Pathophysiology Exam 2 practice questions
A client in the emergency department reports sudden onset of coughing with a feeling of chest tightness. Lung sounds are diminished with wheezing in all lung fields. The client is anxious and the skin is moist. What is the first intervention the nurse should implement? a) Educate about limiting exposure to dust. b) Administer a beta2 agonist. c) Provide the influenza vaccine. d) Give an inhaled corticosteroid.
Administer a beta2 agonist. Explanation: During an acute asthma attack, bronchospasm prolongs expiration, trapping air and decreasing inspiratory capacity. A beta2 agonist, such as albuterol, will relieve the bronchospasm within 30 minutes. A corticosteroid can prevent inflammation, but will not stop an attack in progress. The influenza vaccine and avoiding environmental triggers are measures to prevent asthma attacks.
A pregnant client asks the nurse when the immune system develops in the fetus. The best response is: a) Beginning at 10 to12 weeks as the fetal liver becomes active in hematopoiesis b) Beginning at 8 to 9 weeks as the fetal liver becomes active in hematopoiesis c) Beginning at 2 to 3 weeks as the fetal liver becomes active in hematopoiesis d) Beginning at 5 to 6 weeks as the fetal liver becomes active in hematopoiesis
Beginning at 5 to 6 weeks as the fetal liver becomes active in hematopoiesis Explanation: Embryologically, the immune system develops in several stages, beginning at 5 to 6 weeks as the fetal liver becomes active in hematopoiesis. Development of the primary lymphoid organs (i.e., thymus and bone marrow) begins during the middle of the first trimester and proceeds rapidly.
A client who has suffered a myocardial infarction is being treated in the emergency room. His pain remains severe even though he was given nitrates and oxygen. The physician now orders morphine for the pain. What method should the nurse to administer the morphine? a) Intravenous b) By mouth in pill form c) Subcutaneous d) By mouth in a liquid
Intravenous
A client with a history of heart failure and COPD (caused by 60 pack/year smoking) presents to the clinic with the following complaints: auscultation of breath sounds reveal absent/diminished breath sounds in the right lower lobe. Which other manifestations lead the health care provider to suspect the client may have developed atelectasis? Select all that apply. a) "Having a hard time catching my breath." b) Respiratory rate—32; pulse rate—122 beats/minute. c) Using accessory muscles to help him breathe. d) "Seems like I'm not making much water (decreased urine production)." e) Copious amounts of thick, green sputum.
a) "Having a hard time catching my breath." b) Respiratory rate—32; pulse rate—122 beats/minute. c) Using accessory muscles to help him breathe.
In hypovolemic shock, renal perfusion and urinary output decline. The nurse will monitor urinary output and knows that output below which of the following levels indicates inadequate renal perfusion? a) 20 mL/hour b) 40—20 mL/hour c) 60—40 mL/hour d) 80—60 mL/hour
a) 20 mL/hour
When CO2 levels in the blood rise, a state of hypercapnia occurs in the body. What factors contribute to hypercapnia? (Select all that apply.) a) Abnormalities in respiratory function b) Decrease in carbon dioxide production c) Changes in neural control of respiration d) Disturbance in gas exchange function e) Alteration in carbon dioxide production
a) Abnormalities in respiratory function c) Changes in neural control of respiration d) Disturbance in gas exchange function e) Alteration in carbon dioxide production
Substances foreign to the host that can stimulate an immune response are known as: a) Antigens b) MHC proteins c) Antibodies d) Cytokines
a) Antigens
The nurse is caring for a client who has just experienced an acute myocardial infarction and is diagnosed with "pump failure." The nurse is aware that the client is experiencing which type of shock? a) Cardiogenic b) Septic c) Neurogenic d) Hypovolemic
a) Cardiogenic
The nursing student, when studying about coronary artery disease, learns that it is commonly divided into different types of disorders which include which of the following? Select all that apply. a) Chronic ischemic heart disease b) Tertiary heart disease c) Acute coronary syndrome d) Primary heart disease e) Secondary heart disease
a) Chronic ischemic heart disease c) Acute coronary syndrome
In both the innate and adaptive immune systems, cells communicate information about invading organisms by the secretion of chemical mediators. Which are these mediators? (Select all that apply.) a) Colony-stimulating factors b) Chemokines c) Virulence factors d) Coxiella
a) Colony-stimulating factors b) Chemokines
Which of the following consequences of cardiogenic shock will the nurse monitor? Select all that apply. a) Decreased cardiac output b) Decreased stroke volume c) Increased afterloading d) Decreased preloading e) Decreased blood volume
a) Decreased cardiac output b) Decreased stroke volume c) Increased afterloading
A patient who experienced an ST elevation myocardial infarction (STEMI) received fibrinolytic therapy with streptokinase. Which of the following manifestations alerts the nurse to a developing complication? a) Decreased level of consciousness b) Hypoglycemia c) Diarrhea d) Symmetrical joint pain
a) Decreased level of consciousness
Nearly everyone with pericarditis has chest pain. With acute pericarditis, the pain is abrupt in onset, sharp, and radiates to the neck, back, abdomen, or sides. What can be done to ease the pain of acute pericarditis? a) Have the client sit up and lean forward. b) Have the client swallow slowly and frequently. c) Have the client breathe deeply. d) Have the client change positions to unaffected side.
