EXAMS 1

Question 1

During a discussion on cellular components and their function, a student asked the instructor the purpose of messenger RNA (mRNA). Of the following, which is the most accurate answer?

Answer 1

Performs an active role of protein synthesis, where mRNA molecules direct the assembly of proteins on ribosomes to the cytoplasm.

Question 2

The nurse is providing care for a client with a diagnosis of cirrhosis, and she notes that the client’s sclerae are jaundiced. The nurse recalls jaundice is a pigment that can accumulate in which part of the cell?

Answer 2

Cytoplasm

Question 3

A 14-year-old female has been experiencing severe internal cramps in the region
of the pelvis along with weight loss. She has been admitted with rectal bleeding.
The physician has diagnosed her with inflammatory bowel disease (IBD). She asks
the nurse what causes this disease. Which pathophysiologic basis will guide the
nurse’s response to this adolescent?

Answer 3

Endoplasmic reticulum stress in the gastrointestinal system

Question 4

A professor is teaching a group of students about the role of mitochondria within
the cell. Which statement is true of mitochondria

Answer 4

They are the site of adenosine triphosphate (ATP) production.

Question 5

A client has been diagnosed with a neurodegenerative disease called multiple sclerosis (MS). The physician explains to the client that this disease may be caused by dysregulated apoptosis. Later that day, the client asks the nurse what this
means. The nurse should reply:

Answer 5

Dysregulated apoptosis has caused an excessive rate of programmed cell death along the neuro-pathways.

Question 6

A client experiencing immotile cilia syndrome (Kartagener syndrome) should be frequently assessed by the nurse for which priority complication?

Answer 6

bronchiectasis due to interferences with clearance of inhaled bacteria along the
respiratory tract.

Question 7

The nurse is explaining the workings of selective serotonin uptake inhibitors (SSRIs) to a client with a diagnosis of depression. Within the teaching, the nurse mentions that in the nervous system, the transmission of information by neurotransmitters is:

Answer 7

synaptic signaling.

Question 8

The nurse is teaching a group of colleagues about the cell division cycle as background to caring for oncology clients. Which statement is true of the cell cycle?

Answer 8

The two broad phases of the cell cycle are mitosis and synthesis.

Question 9

A 62-year-old male collapsed while unloading a truck of heavy sacks of feed for his cattle. When he arrived in the emergency department, blood gases revealed a slightly acidic blood sample. The nurse caring for this client is not surprised with this result based on which pathophysiologic rationale?

Answer 9

The skeletal muscles are producing large amounts of lactic acid and release it into the bloodstream during heavy work/exercise.

Question 10

The health caregiver is explaining the rationale for administering a hypotonic intravenous solution (lower concentration of solutes in its surroundings) to a client. Which mechanism of membrane transport most likely underlies this action?

Answer 10

Osmosis

Question 11

A nurse is teaching a client with a recent diagnosis of diabetes about the roles that glucose and insulin play in the disease pathology and the fact that glucose must enter the body cell in order to provide energy for the client. The nurse knows that which process allows glucose to enter body cells?

Answer 11

Facilitated diffusion

Question 12

A student asks the instructor about the origins of different tissues and their cellular origins during the process of development. Which statement by the instructor best describes the process of cell differentiation?

Answer 12

“A fertilized ovum undergoes a series of divisions, yielding many different cell types.”

Question 13

A nurse is providing care for a client with a diagnosis of Crohn’s disease. The nurse recognizes the fact that the disease involves the inflammation and irritation of the intestinal lining. Which type of tissue is most likely involved in the client’s pathology?

Answer 13

Simple columnar epithelium

Question 14

During a crime scene investigation, the coroner confirm that rigor mortis has set in. This helps to confirm an approximate time of death. The forensic nurse can explain this process (rigor mortis) to a group of students based on the fact that:

Answer 14

at death, the body is unable to complete the actin/myosin cycle and release the coupling between the myosin and actin, creating a state of muscular contraction.

Question 15

The home care nurse is making a home visit to a 51 years female client with
a longstanding diagnosis of multiple sclerosis. The nurse knows that the muscle wasting and weakness associated with the disease process is ultimately manifested as a failure of what normal process in muscle tissue?

Answer 15

Thick myosin and thin actin filaments sliding over each other.

Question 16

A caregiver is working with a client who is having poorly controlled pain due to shingles. The associated pain travels to the client’s nervous system via:

Answer 16

afferent neurons.

Question 17

The nurse is administering a calcium channel blocked to a client with a cardiac dysrhythmia. For what side effect should the nurse assess?

Answer 17

Constipation

Question 18

A client has been told she has elevated levels of low-density lipoproteins (LDL). The client says, “I have always followed a low-cholesterol diet, so how could it be elevated?” How should the nurse respond?

Answer 18

LDL needs to be taken up into the intracellular space and this process does not work well in some people, causing LDL elevations in the blood.

Question 19

The nurse is caring for a client whose potassium level is 5.9 mEq/L (5.9 mmol/L). Which treatment should the nurse be prepared to minister?

Answer 19

Medication to promote the movement of potassium into the intracellular space

Question 20

A nurse is teaching clients about the benefits of smoking cessation. What should the nurse include as the most accurate reason for the development of a
chronic “smoker’s cough”?

Answer 20

Damage to cilia in the respiratory tract make it necessary to cough to clear the airway.

Question 21

The nurse is caring for an 8-year-old client who has cystic fibrosis. What aspect of client care should the nurse prioritize?

Answer 21

Airway clearance

Question 22

A community health care worker is explaining to a group of factory workers the importance of wearing gloves when working with strong chemicals such as turpentine and paint thinner. Which characteristics of cell membranes underlies the nurse’s teaching?

Answer 22

Impermeability of cell membranes to all but lipid-soluble substances

Question 23

The parents of a child newly diagnosed with Tay-Sachs disease asks what signs and symptoms they will see if the disease is progressing which response(s) by the nurse is most accurate? Select all that apply.

Answer 23

• loss of motor skills like turning over

- vision loss

Question 24

When discussing the function of the cell membrane during pathophysiology class, which statement(s) by the faculty is accurate? Select all that apply.

Answer 24

• helps determine what can and cannot enter and exit cells
• contains receptors for hormones and neurotransmitters
• allow ions to cross the membrane during electrical signaling in cells

Question 25

Of the following situations, which one would be an example of a maladaptive
cellular change?

Answer 25

44-year-old male with a 60 pack/year smoking history who was diagnosed with a
histological grade-3 lung cancer

Question 26

A client is experiencing muscle atrophy following 2 weeks in traction after a
motor vehicle accident. Which factor has most likely contributed to the atrophy of
the client’s muscle cells?

