Pathophysiology review T1

1. What are the 4 main criteria for SIRS? 2. Give a clinical example that could lead to SIRS. 3. List potential complications of SIRS.

1. High/low temperature, increased resp rate, increased or decreased WBC count, and increased HR 2. Ie. surgery which introduced infection to a sterile area such as the heart, burns 3. Sepsis, Septic shock

Which of the following is the hallmark of humoral immunity? A. Production of interferon B. Production of immunoglobulin C. Phagocytosis of pathogens D. Antigen presentation E. Killing of cells via direct cell-to-cell contact

B. Production of immunoglobulin

In the process of positive selection: A. T-lymphocytes that recognize self-antigens undergo apoptosis B. T-lymphocytes that cannot interact with MHC are eliminated from the repertoire C. T-lymphocytes become anergic in the lymph nodes D. T-lymphocytes present self antigens in the context of MHC I

B. T-lymphocytes that cannot interact with MHC are eliminated

Women who become pregnant for the first time at a later reproductive age (35 years of age or older) are at risk for what complications? Select all answers that apply. A. Preterm labour B. Multiple gestation C. Development of seizures D. Chromosomal abnormalities E. All of the above

A. Preterm labour B. Multiple gestation D. Chromosomal abnormalities

Mr Ralph, 62 years old, presents to the ER with sudden onset of periorbital swelling, cough, wheezing and pruritus. Following administration of epinephrine, Mr Ralph suddenly experiences tremors and restlessness. What is the most appropriate nursing action? A. Reassure the client and family that this a normal side effect of epinephrine B. Inform the physician immediately of the change in the client's condition C. Explain to the client and his family that his condition is deteriorating D. Document the abnormal side effect that the client is experiencing

A. Reassure the client and family that this a normal side effect of epinephrine - Epinephrine: fight or flight response in the stress response - also involved. increases heart rate and may result in tremors and restlessness

A nurse is assessing several postpartum clients. Which clients are at risk for developing post-partum hemorrhage? Select all that apply. A. Twin birth B. Over-distended bladder C. Hypertonic uterine dystocia D. Retained placental fragments E. Mild gestational hypertension

A. Twin birth B. Over-distended bladder D. Retained placental fragments

An intensive care nurse is assessing a patient with suspected sepsis. Which predisposing factors would you expect to be found in a patient with septic shock? A. A 45 year old with a history of renal insufficiency B. A 65 year old with a history of cancer who is recovering from an abdominal peritoneal resection C. A 27 year old with pyelonephritis responding to treatment with an antibiotic D. A 50 year old with community acquired tuberculosis

B. A 65 year old with a history of cancer who is recovering from an abdominal peritoneal resection - Cancer has effect on the immune system - Abdominal surgery has risk of abdominal contents escaping into cavity and blood, resulting in infection

Which of the following is an indication of a complication of septic shock? A. Anaphylaxis B. Acute respiratory distress syndrome (ARDS) C. Chronic obstructive pulmonary disease (COPD) D. Mitral valve prolapse

B. Acute respiratory distress syndrome (ARDS) - Indicative of multi organ failure - Falls along continuum of septic shock

A client with schizophrenia receiving antipsychotic drug therapy is moving her mouth, protruding her tongue, and grimacing as she watches television. The nurse determines that the client is experiencing? A. Pseudo-parkinsonism B. Tardive dyskinesia C. Hypertensive crisis D. Neuroleptic malignant syndrome

B. Tardive dyskinesia

A nurse in a maternity unit is reviewing the records of the clients on the unit. Which client would the nurse identify as being at greatest risk for developing disseminated intravascular coagulation? A. A primigravida with mild preeclampsia B. A primigravida who delivered a macrosomic infant 3 hours ago C. A gravida 2 who was recently diagnosed with dead fetus syndrome D. A gravida 4 who delivered 8 hours ago and has lost 400 mL of blood