a) Have the client sit up and lean forward.
The health care provider is discussing major risk factors for coronary artery disease (CAD) with a client. The most important information for the provider to include would be: a) History of cigarette smoking and elevated blood pressure b) High serum high-density lipoprotein and diabetes c) Physical inactivity and high serum high-density lipoprotein cholesterol d) Advanced age and low serum total and low-density lipoprotein cholesterol
a) History of cigarette smoking and elevated blood pressure
A 20-year-old college student has a pelvic fracture and a severed leg from a motorcycle accident. She lost several units of blood. When the student arrived in the emergency department, her blood pressure was very low, her pulse was high, and her skin was pale. The nurse knows that this patient has developed which of the following types of shock? a) Hypovolemic b) Distributive c) Obstructive d) Cardiogenic
a) Hypovolemic
The nurse is aware that the only class of immunoglobulins to cross the placenta is: a) IgG b) IgM c) IgD d) IgA
a) IgG
While caring for a pediatric client admitted with a viral infection, the nurse knows that which type of cell will be the child's primary defense against the virus? a) Natural killer (NK) cells b) Leukotrienes c) Bradykinin d) Complement
a) Natural killer (NK) cells
Which of the following statements concerning hypoxemia are true? (Select all that apply.) a) Normally, serum lactate levels are between 1 and 0.5 mmol/L. b) When hypoxemia occurs, metabolic acidosis is a possible outcome. c) The condition depends on the body's ability to adapt to lowered oxygen levels. d) The brain is vulnerable to hypoxia. e) With hypoxemia, aerobic metabolism replaces anaerobic metabolism.
a) Normally, serum lactate levels are between 1 and 0.5 mmol/L. b) When hypoxemia occurs, metabolic acidosis is a possible outcome. c) The condition depends on the body's ability to adapt to lowered oxygen levels. d) The brain is vulnerable to hypoxia.
A client who developed a deep vein thrombosis during a prolonged period of bed rest has deteriorated as the clot has dislodged and resulted in a pulmonary embolism. Which of the following types of shock is this client at risk of experiencing? a) Obstructive shock b) Cardiogenic shock c) Distributive shock d) Hypovolemic shock
a) Obstructive shock
While explaining immunity to a client, the nurse responds, "The body's internal organs are protected from pathogens because: a) Our mucosal tissue contains all the necessary cell components to fight a pathogen with an immune response." b) We have special glands that can secrete cytokines on a moment's notice." c) The actions of the cytokines in the mouth can act on different cell types at the same time it is fighting pathogens." d) The tonsils store a large amount of natural killer cells at that location."
a) Our mucosal tissue contains all the necessary cell components to fight a pathogen with an immune response."