Answer 26

A reduction of skeletal muscle use secondary to the traction treatment

Question 27

The nurse is teaching new nursing assistants on the unit about the phenomenon
of muscle hypertrophy. Which client on the unit is most likely to experience muscle
hypertrophy? A client with:

Answer 27

hypertension, obesity, and decreased activity tolerance.

Question 28

Which client is at high risk for developing dilated cardiomyopathy?

Answer 28

44-year-old noncompliant female who forgets to take her hypertensive
medications

Question 29

Which student statement demonstrates a sound understanding of the cellular
processes of hypertrophy and hyperplasia?

Answer 29

“I know that cells like neurons have little capacity for hyperplastic growth.”

Question 30

A home health nurse is making a visit to a family with an 8-month-old infant with
severe motor deterioration. The physician has diagnosed the infant with Tay-Sachs
disease. The parents are asking the nurse why this happened. The nurse will base
her answer knowing the root cause of Tay-Sachs is:

Answer 30

an enzyme defect causing abnormal lipid accumulation in the brain.

Question 31

A 68-year-old male client with aortic stenosis secondary to calcification of the
aortic valve is receiving care. Which statement best captures an aspect of this
client’s condition?

Answer 31

The client has possibly undergone damage as a result of calcification following
cellular injury.

Question 32

A nurse in the emergency department admits a male client who has experienced
severe frostbite to his hands and toes after becoming lost on a ski hill. The nurse
recognizes that which phenomena has contributed to his tissue damage?

Answer 32

Decreased blood flow has induced hypoxia.

Question 33

As part of a first aid class, a health care instructor is teaching a group of
industrial workers about how electrical injuries can cause cell damage. Which
statement made by one of the workers indicates that further teaching is necessary?

Answer 33

“The greater the skin resistance, the greater the amount of deep and systemic
damage a victim is likely to incur.”

Question 34

A client who has a diagnosis of lung cancer is scheduled to begin radiation
treatment. The nurse knows that which statement about potential risks of radiation
is most accurate?

Answer 34

“Some clients experience longer-term irritation of skin adjacent to the treatment
site.”

Question 35

A young client has just been diagnosed with xeroderma pigmentosum. When
teaching this family about this disease, the nurse should emphasize which teaching
points? Select all that apply.

Answer 35

• Wear long sleeves, long pants, gloves, a hat, sunglasses with side shields, and sunscreen while outdoors.
• The best time to allow the child to play outside is in the evening hours after the
  sun goes down.

Question 36

A 7-year-old boy is admitted to the hospital with a suspected diagnosis of lead
toxicity. Which assessment finding is most congruent with the client’s diagnosis?

Answer 36

Hemoglobin 9.9 g/dL (99 g/L)

Question 37

The nurse is teaching a group of new mothers about postpartum nutrition,
when one of the clients states that she was told to avoid eating fish too often due
to the risk of mercury poisoning. Which response by the nurse most accurately
addresses the clients concerns?

Answer 37

“There are some modest risks, but they are only associated with some long-
living fish like tuna.”

Question 38

A nurse is teaching a group of older adults about the value of including foods
containing antioxidants in their diet. Which statement best captures the rationale
underlying the nurse’s advice?

Answer 38

Antioxidants inhibit the actions of reactive oxygen species.

Question 39

During a myocardial infarction (MI), a client with a 97% occlusion of the left
descending artery develops ventricular dysrhythmias due to the amount of ischemia
occurring in the myocardium. While providing education about MI’s, which
statement is most accurate to share with this client?

Answer 39

Treatment needs to be sought immediately so that the buildup of lactic acid is
limited and cellular changes can be reversed.

Question 40

Which statement most accurately conveys an aspect of cell injury due to
impaired calcium homeostasis?

Answer 40

Injured cells tend to accumulate calcium.

Question 41

The nurse is providing care for a client with a diagnosis of amyotrophic lateral
sclerosis (ALS). The nurse recognizes that which mechanism is suspected to play a
role in the cellular death associated with ALS?

Answer 41

Apoptosis

Question 42

Which enzyme listed below is responsible for the ability of cancer cells to resist
aging and contributes to cellular immortality that is so characteristic of this disease
process?

Answer 42

Telomerase

Question 43

The nurse is caring for a client with arterial insufficiency of the left leg with
gangrenous wounds on the second and third toes. What characteristics of the
wounds should the nurse evaluate as expected? Select all that apply.

Answer 43

• A clear demarcation between the healthy and affected tissue
• Diminished pulse strength
• Atrophy to the affected toes
• Darkened appearance of affected tissue

Question 44

The nurse is planning care for a group of clients. Which clients should the nurse
prioritize as “at risk” for hypercalcemia and advocate for monitoring calcium
levels? Select all that apply.

Answer 44

• A client with prolonged immobility
• A client with hypophosphatemia
• A client who has breast cancer with bone metastasis

Question 45

21. A nurse is triaging clients at a disaster site. Local facilities have different
    specialized units. To what facility should the nurse send a client who has sustained
    an electrical injury to his left thigh?

Answer 45

Burn unit

Question 46

Parents bring their 18-month-old child to the emergency room exhibiting
behavior changes and vomiting. They are concerned the child ingested something in the older home they are renovating. Laboratory findings indicate low hemoglobin
and elevated creatinine. Which diagnostic test should the nurse advocate for first?

Answer 46

Erythrocyte protoporphyrin (EP) level

Question 47

The nurse is caring for a 45-year-old client undergoing radiotherapy of the
mediastinal nodes due to lymphoma. Which interventions should the nurse
prioritize? Select all that apply.

Answer 47

• Assessing for fatigue
• Avoiding invasive procedures
• Performing respiratory assessment

Question 48

A worker in a warehouse is trying to have children but think he or she has
handled “mercury” while cleaning equipment. Which statement by the occupational
nurse is most appropriate at this time?

Answer 48

Most mercury toxicity involves central nervous system changes.

Question 49

The health care provider is discussing the treatment protocol using ionizing
radiation to treat the client’s cancer. The client asks, “What side effects can occur
with this treatment?” Which response(s) is accurate? Select all that apply.

Answer 49

• Low blood counts

- Excessive diarrhea

Question 50

A 23-year-old man has received a recent diagnosis of appendicitis. The nurse
providing care for the man is explaining that the inflammation of his appendix is
playing a role in his body’s fight against the underlying infectious process. Which
teaching points should the nurse eliminate from client education?

Answer 50

“Inflammation helps your body to produce the right antibodies to fight the
infection.”

Question 51

A client presented to the emergency department of the hospital with a swollen,
reddened, painful leg wound and has been diagnosed with methicillin-resistant
Staphylococcus aureus (MRSA) cellulitis. The client’s physician has ordered a
complete blood count and white cell differential. Which blood component would the
physician most likely anticipate to be elevated?

