysmorphic features, but these are different from the ones that occur with Down syndrome.

A nurse is caring for a client with diabetes insipidus. Upon assessment, which classic manifestations will the nurse observe? Select all that apply. Polyuria Polydipsia Polyphagia Dehydration Ketoacidosis Frequent infections

polyuria, polydipsia, dehydration

In addition to tachycardia, what are other clinical manifestations the nurse will find upon assessment of a client with acute hypoxemia? Select all that apply Some correct answers were not selected Edema Cyanosis Clubbing Confusion Decreased renal output

edema, cyanosis, confusion, decreased renal output CLUBBING IS WITH CHRONIC HYPOXEMIA

Which statement by the client indicates teaching was successful regarding ankylosing spondylitis? The disease is more common in men. The disease in women is usually more severe. The disease in women is predominantly in the spine. The disease in men affects predominantly synovial joints.

more common in men

Emphysema, chronic bronchitis, and chronic asthma are not restrictive but are ------ lung disorders.

obstructive

A client has a duodenal ulcer. What should a nurse expect to find in an assessment? Pain at night Constant pain Pain in the lower abdomen Pain immediately after eating

pain at night

A nurse concludes that the teaching about sickle cell anemia has been understood when an adolescent with the disorder makes which statement? A. "I'll start to have symptoms when I drink less fluid." B. "I'll start to have symptoms when I have fewer platelets." C. "I'll start to have symptoms when I decrease the iron in my diet." D. "I'll start to have symptoms when I have fewer white blood cells."

A. Dehydration precipitates sickling of red blood cells and therefore is a major causative factor for painful episodes associated with sickle cell anemia. An inadequate number of platelets (thrombocytes) is unrelated to painful episodes associated with sickle cell anemia. Iron intake is unrelated to the sickling phenomenon. An inadequate number of white blood cells is unrelated to painful episodes associated with sickle cell anemia.

A client who has syphilis tells the nurse that it must have been contracted from a toilet seat. The nurse knows that this cannot be true because of what property of the causative agent of syphilis? A. It is immobilized by body contact. B. It is chelated by wood and plastic. C. It is inactivated when exposed to a dry environment. D. It is destroyed when exposed to a warm environment.

C. A dry environment inactivates the Treponema pallidum, making it incapable of causing disease. The organism is transferred by sexual contact; warm, moist body contact supports growth of the organism. Nothing chelates this organism

The nurse is monitoring a client's hemoglobin level. The nurse recalls that the amount of hemoglobin in the blood has what effect on oxygenation status? A. Except with rare blood disorders, hemoglobin seldom affects oxygenation status. B. There are many other factors that affect oxygenation status more than hemoglobin does. C. A low hemoglobin level causes reduced oxygen-carrying capacity. D. Hemoglobin reflects the body's clotting ability and may or may not affect oxygenation status.

C. Hemoglobin carries oxygen to all tissues in the body. If the hemoglobin level is low, the amount of oxygen-carrying capacity is also low. Higher levels of hemoglobin will increase oxygen-carrying capacity and thus increase the total amount of oxygen available in the blood. Hemoglobin does not reflect clotting ability.

A nurse is caring for an infant with hypertrophic pyloric stenosis. A pyloromyotomy is scheduled. Which pathophysiologic modification must be addressed before this surgery can be performed safely? A. Hydration must be restored. B. The serum chloride level must be restored. C. Fluid and electrolyte imbalances must be corrected. D. Malnutrition and respiratory problems must be corrected.

C. The risks of surgery are greatly increased unless dehydration and metabolic alkalosis from prolonged vomiting are corrected. Although adequate hydration must be achieved, electrolyte balance must be restored as well. Although the chloride level is low, the fluid imbalance must be corrected as well. Malnutrition will be corrected after surgery when the infant retains feedings. Respiratory problems are not associated with pyloric stenosis.

Which diseases may occur due to rickettsial infections? Select all that apply. A.Leprosy B. Lyme disease C. Epidemic typhus D. West Nile fever E. Rocky Mountain spotted fever

C. & E.

A nurse is caring for a client that developed heparin-induced thrombocytopenia (HIT). Which pathophysiologic mechanism caused this condition? Pooling of platelets in the spleen Lysis of megakaryocytes in bone marrow Platelet aggregation and thrombus formation Release of deformed platelets that are unable to form clots

platelet aggregation and thrombus formation

A nurse is caring for a client who developed aseptic necrosis after a fracture of the head of the femur. The nurse prepares to administer care based on which factor? A. Infection at the site of the wound B. Weight-bearing before the fracture is healed C. Immobilization after reduction of the fracture D. Loss of blood supply to the head of the femur

D. After a fracture, if blood supply is cut off or impaired, necrosis of the bone may occur from lack of oxygen and nutrient perfusion. The word aseptic indicates that infection is not present.

A young child is admitted to the pediatric unit with a diagnosis of Wilms tumor. Considering the unique needs of a child with this diagnosis, what statement should be on a sign placed by the nurse at the child's bedside? A. Keep NPO. B. No IV medications. C. Record intake and output. D. Do not palpate the abdomen

D.

An infant is found to have communicating hydrocephalus. The parents ask for clarification of the primary healthcare provider's explanation of the problem. How should the nurse respond? A. "Too much spinal fluid is being produced within the spaces (ventricles) of the brain." B. "The flow of spinal fluid through the brain cells does not empty effectively into the spinal cord." C. "The spinal fluid is prevented from being adequately absorbed by a blockage in the spaces (ventricles) of the brain." D. "There is a part of the brain surface that usually absorbs spinal fluid after its production that is not functioning adequately."

D.

When a preterm newborn requires oxygen, the nurse in the neonatal intensive care unit monitors and adjusts the oxygen concentration. Which complication do these adjustments attempt to prevent? A. Cataracts B. Strabismus C. Ophthalmia neonatorum D. Retinopathy of prematurity

D.

Which statement is true regarding the Hering-Breuer reflex? A. Increases tidal volume B. Decreases respiratory rate C. Prevents overdistension of the lungs D. Reduces the number of functional alveoli

C.

A nurse is caring for a client with chronic pyelonephritis. Which pathophysiologic mechanism should the nurse consider when planning care? Fibrosis around the kidney Hypertrophy of the renal tubules Inflammation of the renal capsule Diffuse scarring of one or both kidneys

diffuse scarring of one or both kidneys