The nursing instructor when teaching about disorders of cardiac function informs the students that all people presenting with ST-segment elevation myocardial infarction (STEMI) should be assessed for reperfusion therapy as quickly as possible. Reperfusion therapy includes which of the following? Select all that apply. a) Percutaneous coronary intervention (PCI) b) Dialysis c) Coronary artery bypass grafting (CABG) d) Fibrinolytic therapy e) Mechanical ventilation
a) Percutaneous coronary intervention (PCI) c) Coronary artery bypass grafting (CABG) d) Fibrinolytic therapy
A client comes to the emergency room exhibiting signs and symptoms of right-sided heart failure. Upon X-ray it is determined that he has 250ML of fluid in the pericardial cavity. Which disease should the nurse suspect this client to be suffering? a) Pericardial effusion b) COPD c) Myocardial infarction d) Pericarditis
a) Pericardial effusion
On a holiday trip home, the nurse's mother states that the nurse's father was diagnosed with right heart failure. Which of the following manifestations exhibited by the father does the nurse know might have preceded this diagnosis? a) Peripheral edema weight gain b) Weakness, palpitations c) Dyspnea, cough d) Vertigo, headache
a) Peripheral edema weight gain
A client is at high risk for the development of rheumatic heart disease. The most important information for the nurse to provide would be: a) Prompt diagnosis and treatment of streptococcal infections b) Avoiding frequent dental examinations c) Yearly electrocardiography after the age of 50 d) Annual blood specimen assessed for rheumatoid factor
a) Prompt diagnosis and treatment of streptococcal infections
The nurse needs to assess the oxygen status of a client who is suddenly experiencing shortness of breath. The most appropriate noninvasive measurement techniques would be: a) Pulse oximetry b) Assessment of the rate and depth of respiration c) Pulmonary function tests d) Arterial blood gas analysis
a) Pulse oximetry
A client who is experiencing angina at rest that has been increasing in intensity should be instructed to do which of the following? a) See the doctor for evaluation immediately. b) Not worry about it as this is common for someone who has already had a myocardial infarction. c) Take a second nitroglycerine. d) Give it 5-10 minutes more to see if there is relief.
a) See the doctor for evaluation immediately.
An elderly client who has been restricted to bed by numerous comorbidities for several weeks has been diagnosed with a large pleural effusion. Which of the following treatment modalities is most likely to resolve the client's most recent health problem? a) Thoracentesis b) Supplementary oxygen therapy c) Administration of bronchodilators d) Administration of corticosteroids
a) Thoracentesis
Stem cells in the bone marrow produce T lymphocytes or T cells and release them into the vascular system. The T cells then migrate where to mature? a) Thymus b) Spleen c) Liver d) Pancreas
a) Thymus
A mother is diagnosed with a bacterial infection and is worried that her newborn infant will also contract the infection. Which of the following statements should the nurse include in the teaching plan for the client? a) Your newborn has maternal IgG antibodies that were transferred through the placenta before birth, providing some protection from infection. b) Since you are not immune to this infection, your infant is also at risk for contracting the infection. c) Since the newborn immune system is not mature your infant cannot contract the infection. d) Your infant will require a vaccination to avoid getting the infection.
a) Your newborn has maternal IgG antibodies that were transferred through the placenta before birth, providing some protection from infection.
Cardiac tamponade and pericardial effusion can be life-threatening when the pericardial sac _______ and ______ the heart. a) fills rapidly; compresses b) ruptures; releases c) thickens; stretches d) contracts; friction rubs
a) fills rapidly; compresses
Anaphylactic shock is directly associated with: a) type I hypersensitivity response. b) bacterial blood infection. c) loss of blood volume. d) failure of the heart as a pump.
a) type I hypersensitivity response.
An elderly patient who was recently diagnosed with emphysema asks the nurse what caused the disease. Which of the following statements is the best response? a) "There is no known cause for emphysema; however, it does seem to run in families. Has anyone in your family been diagnosed with this disease?" b) "One of the causes of emphysema is a history of cigarette smoking that causes damage to the lungs. Have you ever smoked?" c) "This disease is seen most commonly in middle-aged men and is associated with chronic irritation from smoking and recurrent infections." d) "Emphysema is a permanent dilation of the bronchi and bronchioles caused by destruction of the muscle and elastic supporting tissue as the result of infection and inflammation."
b) "One of the causes of emphysema is a history of cigarette smoking that causes damage to the lungs. Have you ever smoked?"