Answer 51

Neutrophils

Question 52

A 16-year-old girl has broken her arm while snowboarding and is shocked at the
amount of swelling at the injury site. Which statement best explains the
physiologic rationale for her swelling?

Answer 52

Loss of plasma proteins causes an increase in interstitial osmotic pressure.

Question 53

Which phenomena best accounts for the increased presence of leukocytes at the
site of inflammation?

Answer 53

Existing leukocytes stick to the epithelial cells and move along blood vessel
walls.

Question 54

When explaining the final stages of the inflammatory response to pathogens, the
nurse should include which educational topics?

Answer 54

How the body can kill the pathogen by generating toxic oxygen and nitrogen
products, producing such things as nitric oxide and hydrogen peroxide

Question 55

A deficiency in which of these would result in an inhibition of the inflammatory
response?

Answer 55

Histamine

Question 56

When educating a client with a wound that is not healing, the nurse should stress
which dietary modifications to ward off some of the negative manifestations that
can occur with inflammation?

Answer 56

Increase your intake of oily fish and fish oil so that you will increase absorption
of omega-3 polyunsaturated fatty acids.

Question 57

Tumor necrosis factor-α and IL-1 are major cytokines that mediate inflammation.
If the client is developing a systemic response to an infection, the nurse will likely
assess which clinical manifestations? Select all that apply.

Answer 57

• Elevated temperature
• Tachycardia
• Anorexia

Question 58

A 63-year-old woman has begun a diet that purports to minimize the quantity
and effects of free radicals in her body. Which physiologic process could best
underlie her care provider’s teaching about her new diet?

Answer 58

Free radicals increase cytokine expression and adhesion molecule levels,
resulting in increased inflammation.

Question 59

A nurse is changing the wound dressing on a coccyx-region pressure injury of
an immobilized client. The existing dressing is saturated with both watery, clear
discharge and foul, grayish-colored liquid. Which entry in the client’s chart most
accurately documents these findings?

Answer 59

“Large amounts of suppurative and serous exudates noted.”

Question 60

Which aspect of a client’s site of inflammation would help the care provider rule
out chronic inflammation?

Answer 60

Increased neutrophils

Question 61

A 24-year-old woman presents with fever and painful, swollen cervical lymph
nodes. Her blood work indicates neutrophilia with a shift to the left. She most likely
has:

Answer 61

A severe bacterial infection

Question 62

Which client would have a very poor response related to tissue regeneration of
his or her injured area?

Answer 62

54-year-old male who had a massive MI 4 days ago and came to the ED today
for treatment.

Question 63

A hospital client has a large, superficial wound on her elbow that was the result
of shearing action when she was moved up in her bed. The client’s husband mentions that the wound looks infected and irritated since it is completely red. Which response by the nurse would be inappropriate?

Answer 63

“A thin sheet of blood clotting is actually desirable and not a sign that your wife’s
wound is infected.”

Question 64

Which process would most likely be considered an anomaly during the cellular
phase of inflammation?

Answer 64

Vasoconstriction

Question 65

A client who is recovering from burn injuries is discussing his prognosis with a
physician. Which teaching point about expectations for healing should the physician
offer?

Answer 65

“You may find that the scar is a bit smaller than the area of the wound.”

Question 66

Which client is most likely to have impairments to the wound healing process?
A client with:

Answer 66

poorly controlled blood sugars with small blood vessel disease.

Question 67

A 79-year-old female resident of an assisted living facility receives care from a
community nurse on a regular basis for treatment of a chronic venous leg ulcer.
Which factor would the nurse be most justified in ruling out as a contributing factor
to the client’s impaired wound healing?

Answer 67

Decreased antibody levels

Question 68

An 80-year-old client has a stage 3 decubitus ulcer on the left ischial tuberosity
which has not shown much improvement despite optimal local wound treatment.
What other interventions should the nurse recommend to promote wound healing?
Select all that apply.

Answer 68

• A review of the client’s medications
• Placing the client on an alternating pressure mattress
• Nutritional supplements

Question 69

A client with a surgical wound has developed excessive granulation tissue
extending above the wound edges. Which action should the nurse take?

Answer 69

Ask the health care provider about surgical options to remove the excess tissue
and promote wound healing.

Question 70

The nurse is caring for a client with a diabetic foot ulcer who has difficulty
adhering to dietary restrictions. This has resulted in elevated blood glucose levels.
What information is most important for the nurse to share with the client?

Answer 70

Elevations in blood glucose make it more difficult for your white blood cells to
fight the infection.

Question 71

The nurse is caring for a group of postoperative clients. Who should the nurse
prioritize as having the greatest risk for infection at the surgical site?

Answer 71

A 45-year-old with external fixation of a fractured tibia

Question 72

A parent brings a 12-year-old to the emergency room with multiple bite wounds
to the arms and hands from a stray cat. Which interventions should the nurse be
prepared to apply? Select all that apply.

Answer 72

• A review of the client’s immunization record
• Rabies prophylaxis
• Irrigation of the wounds
• Administration of prophylactic antibiotics

Question 73

A client with a large decubitus ulcer asks the nurse, “How it is possible for a
wound this deep to ever fully heal?” What is the nurse’s best response?

Answer 73

With adequate resources, the body is capable of regenerating tissue and blood
flow to the area over time.

Question 74

A student arrives at the health clinic anxious and afraid. The student found an
enlarged lymph node in the groin area that is extremely painful to touch and
“knows” it is cancer. What information should the health care provider relay to this
student about lymphadenitis?

Answer 74

Not all swollen lymph nodes are due to cancer. It could be caused by an infection
in the genital region.

Question 75

The nurse knows that which statement listed below relative to a client with
malignant melanoma treated with alpha interferon (IFN-α) is accurate? Alpha
interferon (IFN-α):

Answer 75

plays an important role in the modulation of the inflammatory response.

Question 76

The nurse knows which statement listed below is accurate regarding the
functions and nature of cytokines relative to a variety of pathologies?

Answer 76

“A particular cytokine can have varied effects on different systems, a fact which
limits their therapeutic use.”

Question 77

The nurse knows a drug in a category identified as a colony-stimulating factor
(CSF) helps:

Answer 77

to stimulate bone marrow to produce large numbers of mature cells such as
platelets and erythrocytes.

Question 78

Which individual situation listed below best exemplifies the processes of innate
immunity?

Answer 78

A child who has experienced heat and swelling of his skinned knuckle

Question 79

The nurse knows which component is needed for long-lasting immunity in a
client with a diagnosis of sepsis without the causative agent identified?

Answer 79

Lymphocytes

Question 80

A client has been identified as having an excess of macrophage inhibitory factor,
causing the client to have inhibited movement and activity of macrophages. Which
process listed below would the health care team member expect to remain
unaffected?