C. A gravida 2 who was recently diagnosed with dead fetus syndrome - After dx of a dead fetus, the body should be removed as components of the body may lead to DIC

A 25 year old female client is brought to her doctor by her mother. Described as "odd" since she lost her job a year ago, the patient has complained of hearing voices and believes that her body is a receiving antenna for a foreign spy operation. Her mother notes she has been isolating herself in her room. She is alert, and oriented but suspicious and guarded on examination. Her affect is flat and her speech reveals loose associations. A complete medical workup is negative. Which of the following symptoms is considered a "negative symptom" of schizophrenia? A. Auditory hallucinations B. Delusions C. Flat affect D. Loose associations E. Paranoia

C. Flat affect - ie. monotone voice

A pregnant client is making her first antepartum visit. She has a 2 year old son born at 40 weeks, a 5 year old daughter born at 38 weeks, and 7 year old twin daughters born at 35 weeks. She had a spontaneous abortion 3 years ago at 10 weeks. Using the GTPAL format, what does the nurse document about the client's obstetric history? A. G4 T3 P2 A1 L4 B. G5 T2 P2 A1 L4 C. G5 T2 P1 A1 L4 D. G4 T3 P1 A1 L4

C. G5 T2 P1 A1 L4

Which of the following is the most important goal of nursing care for a client who is in shock? A. Manage fluid overload B. Manage increased cardiac output C. Manage inadequate tissue perfusion D. Manage vasoconstriction of vascular beds

C. Manage inadequate tissue perfusion - Inadequate tissue perfusion - need to supply

All of the following are examples of autoimmune disorders except: A. Systemic lupus erythematosus B. Rheumatoid arthritis C. Sickle cell anemia D. Graves' disease E. Myasthenia gravis

C. Sickle cell anemia - Due to mutation

The nurse is caring for a hospitalized patient who has been taking haloperidol (Haldol) for 3 days. To assess the patient for NMS (neuroleptic malignant syndrome), the nurse should assess the patient's: A. Blood pressure B. Serum sodium C. Temperature D. Weight

C. Temperature - Pt will be febrile

Sepsis is the most common cause of DIC. All of the following statements concerning this life threatening complication are true except: A. The rapidity of onset is determined by the intensity of the trigger and is related to the condition of the patient's liver, bone marrow and endothelium B. In the early phase, the patient may demonstrate manifestations of thrombosis and microemboli C. Though a coagulopathy is present, excessive blood loss rarely results in hemorrhagic shock D. The most critical intervention for DIC is the early identification and treatment of the underlying disorder

C. Though a coagulopathy is present, excessive blood loss rarely results in hemorrhagic shock

A client with schizophrenia is prescribed the neuroleptic drug clozapine (Clozaril). A nurse assesses the results of which laboratory study to monitor for adverse effects from this medication? A. Platelet count B. Blood glucose level C. White blood cell count D. Liver function studies

C. White blood cell count - Effect on the WBCs, esp the neutrophils

A client experiencing delusions says to a nurse, "The federal guards were sent to kill me." The nurse's best response is: A. I don't believe this is true B. The guards are not out to kill you C. What makes you think the guards were sent to hurt you? D. I don't know anything about the guards. Do you feel afraid that people are trying to hurt you?

D. I don't know anything about the guards. Do you feel afraid that people are trying to hurt you? - Show of empathy - Not agreeing or disagreeing

Which of the following findings are consistent with a diagnosis of PCOS? Elevated levels of: A. Estrogen, insulin, and progesterone B. FSH, insulin, LH, and SHBG C. FSH, LH, SHBG, and testosterone D. Insulin, DHEA-S, testosterone, and estrogen E. FSH, progesterone, and SHBG

D. Insulin, DHEA-S, testosterone, and estrogen

A home nurse visits a pregnant client who has been diagnosed with mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the physician? A. Urinary output has increased B. Dependent edema has resolved C. Blood pressure reading is at the prenatal baseline D. The client complains of a headache and blurred vision

D. The client complains of a headache and blurred vision