A sixth grade science teacher asks the students to explain the role of cilia in the lower respiratory tract. Which student response is the best? a) "Cilia can trap the microbes in one location so the body can grow scar tissue around them and wall them off so they can't cause disease." b) "These little hairs move germs trapped in mucous toward the throat so the body can cough them out." c) "Cilia help to warm the airways so that moisture in the air can neutralize any germs that get in our lungs." d) "Cilia help facilitate a chemical defense against germs by secreting an enzyme that will cement the germ to the lining of the airways."
b) "These little hairs move germs trapped in mucous toward the throat so the body can cough them out."
The nurse is monitoring hourly urine output of a client diagnosed with hypovolemic shock. The nurse is most concerned if the client's output is: a) 60 mL/hour b) 20 mL/hour c) 40 mL/hour d) 80 mL/hour
b) 20 mL/hour
A client is brought to the physician's office with a raised red macular rash on the trunk and arms accompanied by a fever. A diagnosis of measles is made. Which type of immunity does this disease process provide? a) Passive artificial immunity b) Active natural immunity c) Passive natural immunity d) Active artificial immunity
b) Active natural immunity
A client is rushed to the emergency department with symptoms of urticaria, wheezing, chest tightness, and difficulty in breathing. The client is most likely experiencing which type of shock? a) Septic b) Anaphylactic c) Neurogenic d) Cardiogenic
b) Anaphylactic
A car accident client is admitted with a chest tube following pneumothorax. He also has an elevated blood alcohol level. When the nurse enters his room, she notes the client is dyspneic, short of breath, and holding his chest tube in his hand. When the nurse pulls the linens back, she finds a "sucking" chest wound. After calling a "code blue," the next priority intervention would be to: a) Try to calm the patient down by maintaining therapeutic communication b) Apply a Vaseline gauze (airtight) dressing over the insertion site c) Observe and wait for the code blue team to bring equipment d) Place the client's meal napkin over the wound
b) Apply a Vaseline gauze (airtight) dressing over the insertion site
Select the type of lymphocyte that matures in the bone marrow. a) Macrophages b) B lymphocytes c) T lymphocytes d) Cytotoxic T lymphocytes
b) B lymphocytes
A lactation nurse visits a new mother after delivery of her first child and encourages the mother to breastfeed her infant, even for a short time. Which statement made by the nurse correctly explains the importance of breastfeeding? a) Colostrum will provide the infant with innate immunity to diseases to which the mother is immune. b) Colostrum will provide the infant with passive immunity for several months to diseases to which the mother has immunity. c) Colostrum will provide the infant with active immunity to many childhood illnesses for several years. d) Colostrum will provide the infant with passive immunity to all childhood illnesses for several months.
b) Colostrum will provide the infant with passive immunity for several months to diseases to which the mother has immunity.
A patient who experienced an ST elevation myocardial infarction (STEMI) received fibrinolytic therapy with streptokinase. Which of the following manifestations alerts the nurse to a developing complication? a) Hypoglycemia b) Decreased level of consciousness c) Diarrhea d) Symmetrical joint pain
b) Decreased level of consciousness
Select the statement that best describes the effectiveness of vaccination in the elderly population. a) Vaccinations are only effective in the elderly populations if their families have been vaccinated. b) Experimental evidence suggests that vaccination is less successful in inducing immunization in older persons than in younger adults. c) Elderly persons who are immunized have the same effective response in immunity as younger persons do. d) Age does not influence the effectiveness; it depends on the amount of medication you receive.
b) Experimental evidence suggests that vaccination is less successful in inducing immunization in older persons than in younger adults.
A client has just returned from his surgical procedure. During initial vital sign measurements, the nurse notes that the client's heart rate is 111 beats/minute and the BP is 100/78 (borderline low). In this early postoperative period, the nurse should be diligently monitoring the client for the development of: a) Pulmonary embolism due to development of deep vein thrombosis b) Hypovolemic shock due to acute intravascular volume loss c) Side effects from versed administration causing excessive vasoconstriction d) Renal failure due to an overdose of medication
b) Hypovolemic shock due to acute intravascular volume loss
A child has a congenital condition in which the thymus gland is absent. What should the nurse include in the education of care of this patient to the parents? a) Observe and report any signs of bleeding. b) Observe and report signs and symptoms of infection. c) Report if the child has 2-3 loose stools in a day. d) Do not immunize the child with inactive or live viruses.
b) Observe and report signs and symptoms of infection.