Answer 80

Specificity and memory of the immune response

Question 81

A client who has a diagnosis of an autoimmune disease asks his nurse why it is
that their immune system does not attack all of the cells that make up his body.
Which of the following aspects of pathogen recognition in the innate immune
system listed below would underlie the nurse’s response?

Answer 81

Pattern recognition receptors (PRRs) ensure cells are correctly identified.

Question 82

Which phenomenon would be least likely to result in activation of the
complement system?

Answer 82

Activation of toll-like receptors (TLRs) on complement proteins.

Question 83

A nurse is providing care for a client who is immunocompromised following
chemotherapy. The nurse knows that which characterization of the adaptive
immune system is responsible for the client’s disruption in normal immune
function?

Answer 83

Epitopes on antigens are recognized by immunoglobulin receptors following
presentation by accessory cells.

Question 84

The nurse knows that the cells primarily programmed to remove the invading
organisms and remember the antigen to respond rapidly during the next exposure
are:

Answer 84

T-lymphocytes and B-lymphocytes.

Question 85

A 53-year-old female hospital client has received a kidney transplant following
renal failure secondary to hypertension. The teaching prior to transplant made her
aware that she would need to take anti-rejection drugs for the rest of her life.
Which aspect of the immune system underlies this necessity?

Answer 85

MHC molecules will never develop in the cells of the donor organ and effector
cells will be continually stimulated.

Question 86

A client has been inhaling viruses periodically while on a cross-country flight.
Which situation listed below would most likely result in the stimulation of the
client’s T lymphocytes and adaptive immune system?

Answer 86

Recognition of a foreign peptide bound to a self-major histocompatibility complex
(MHC) molecule

Question 87

Three days ago, a mother delivered her full-term infant who had been identified
as having an in utero infection. The infant is receiving antibiotic and phototherapy,
and the mother is breast-feeding. Which types of immunoglobulins could most
reasonably be expected to predominate in the infant’s immune system?

Answer 87

IgG, IgA, IgM

Question 88

A middle school student is scheduled to receive booster immunizations and the
father asks the nurse why the booster is necessary. What characteristic of the
adaptive immune system listed below would provide the rationale for the nurse’s
response?

Answer 88

A secondary response causes a sharp rise in antibody levels.

Question 89

A student states, “It seems like helper T cells do a lot more than just ‘help’ the
cellular immunity process”. Which response listed below best conveys an aspect of
the role of CD4+ helper T cells in immunity?

Answer 89

“Helper T cells play a major role in stimulating and regulating the whole
process.”

Question 90

A newly diagnosed HIV-positive adolescent has blood work drawn that includes
a CD8+ T-cell count. The nurse knows that which functions of CD8+ T cells listed
below will assist the adolescent’s immune system in fighting off the viral attack?
Select all that apply.

Answer 90

• Release of destructive enzymes

- Trigger intracellular programmed death

Question 91

A 10 year old child with strep throat asks the nurse, “Why are there large
bumps [lymph nodes] on my neck when my throat gets sore?” The nurse replies
that lymph nodes:

Answer 91

help your body fight off infections by allowing special cells [lymphocytes and
macrophages] to move through the lymph chain and engulf and destroy germs.

Question 92

Which situation can best be characterized as an example of passive immunity?

Answer 92

A 6-week-old infant receives antibodies from his mother’s breast milk.

Question 93

The nurse knows high incidences of infectious illnesses among the older adults
who reside in a long-term care facility are most likely to have diminished immune
capacity because of:

Answer 93

decreased numbers and responsiveness of T lymphocytes.

Question 94

A community health nurse is conducting an education session with a group of
pregnant women. One of the clients states, “I am not feeling right about getting a
flu vaccine while pregnant.” What is the nurse’s best response?

Answer 94

“By getting vaccinated, you reduce the risk of you and your baby getting
influenza.”

Question 95

A 60-year-old male client with an acute viral infection is receiving interferon
therapy. The nurse is teaching the client about the ways interferon differs from
other anti-infective therapies. What point should the nurse include?

Answer 95

“Interferon stimulates the activity of natural killer cells that attack viruses.”

Question 96

A client has been diagnosed with rheumatoid arthritis and asks the nurse what
causes this condition. What is the nurse’s best response?

Answer 96

Your immune system is attacking your own tissues as if they were harmful
organisms.

Question 97

A nurse is conducting an immunization clinic when a 14-year-old client asks,
“Does this vaccine make me immune to the disease?” What is the nurse’s best
response?

Answer 97

“The vaccine imitates a disease without causing illness, resulting in the creation
of antibodies to the disease.”

Question 98

The parent of a child with allergies has been told the child will have a blood test
done for immunoglobulin measurement. The nurse should tell the parent that which
immunoglobulin will be tested?

Answer 98

IgE

Question 99

The nurse is preparing a client for bone marrow transplant. The client asks,
“How long will it take for the new marrow to make the blood cells?” What is the
nurse’s best response?

Answer 99

Although it can vary, we will administer medication that will stimulate the bone
marrow to create the cells.

Question 100

While teaching about HIV/AIDS to a group of high school seniors, the school
health nurse will begin by explaining the basic facts. Which information will this
likely include?

Answer 100

HIV is different from other viruses since it is a retrovirus that selectively attacks
the body’s immune cells.

Question 101

As part of her prenatal education, a 29-year-old woman who is pregnant with her first child is receiving teaching from her primary care provider. Which statement by the woman reflects an accurate understanding of HIV transmission?

Answer 101

“It’s discouraging to know that my breast milk can pass on HIV to my baby.”

Question 102

A potential donor is angry at the personal nature of the questions about HIV risk
factors that he is required to answer at a blood collection center, and states that
simple blood testing should suffice. How can the nurse at the center best respond?

Answer 102

“There’s a period shortly after someone is infected with HIV when blood tests
might still be negative.”

Question 103

A 19 year-old intravenous drug user was exposed to the HIV virus 3 weeks ago
and is experiencing a rapid proliferation in viral load. Which statement best
captures an aspect of the process of HIV replication that underlies this proliferation?

Answer 103

HIV is able to change its RNA into DNA to allow for replication by CD4+ cells.

Question 104

Which client would be considered to be in the latent period of HIV infection?

Answer 104

33-year-old heroin drug abuser who has numerous enlarged lymph nodes in his
axilla and cervical neck region for the past 4 months.

Question 105

A person who has been diagnosed with HIV infection 12 years ago and still has a
CD4+ cell count of 800 cells/μL and a low viral load is considered to be in which

Answer 105

Long-term nonprogressor

Question 106

A 39-year-old female with HIV has been characterized as a typical progressor by
her care team, and is experiencing an increase in her manifestations and complaints as her CD4+ count declines. Which health problem would her care team
most likely attribute to a cause other than her HIV?

Answer 106

Her decreased bone density and recent fractures

Question 107

A 48-year-old man who has been HIV positive for 6 years has just learned that
he has been diagnosed with Kaposi sarcoma (KS). Which fact most accurately
conveys an aspect of his diagnosis?

Answer 107

He is likely to have lesions on his skin, mouth, or GI tract.

Question 108

When counseling a male client with suspected HIV, the nurse informs him that if
the enzyme-linked immunosorbent assay (ELISA) comes back positive, then:

Answer 108

a second test known as the Western blot assay will be ordered to confirm
positive HIV status.

Question 109

After years of going to different physicians with vague symptoms, a 55-year-old
client with a history of Hodgkin lymphoma has been diagnosed with a secondary
immunodeficiency syndrome. The client asks the nurse what this means. The nurse
knows that secondary immunodeficiency disorders may occur if which background
information is available? Select all that apply.

Answer 109

• Usually develop later in life
• May be a result of chemotherapy being used to treat a cancer
• Can occur in clients taking corticosteroids daily.

Question 110

A 2-year-old girl has had repeated ear and upper respiratory infections since
she was born. A pediatrician has determined a diagnosis of transient
hypogammaglobulinemia of infancy. What is the physiologic origin of the child’s
recurrent infections?

Answer 110

The child’s immune system is unable to synthesize adequate immunoglobulin on its own.

Question 111

A nurse is providing care for a 17-year-old boy who has experienced recurrent
sinus and chest infections throughout his life and presently has enlarged tonsils and
lymph nodes. Blood work indicated normal levels of B cells and free immunoglobins
but a lack of differentiation into normal plasma cells. The boy is currently receiving
intravenous immunoglobulin (IVIg) therapy. What is the boy’s most likely
diagnosis?

Answer 111

Common variable immunodeficiency

Question 112

An 8-week-old boy has been recently diagnosed with a severe combined
immunodeficiency (SCID). His parents have performed a significant amount of
research on the Internet and have brought a large amount of material to discuss
with their care provider. Which statement best reflects an accurate understanding
of their son’s health situation?

Answer 112

“Our son likely has a deficiency of B-lymphocytes and can’t produce antibodies.”

Question 113

A 1-year-old child who has experienced low platelet counts and bacterial
susceptibility has been admitted to a pediatric medical unit of a hospital for
treatment of Wiskott-Aldrich syndrome. The nurse who has admitted the child to
the unit would anticipate which short-term and longer-term treatment plans?

Answer 113

Treatment of eczema; management of bleeding; bone marrow transplant

Question 114

A 4-year-old boy presents with a chronic cough and swollen lymph nodes. His
records show that he has been given antibiotics several times in the past year with
limited success, most recently for a liver abscess. He also has a recurring fungal
skin condition. Which diagnosis is most likely the cause of this child’s
manifestations?

Answer 114

Chronic granulomatous disease

Question 115

When explaining to parents what is occurring when their child has an acute
bronchial asthma attack, the nurse will emphasize that which mediator is primarily
responsible for the bronchial constriction?

Answer 115

Histamine

Question 116

A 40-year-old woman who experiences severe seasonal allergies has been
referred by her family physician to an allergist for weekly allergy injections. The
woman is confused as to why repeated exposure to substances that set off her
allergies would ultimately benefit her. Which phenomenon best captures the
rationale for allergy desensitization therapy?

Answer 116

Injections of allergens simulate production of IgG, combining with the antigens
to prevent activation of IgE antibodies.

Question 117

Following a spider bite she received while camping, a 20-year-old female
presented to the emergency department with rash, edema, and fever and was
subsequently diagnosed with serum sickness. Which statement best conveys the
physiologic rationale for the broad systemic effects of this event?

Answer 117

Antigen-antibody complexes have been deposited in a variety of locations
throughout the body.

Question 118

A female dental assistant has developed signs and symptoms of a latex
sensitivity, and is undergoing allergy testing as well as blood work. Which
component of the assistant’s blood work would most likely be the focus of her
health care provider’s analysis?

Answer 118

Serum IgE immunoassays

Question 119

While undergoing a kidney transplant from a non-family member, the client’s
transplanted kidney has just had the arterial clamps removed. The OR staff notices
that the organ is turning purple with no urine output. When explaining to the family
why they had to remove the donor kidney, the nurse will anticipate that the
surgeon would likely include which statement?

Answer 119

Hyperacute rejection occurs because antibodies against HLA antigens are
deposited in vessels, causing necrosis.

Question 120

After several months on a waiting list, a 44-year-old male received a liver
transplant 5 days ago. In the last 36 hours, he has developed a rash beginning on
his palms and soles, along with abdominal pain and nausea. It has been determined
by his care team that the immune response that is causing his symptoms originates
not with his own compromised immune components but with those introduced with
his new organ. This man’s most likely medical diagnosis is:

Answer 120

Graft-versus-host-disease (GVHD)

Question 121

While volunteering in an HIV clinic in a big city, the nurse notices a new mom
and her 6-month old child in the waiting room. Upon assessing the infant for
possible HIV infection, the nurse will be assessing for which clinical manifestations
of HIV infection? Select all that apply.

Answer 121

• Weighing him to determine if he is gaining 1.5 to 2 pounds/month.
• Lack the coordination to play with toys/stuffed animals.
• History of repeated episodes of bacterial pneumonia and ear infections.
• Listlessness and poor eye contact.

Question 122

Which client is most likely to be a candidate for a thymus transplant as the
treatment of choice to reconstitute T-cell immunity?

Answer 122

A 7-year-old boy with diagnosis of thymic aplasia whose blood work indicates
absence of T cells

Question 123

Which clients are at increased risk for developing secondary
hypogammaglobulinemia, a secondary humoral immunodeficiency? Select all that
apply.

Answer 123

• client with burns covering more than 45% of the body
• malnourished child who only drinks cow’s milk
• client witha a history of seizures controlled by an antiepileptic

Question 124

A health care provider has prescribed blood products for a trauma client with a
history of selective immunoglobulin A deficiency (SIGAD) who is going into
hypovolemic shock. Which blood product is most appropriate for the nurse to
infuse?

Answer 124

specially washed erythrocytes from normal donor

Question 125

Staphylococcus aureus commonly found in the skin, nares, and other body sites
of clients without any signs and symptoms of infection is known as which condition?

Answer 125

Bacterial colonization

Question 126

Which statement is an accurate descriptor of the role of viruses in human
infections?

Answer 126

Some viruses are capable of transforming normal host cells into malignant cells.