Exudate in the pericardial cavity is a characteristic of which cardiac condition? a) Cardiac tamponade b) Pericardial effusion c) Acute pericarditis d) Constrictive pericarditis
b) Pericardial effusion
A client is seen in the emergency room with complaints of sharp chest pain that started abruptly. He says it has radiated to his neck and abdomen. He also states that it is worse when he takes a deep breath or swallows. He tells the nurse that when he sits up and leans forward the pain is better. Upon examination the nurse notes a pericardial friction rub and some EKG changes. Which disease should the nurse suspect this client to have? a) Pneumonia b) Pericarditis c) Myocardial infarction d) Abdominal aortic aneurysm
b) Pericarditis
A nurse preceptor is evaluating the skills of a new registered nurse (RN) caring for clients experiencing shock. Which action by the new RN indicates a need for more education? a) Inserting an IV to begin a normal saline infusion b) Raising the head of the bed to a high Fowler's position c) Administration of 2L of oxygen by nasal cannula d) Placing a pulse oximeter on the client to monitor oxygenation status
b) Raising the head of the bed to a high Fowler's position
The pathogenesis of multiorgan dysfunction syndrome (MODS) is not clearly understood at this time. Supportive management is currently the focus of treatment in this disorder. What is not a major risk factor in MODS? a) Infarcted bowel b) Respiratory dysfunction c) Alcohol abuse d) Advanced age
b) Respiratory dysfunction
A child is brought to the emergency department struggling to breathe with a prolonged bronchospasm and severe hypoxemia. Assessment revealed the use of accessory muscles, a weak cough, audible wheezing sound, moist skin, and tachycardia. Which of the following is the most likely diagnosis? a) Pulmonary embolism b) Severe asthma attack c) Chronic obstructive pulmonary disease d) Cystic fibrosis
b) Severe asthma attack
What is the primary cause of heart failure in infants and children? a) Reactions to medications b) Structural heart defects c) Hyperkalemia d) Idiopathic heart disease
b) Structural heart defects
Proper perfusion of vital organs requires which of the following conditions? Select all that apply. a) Efficient renal function b) Sufficient blood volume to fill the vascular compartment c) Intact vascular system d) Efficient cardiac pumping ability e) Ability of organs to extract oxygen and nutrients from blood
b) Sufficient blood volume to fill the vascular compartment c) Intact vascular system d) Efficient cardiac pumping ability e) Ability of organs to extract oxygen and nutrients from blood
Which of the following explains how T lymphocytes and B lymphocytes differ? a) T lymphocytes secrete antibodies; B lymphocytes provide cellular response to antigens. b) T lymphocytes mature in the thymus gland; B lymphocytes mature in the bone marrow. c) T lymphocytes recognize bacteria; B lymphocytes recognize viruses and cancer. d) T lymphocytes are helpers that assist B lymphocytes to amplify the lysis of antigens.
b) T lymphocytes mature in the thymus gland; B lymphocytes mature in the bone marrow.
The nurse is caring for the following clients. Select the client at highest risk for the development of atelectasis. a) The client who is mobile within 24 hours after abdominal surgery b) The client who is postop total knee replacement and receiving client-controlled analgesia c) The client with a lower leg cast who changes position every 2 hours d) The client diagnosed with pneumonia who performs frequent coughing and deep breathing exercises
b) The client who is postop total knee replacement and receiving client-controlled analgesia
The parents of a child with cystic fibrosis ask the nurse to explain the sweat test performed on their newborn. How should the nurse respond? a) Abnormal pancreatic enzymes may cause the infant to sweat more. b) The sweat test measures the concentration of salt in the infant's sweat. c) The sweat test evaluates the infant's ability to sweat in response to heat. d) Cystic fibrosis decreases the amount of salt in the infant's sweat.
b) The sweat test measures the concentration of salt in the infant's sweat.
A client with a suspected MI is brought to the emergency department by ambulance. The nurse caring for this client would expect to receive an order for which laboratory test to confirm a diagnosis of MI? a) Creatine kinase marker b) Troponin level c) Complete blood components d) Calcium level
b) Troponin level
A nurse is performing client health education with a 68-year-old man who has recently been diagnosed with heart failure. Which of the following statements demonstrates an accurate understanding of his new diagnosis? a) "I'm going to avoid as much physical activity as I can so that I preserve my strength." b) "I'll be sure to take my beta blocker whenever I feel short of breath." c) "I'm trying to think of ways that I can cut down the amount of salt that I usually eat." d) "I know it's healthy to drink a lot of water, and I'm going to make sure I do this from now on."
c) "I'm trying to think of ways that I can cut down the amount of salt that I usually eat."
ST-elevated myocardial infarction is accompanied by severe, crushing pain. Morphine is the drug of choice used to treat the pain of STEMI when the pain cannot be relieved with oxygen and nitrates. Why is morphine considered the drug of choice in STEMI? a) Action relieves pain and gives sense of depression. b) Action increases autonomic nervous system activity. c) Action decreases metabolic demands of the heart. d) Action increases anxiety increasing metabolic demands of the heart.
c) Action decreases metabolic demands of the heart.
A child's history of a recurrent sore throat followed by severe knee and ankle pain has resulted in a diagnostic workup and a diagnosis of rheumatic fever. What are the treatment priorities for this child? a) Pain control and oxygen therapy b) Cardiac catheterization and corticosteroid therapy c) Antibiotics and anti-inflammatory drugs d) Implanted pacemaker and β-adrenergic blockers
c) Antibiotics and anti-inflammatory drugs
Coronary artery bypass grafting (CABG) is a treatment modality for which of the following disorders of cardiac function? a) Pericardial effusion and cardiac tamponade b) Aortic valve regurgitation and aortic stenosis c) Atherosclerosis and unstable angina d) Dilated cardiomyopathies
c) Atherosclerosis and unstable angina
Of the pathways available to recognize microbes and activate the complement system, which one requires the presence of an antibody? a) Alternative b) Adaptive c) Classical d) Lectin
c) Classical
Increased cardiac workload with left heart failure can result in which of the following change to the myocardial cells? a) Hyperplasia b) Dysplasia c) Hypertrophy d) Atrophy
c) Hypertrophy
A client has just been told that he has an infection of the inner surface of the heart. He is also told that the bacteria has invaded his heart valves. What term is used for this disease process? a) Pericarditis b) Myocardial infarction c) Infective endocarditis d) Cardiomyopathy
c) Infective endocarditis
While studying the heart the nursing instructor teaches about pericarditis. Which of the following does she tell the student best defines this disease? a) It is a result of suffering a myocardial infarction. b) It is a congenital disease. c) It is an inflammatory process. d) It is an autoimmune response to stress.
c) It is an inflammatory process.
A 30-year-old male brought to the emergency department has the following admission data: Blood pressure 50/30, pulse 100, respiratory rate 12, temperature 101°F. The nurse does not know the exact cause but does know that patient is in shock because of which of the following readings? a) Elevated pulse rate b) Slow respiratory rate c) Low blood pressure d) Elevated temperature
c) Low blood pressure
Adaptive immune responses, also called acquired or specific immunity, are composed of which of the following and their products? a) Toll-like receptors b) Granulocytes c) Lymphocytes d) Epithelial cells
c) Lymphocytes
A client with a long history of stable angina suddenly experiences substernal pain that radiates to the left arm, neck, and jaw. He describes the pain as severe and feels as if he is suffocating. He has taken nitroglycerin and not experienced any relief. The client is most likely experiencing: a) Acute respiratory distress syndrome (ARDS) b) Gastroesophageal reflux disease (GERD) c) Onset of STEMI d) Pneumonia
c) Onset of STEMI
A client with a long history of stable angina suddenly experiences substernal pain that radiates to the left arm, neck, and jaw. He describes the pain as severe and feels as if he is suffocating. He has taken nitroglycerin and not experienced any relief. The client is most likely experiencing: a) Gastroesophageal reflux disease (GERD) b) Acute respiratory distress syndrome (ARDS) c) Onset of STEMI d) Pneumonia
c) Onset of STEMI
Unilateral chest pain associated with respiratory movements is usually described as which of the following? a) Bronchitic b) Myocardial c) Pleuritic d) Musculoskeletal
c) Pleuritic
A child is brought to the emergency department with an asthma attack. Assessment revealed the use of accessory muscles, a weak cough, audible wheezing sound, moist skin, and tachycardia. Which of the following drugs will the nurse anticipate administering first? a) Anti-inflammatory agents such as sodium cromolyn b) Oral corticosteroids c) Short-acting beta 2-adrenergic agonists such as albuterol (SABA) d) Anticholinergic medications such as ipratropium
c) Short-acting beta 2-adrenergic agonists such as albuterol (SABA)
The first physical line of defense in innate immunity is: a) Neutrophils b) Specialized lymphocytes c) Skin and mucous membranes d) Plasma proteins
c) Skin and mucous membranes
A client has been diagnosed with aortic stenosis and asks the nurse what this means. The most appropriate response would be: a) The valve opening permits backward flow to occur when the valve should be closed. b) The valve opening is incompetent, thereby allowing blood to flow back from the pulmonary artery and into the left atrium. c) The valve opening is narrowed and produces increased resistance to blood flow out of the left ventricle and into the aorta. d) The valve opens backward permitting blood to flow from the right ventricle into the right atrium.