Question 127

Which type of pneumonia is best characterized by an infective agent that
produces sputum samples with a peptidoglycan cell wall, expresses endotoxins,
replicates readily in broth and on agar, grows in clusters, has pili, and does not
stain when exposed to crystal violet?

Answer 127

Bacterial

Question 128

The nurse will most likely assess which clinical manifestation in a client
diagnosed with Creutzfeldt-Jakob disease?

Answer 128

Change in behavior and memory, loss of coordination leading to encephalopathy

Question 129

The spirochete Leptospira is primarily transmitted to farmers by:

Answer 129

direct contact with infected animals.

Question 130

The nurse knows which statement best describes a characteristic trait of
Rickettsiae related to Rocky Mountain spotted fever? Rickettsiae:

Answer 130

have both RNA and DNA.

Question 131

An 81-year-old female client in a subacute medical unit of a hospital has
developed an oral Candida albicans infection. Which phenomena would the client’s
nurse suspect as a key contributing factor to her infection?

Answer 131

Antibiotic therapy that eliminated normal bacterial flora

Question 132

The nurse knows which of statement below is appropriate to be included in an
education session for a 21-year-old male with a diagnosis of malaria?

Answer 132

“The infectious organisms are considered tiny, single-celled animals, given their
complete eukaryotic machinery.”

Question 133

The physician knows the client, G1P0, has correctly understood the prenatal
education regarding sexually transmitted infection as evidenced by which statement
listed below?

Answer 133

“My baby could become infected either across the placenta or during the birth
itself.”

Question 134

Which procedure reduces the potential for infection primarily by addressing the
portal of entry?

Answer 134

Wearing gloves when contact with blood or body fluids is anticipated

Question 135

A school-age child with a history of asthma has brought a note home from
school stating there has been one case of meningitis (Neisseria meningitidis) in the
school. Since the mother is a nurse, she is very concerned since she knows the
portal of entry of this pathogen is:

Answer 135

inhalation via the respiratory tract such as through breathing or yawning.

Question 136

Which scenario best describes an example of infection originating with a
fomite?

Answer 136

A client who contracted hepatitis C through sharing a contaminated syringe with
an infected person

Question 137

A client presents with sudden, violent diarrhea and vomiting after consuming
chicken and potato salad 8 hours prior at the beach on a hot day. The nurse knows
which statement best matches the phase of the infectious process of food
poisoning?

Answer 137

Maximum impact of infectious process

Question 138

Which infectious agent would be a site-specific pathogen and not spread
throughout the body via the circulatory system? A client diagnosed with:

Answer 138

Helicobacter pylori diagnosed after an endoscopic procedure.

Question 139

A client diagnosed with H. pylori asks the nurse, “How can an infection occur in
the stomach since it is an acid environment?” The nurse responds:

Answer 139

“H. pylori produces an enzyme called urease that converts gastric juices into
ammonia, which neutralizes the acidic stomach environment.”

Question 140

A client has been diagnosed with herpes simplex virus. The client states that,
“modern medicine produces more and more antivirals every year and so the
treatment should be simple.” Which statement is the best response?

Answer 140

“Treatment options for viruses are often limited because what destroys viruses
often damages your own body cells.”

Question 141

The nurse in the emergency department knows clients exposed to Clostridium
botulinum, an agent of bioterrorism, would likely be exhibiting which clinical
manifestation listed below?

Answer 141

Muscle weakness in extremities eventually leading to paralysis of respiratory
muscles

Question 142

Health care team members know recently an increased incidence of infections
such as West Nile virus and SARS do not match previously established patterns.
Which phenomenon constitutes the most significant contributor to the spread of
new diseases in the United States?

Answer 142

Increased ease and speed of travel for individuals and groups

Question 143

A 72-year-old client being treated for rheumatoid arthritis is admitted with
suspected ehrlichiosis. What should the nurse implement as a treatment priority?
A. Isotonic intravenous fluids at a minimum rate of 200 mL/hr

Answer 143

Administration of empirically chosen antibiotics

Question 144

A family of five vacationed together, but only the client contracted traveler’s
diarrhea. The client asks the nurse, “We all ate and drank the same things. Why am
I the only one with this condition?” What should the nurse offer to the client as the
most likely reason for susceptibility for this condition?

Answer 144

You are taking a proton pump inhibitor for gastric reflux disease.

Question 145

A client is suspected of having an infection, but the microorganism suspected as
the cause cannot be cultured. The client asks how the health care provider will
identify the organism. What is the nurse’s best response as to the methods used?

Answer 145

The health care provider will introduce cultured, marked antibodies to your blood
sample and observe for a reaction with antigens.

Question 146

The nurse is performing discharge teaching for a client who has recovered from
sepsis following an open cholecystectomy. What should be the nurse’s primary
focus?

Answer 146

Signs and symptoms of infection

Question 147

A nurse is interviewing a client with fever, myalgia, headache, and lethargy.
Which question is most important for the nurse to ask related to identifying the
cause of these symptoms and the possible need for quarantining the client?

Answer 147

Have you or any family members traveled outside the country recently?

Question 148

The nurse is caring for a client who meets the physical assessment criteria for
sepsis, but the specimen cultures are negative for a causative organism. What
action should the nurse take next?

Answer 148

Administer the prescribed antibiotics.

Question 149

The nurse is caring for a client who has just been diagnosed with shingles. The
client states, “I have not been around anyone with this condition. How could I have
caught it?” What is the nurse’s best response?

Answer 149

“This is a latent virus that you likely were exposed to as a child and it has now
become active in the form of shingles.”

Question 150

When asked to name the parts of the pilosebaceous unit of the skin, the student
has answered correctly when he states:

Answer 150

Sebaceous glands

Question 151

Which term is usually associated with nail growth?

Answer 151

Continuously

Question 152

Mitosis that results in the production of new epidermal cells occurs in which layer
of the epidermis?

Answer 152

Stratum germinativum

Question 153

After falling off his bicycle, an 8-year-old boy has a large abrasion on his
posterior thigh that has removed the epidermis in the region but left the dermis
largely intact. Which change in integumentary system would be expected in the
area of his wound?

Answer 153

Fewer Merkel and Langerhans cells in the region

Question 154

Which statement best conveys an aspect of the process of keratinization?

Answer 154

The stratum germinativum continuously produces new keratinocytes to replace
losses.

Question 155

A nurse is teaching a client about the role that skin plays in forming a barrier to
environmental agents and microorganisms. The nurse would recognize that which
type of cells/junctions are involved in the communication and regulation of the
immune response and the secretions of cytokines?

Answer 155

Keratinocytes

Question 156

While studying the skin in a science class, a student asks why all people have a
pinkish color to their lips/mucous membranes. The instructor would respond by
stating:

Answer 156

Pheomelanin is the yellow to red pigment particularly concentrated in the lips
and nipples in humans.