c) The valve opening is narrowed and produces increased resistance to blood flow out of the left ventricle and into the aorta.
A client comes to the emergency room with all the symptoms of a myodardial infarction. Which lab value does the nurse suspect the physician will order which is known to have a high specificity for myocardial tissue and has become the primary biomarker test for diagnosing an MI? a) Creatine kinase b) Potassium c) Troponin assays d) Phosphorous
c) Troponin assays
The parents of a child diagnosed with cystic fibrosis (CF) ask about the risk of any future children having the condition. How should the nurse respond? a) Since the male carries the CF gene, you might consider a sperm donor. b) CF is autosomal dominant, so you have a 50% risk in another child. c) You have a 25% chance that your next child will have CF. d) Now that you have one child with CF, the rest will also have it.
c) You have a 25% chance that your next child will have CF.
Cardiac tamponade and pericardial effusion can be life-threatening when the pericardial sac _______ and ______ the heart. a) ruptures; releases b) contracts; friction rubs c) fills rapidly; compresses d) thickens; stretches
c) fills rapidly; compresses
Acute-onset bronchial asthma causes wheezing and breathlessness as a result of which of the following? a) Pulmonary hypertension b) Alveolar collapse c) Compression atelectasis d) Airway inflammation
d) Airway inflammation
A 20-year-old male client is experiencing a severe immunologically mediated reaction in which histamines have been released into the blood. Select the type of reaction most likely occurring with this client. a) Distributive shock b) Neurogenic shock c) Septic shock d) Anaphylatic shock
d) Anaphylatic shock
The nurse is preparing to auscultate for a mitral valve stenosis murmur Where is the best location to place the stethoscope? a) Over the aorta b) Over the sternum c) At the carotid arteries d) At the apex of the heart
d) At the apex of the heart
The nurse determines that the client has clubbing of the fingertips. Which is the best intervention? a) Assess peripheral capillary refill. b) Monitor the client's heart rate. c) Call the health care provider. d) Check the patient's O2 saturation level.
d) Check the patient's O2 saturation level.
Which of the following describes surgical correction of tetralogy of Fallot? a) Resection of the narrowed segment of the aorta and end-to-end anastomoses of healthy tissue b) An arterial switch procedure c) Redirection of systemic venous return to the pulmonary arteries d) Closure of the ventricular-septal defect and relief of the right ventricular outflow obstruction
d) Closure of the ventricular-septal defect and relief of the right ventricular outflow obstruction
A lactation nurse visits a new mother after delivery of her first child and encourages the mother to breastfeed her infant, even for a short time. Which statement made by the nurse correctly explains the importance of breastfeeding? a) Colostrum will provide the infant with active immunity to many childhood illnesses for several years. b) Colostrum will provide the infant with innate immunity to diseases to which the mother is immune. c) Colostrum will provide the infant with passive immunity to all childhood illnesses for several months. d) Colostrum will provide the infant with passive immunity for several months to diseases to which the mother has immunity.
d) Colostrum will provide the infant with passive immunity for several months to diseases to which the mother has immunity.
A client has just been admitted to the postsurgical unit following a below-the-knee amputation. Which of the following measures should her care team prioritize to prevent atelectasis during the client's immediate recovery? a) Bedrest and supplementary oxygen by nasal cannula b) Adequate hydration and a high-humidity environment c) Administration of bronchodilators by nebulizer d) Deep-breathing exercises and early mobilization
d) Deep-breathing exercises and early mobilization
The health care provider suspects a newly admitted client may have a hemothorax. The client most likely experienced: a) Renal failure b) Pneumonia c) Congestive heart failure d) Fractured or dislocated ribs
d) Fractured or dislocated ribs
A woman experiences a viral infection while pregnant. Which of the following types of immunity does an infant have at birth against this infection? a) Active b) Tolerance c) Adaptive d) Passive
d) Passive
Which of the following is most likely to precipitate an asthmatic attack in a child with a diagnosis of extrinsic, or atopic, asthma? a) Cold weather b) Respiratory tract infections c) Stress d) Pet dander
d) Pet dander
Cystic fibrosis (CF) is an autosomal recessive disorder involving the secretion of fluids in specific exocrine glands. The genetic defect in CF inclines a person to chronic respiratory infections from a small group of organisms. Which organisms create chronic infection in a child with cystic fibrosis? a) Staphylococcus aureus and hepatitis C b) Pseudomonas aeruginosa and Escherichia coli c) Haemophilus influenzae and influenza A d) Pseudomonas aeruginosa and Staphylococcus aureus
d) Pseudomonas aeruginosa and Staphylococcus aureus
A 20-year-old college student being treated for a kidney infection developed a temperature of 104ºF in spite of treatment with antibiotics. Her pulse was high, her blood pressure was low, and her skin was hot, dry, and flushed. The nurse knows that this patient most likely is experiencing which of the following types of shock? a) Anaphylactic b) Cardiogenic c) Neurogenic d) Septic
d) Septic
The American College of Cardiology/American Heart Association (ACC/AHA) has devised a system to classify the severity of heart failure. Which of the following does the nurse know is Stage C in this system? a) Structural changes, no signs or symptoms of failure b) High risk for heart failure, no structural abnormalities or sign of failure c) Advanced structural changes and symptoms of failure at rest despite aggressive medical treatment d) Structural changes with current or previous symptoms of failure
d) Structural changes with current or previous symptoms of failure
Which of the following patients is at the greatest risk of developing rheumatic heart disease? a) Young adult with viral meningitis b) Older adult with shingles c) Child with impetigo on the face d) Teenager with untreated strep throat
d) Teenager with untreated strep throat
A client has just been admitted to the cardiac intensive care unit with a diagnosis of infective endocarditis. His wife appears distraught and asks the nurse what caused this to happen to her husband. What would be the nurse's best response? a) Let's not worry about the cause as we need to focus on getting him better. b) It can be attributed to drug abuse. c) Sometimes a parasite is involved. d) The most common cause is a staph infection.
d) The most common cause is a staph infection.
The nursing instructor is teaching the students about rheumatic fever. She tells the students that it is an important cause of heart disease and is very serious mainly for which reason? a) That there is no definitive test used for diagnoses b) The cost associated with treating the disease c) The fact that it affects young and old d) The disabling effects that result from involvement of heart valves
The disabling effects that result from involvement of heart valves Explanation: Rheumatic fever is a very important cause of heart disease and its most serious and disabling effects result from involvement of the heart valves.
A client with a suspected MI is brought to the emergency department by ambulance. The nurse caring for this client would expect to receive an order for which laboratory test to confirm a diagnosis of MI? a) Calcium level b) Creatine kinase marker c) Troponin level d) Complete blood components
Troponin level Explanation: The troponin assays have high specificity for myocardial tissue and have become the primary biomarker for the diagnosis of myocardial infarction (MI). The troponin complex, which is part of the actin filament, consists of three subunits (i.e., TnC, TnT, and TnI) that regulate calcium-mediated actin-myosin contractile process in striated muscle (see Chapter 1, Fig. 1-19). TnI and TnT, which are present in cardiac muscle, begin to rise within 3 hours after the onset of MI and may remain elevated for 7 to 10 days after the event. This is especially adventitious in the late diagnosis of MI. The other blood work may be ordered, but not to confirm the diagnosis of MI.