Question 157

A 40-year-old male client has a congenital syndrome that affects the function of
the Langerhans cells of his epidermis. The man’s care provider would expect which
manifestation of his condition?

Answer 157

Increased susceptibility to infection

Question 158

Clinical investigation of a 40-year-old female client with diverse dermatologic
signs and symptoms has focused on the woman’s basement membrane. Which skin
function would a clinician most likely attribute to a region of the integument other
than the basement membrane?

Answer 158

Lack of sensory nerve impulse conduction

Question 159

A person with severe lymphedema is asking the nurse where specifically the
lymph vessels are located in the skin layers. What would the nurse would respond?

Answer 159

Basement membrane

Question 160

Which component of immune function is absent in the dermis?

Answer 160

Lymph nodes

Question 161

The skin is richly supplied with arteriovenous anastomoses in which blood flows
directly between an artery and a vein, bypassing the capillary circulation. What is
the primary significance of these structures?

Answer 161

They regulate body temperature.

Question 162

A 51-year-old woman who was born congenitally blind and deaf is able to
distinguish individuals by light touch of the individual’s face. Which component of
the woman’s skin innervation likely contributes the most to this ability?

Answer 162

Meissner corpuscles

Question 163

A frustrated 26-year-old female has sought a referral to a dermatologist in an
effort to resolve her sweating and body odor which persist despite good hygiene.
Which facts would underlie the explanation that her health care provider provides
about her problem?

Answer 163

Aprocrine sweat glands produce a substance that is more oily than sweat from
other sources.

Question 164

While working in an allergy clinic, the nurse notices that many clients come in
with all types of skin reactions. The nurse working in this area knows that which
cells play a role in the development of allergic skin condition?

Answer 164

Langerhans cells

Question 165

With eyes closed, an object is placed in a student’s hand. The instructor asks
the student to identify the object. When he does so correctly, this is primarily the
responsibility of:

Answer 165

Meissner corpuscles

Question 166

While lecturing about frostbite, the instructor asks the students, “Which
substance prevents undue evaporation from the stratum corneum during the cold
winter weather, which then helps conserve body heat?” The best answer is:

Answer 166

Sebum, secreted by the sebaceous gland

Question 167

The nurse is caring for a client with an infection and fever. The client reports
feeling chilled and having “goose bumps.” The nurse will anticipate what change in
the client’s assessment findings as a result of this physiologic reaction?

Answer 167

An increase in body temperature

Question 168

A client arrives with a very large blister on the heel from “new shoes” and fear
having “damaged” the structures (ligaments and tendons) beyond repair and want
to know “what caused this blister?” Which nursing response is best in this situation?

Answer 168

“This blister is caused by mechanical friction from repeated rubbing on this area.
The fluid is in the basement membrane between the epidermis and dermis.”

Question 169

The parent of a infant recently diagnosed with albinism asks, “Why did this
happen to my infant?” Which response by the nurse is most appropriate?

Answer 169

“Your infant is not producing the enzyme tyrosinase, which is needed to
synthesize melanin. Melanin protects the skin from UV rays and adds color to the
skin.”

Question 170

The pathology instructor asks, “What function do keratinocytes perform in the
epidermis?” Which student has the correct answer?

Answer 170

“Keratinocytes in this layer secrete lamellar bodies to provide important water-
impermeable properties.”

Question 171

An adolescent client of African descent arrives at the dermatology clinic asking,
“Why do I have these white (light) patches of skin all over my body. I try sun
tanning, but it does not get darker?” The health care provider suspects the teen has
developed which skin condition?

Answer 171

Vitiligo, lighten skin due to decreased pigment or melanin.

Question 172

Following laproscopic gall bladder surgery, a client has a 2-in (5-cm) incision
that is elevated, irregular, and a different color from the normal skin. The client
asks, “What is wrong with this incision? It’s been 2 years and I expected no visible
sign of this surgery since it was laproscopic.” How will the nurse explain this
condition?

Answer 172

“Your body formed excessive collagen during the healing process.”

Question 173

An adolescent reports a small (0.2 cm), round, serous-filled spot at the corner
of the mouth. How should the nurse document this finding?

Answer 173

Vesicle

Question 174

A high school athlete has developed a fungal infection between the toes where
it is red, sore, and cracked into the dermis. Which term is the most accurate for the
nurse to document in the client’s record?

Answer 174

A fissure

Question 175

An 18-year-old female of Asian ancestry is distraught over the recent appearance
of white patches on her forearms and upper arms which have been subsequently
confirmed as vitiligo. Which statement by the woman expresses an accurate
understanding of her condition?

Answer 175

“I suppose this shouldn’t come as too much of surprise, since this tends to run in
my family.”

Question 176

An 11-year-old boy with skin lesions on his trunk characteristic of ringworm has
been brought to the health care provider. Which aspect of the clinician’s
assessment relates most directly to the suspected diagnosis?

Answer 176

Potential contact with the fungus from pets or other children

Question 177

An older adult client has arrived at the physician’s office complaining of a rash.
Upon further investigation, the client states the rash feels like a burning pain but
also has some tingling. It is extremely sensitive to touch. The nurse notes that the
rash is made up of vesicles and located on the right thoracic region. The nurse
suspects the client has:

Answer 177

Herpes zoster

Question 178

Which teaching point is most appropriate for an adolescent who has sought care
for the treatment of severe acne located on the face and back?

Answer 178

“You might need antibiotic pills in addition to a cream for your face.”

Question 179

A 30-year-old woman who just found out that she is pregnant seeks a treatment
for her severe acne. What is the most appropriate treatment for her skin condition?

Answer 179

A benzoyl peroxide agent

Question 180

A 31-year-old man who has worked for several years installing fiberglass
insulation has developed itchy, irritating lesions on his wrists and forearms over the
last several months. He has applied moisturizing creams repeatedly and has taken
antihistamines but has experienced no significant improvement. He is
understandably concerned about the potential effect this could have on his
livelihood and has asked his health care provider when treatment will resolve the
problem. What is the health care provider’s most appropriate response?

Answer 180

“A steroid cream will likely help, but often the skin problem lasts long after
contact with the product that irritates the skin.”

Question 181

A 44-year-old man has been diagnosed with chronic urticaria, the exact cause of
which cannot be determined. Which pharmacologic treatment is likely to be of most
use to the man?

Answer 181

Antihistamines

Question 182

Which aspects of the woman’s history and assessment could be potential
contributors to her diagnosis of psoriasis? Select all that apply.

Answer 182

• The woman takes an angiotensin-converting enzyme (ACE) inhibitor for the
  treatment of hypertension.
• She takes hydroxychloroquine for rheumatoid arthritis.
• Skin trauma of any kind often precedes an outbreak.

Question 183

The nurse is caring for a client with pneumonia and a severe case of psoriasis
that is being treated with methotrexate. During the morning assessments, which
laboratory values would alert the nurse that the client is experiencing a side effect
to this medication? Select all that apply.

Answer 183

• Platelet count 37 x 103/μL (37 x 109
  /L
• White blood cell count 1.2 x 103/μL (1.2 x 109
  /L)

Question 184

A 13-year-old girl has presented to a clinic with her mother explaining that she
had an oval-shaped red patch on her chest a week ago, but that more of the lesions
are now appearing on her back. On examination, the lesions on her back are in a
“Christmas tree” pattern. What is the girl’s most likely diagnosis?

Answer 184

Pityriasis rosea

Question 185

A 22-year-old male who has been backpacking around Southeast Asia for
several months has responded well to treatment for scabies that he acquired while
on his trip. What follow-up measures should be taken?

Answer 185

Treatment of individuals that he has been in close contact with.

Question 186

When trying to discern the extent of a burn, the nurse will note that second-
degree full-thickness burns are characterized by:

Answer 186

extensive pain along with waxy white areas with blister formation.

Question 187

A nurse working in a long-term care facility has attended an educational
conference on pressure ulcer care in older adults. Which protocol in the facility
would the nurse advocate changing for the client who develops a stage I ulcer?
A. Residents with persistently low food intake are identified.

Answer 187

Wound dressings are applied promptly to all identified or potential pressure
ulcers.

Question 188

Which client of an oncologist is likely to have the poorest prognosis?

Answer 188

A 69-year-old man who has been diagnosed with stage IV malignant melanoma.

Question 189

Which changes in an 86-year-old male’s skin would necessitate further
examination and possible medical treatment?

Answer 189

A new mole-like growth on his forearm.

Question 190

A nurse practitioner student is trying to distinguish the various rashes she will
be seeing in her pediatric rotation. Their nurse preceptor is assisting by describing
the rash associated with rubeola. Which characteristics would apply to rubeola?
Select all that apply.

Answer 190

• Rash is macular and blotchy.

- The rash usually begins on the face and then spreads to the legs/arms.

Question 191

A few of the more experienced nurses are sitting around a lunch table
discussing the changes they are seeing in their skin. Which of these would be
considered normal age-related changes? Select all that apply.

Answer 191

• Reduction in subcutaneous tissue.

- Dry, scaly skin.

Question 192

An older adult client is showing the nurse some changes in the skin that the
client found while taking a shower. Which lesion(s) would give the nurse concern
that it might be a precancerous lesion? Select all that apply.

Answer 192

• Several dry, brown, scaly lesions that are approximately 1 cm in diameter; a few
  of the lesions are showing some ulceration.
• Tan-to-brown lesions commonly called ‘liver spots” located on forearm and
  hands.

Question 193

A client has sustained superficial or first-degree burns to both legs and the left
arm. According to the rule of nines, what percentage of total body surface area
should the nurse record as affected by this burn?

Answer 193

45%

Question 194

A client who has sustained partial-thickness or second-degree burns to 70% of
total body surface area is arriving via ambulance to the emergency department.
What aspects of care will the nurse prioritize for this client? Select all that apply.

Answer 194

• Blood pressure support
• Infection control
• Pain management

Question 195

The nurse is caring for a 22-year-old client with a circumferential burn to the
left thigh. What assessment should the nurse perform as a priority specific to this
type of burn?

Answer 195

Color, warmth, circulation, sensation, and movement of the left lower leg and
foot

Question 196

The nurse is caring for a client who is incontinent and at risk for pressure ulcer
formation. What should the nurse include in the plan of care to reduce the risk for
pressure ulcer formation? Select all that apply.

Answer 196

• Inspect bed sheets for cleanliness each time client is turned.
• Record client’s intake and address nutritional deficits.
• Establish a toileting routine during waking hours.

Question 197

The nurse is changing an occlusive dressing on a stage III pressure ulcer and
notes the formation of new eschar in the wound bed. For what change in the wound
care plan should the nurse advocate?

Answer 197

Switching to using wet-to-dry dressings.

Question 198

A client experienced third-degree, full-thickness burns 2 days ago to the lower
limbs after a fire at his workplace. Which systemic complications should the nurse
regularly assess for? Select all that apply.

Answer 198

• Decreased peristalsis of bowel
• Respiratory dysfunction
• Hypermetabolic response
• Sepsis

Question 199

A child is sent home from school following a check for head lice by the nurse.
The parents call to ask, “How do you know it is head lice? We thought our child just
had dry skin and dandruff.” Which manifestation(s) will the school nurse share with
these parents? Select all that apply.

Answer 199

• The child is scratching at the head.
• There are firmly attached nits on the hair shaft.
• The child has red, excoriated scalp lesions.

Question 200

Following a biopsy, a 54-year-old man has been diagnosed as having a benign
neoplastic tumor. Which characteristic most likely applies to his tumor?

Answer 200

The well-differentiated, neoplastic cells are clustered together in a single mass.

Question 201

A 77-year-old male client with a diagnosis of stomach cancer has been found to
have metastases in his liver. The client and his family are surprised at this turn of
events, stating that they don’t see how he could have developed cancer in his liver.
Which fact would underlie the reply that the care team provides?

Answer 201

The portal circulatory system brings venous blood from the GI tract into the
liver.

Question 202

A 41-year-old female with a family history has had a baseline mammogram. She states that she performs monthly self breast exams but really has a hard time
evaluating her lumps since she has numerous cysts. At her annual mammogram, the technician views a suspicious area and refers her to the radiologist. She asks
the nurse in the office, “How can a lump appear so quickly?” The nurse’s response
is based on which principle?

Answer 202

A tumor is undetectable until it has doubled 30 times and contains at least 1 billion cells.

Question 203

Unbeknownst to her or her care team, a 51-year-old woman’s breast cancer has
an etiology rooted in the fact that tumor suppressing genes are present but have
been silenced. Consequently, she has not synthesized normal cancer-suppressing
proteins and neoplasia has resulted. What process has accounted for the woman’s
cancer?

Answer 203

Epigenetic mechanisms

Question 204

Which client of a primary care physician would not require extra screening for
cancer?

Answer 204

A 38-year-old female with Down syndrome and congenital scoliosis

Question 205

Blood-borne cancerous cells have recently spread from a woman’s primary
pancreas tumor to her bones. Which components of the woman’s immune system
are likely to be directly involved in the attempt to eradicate the potential
metastasis? Select all that apply.

Answer 205

• T lymphocytes
• Macrophages
• Natural killer (NK) cells
• B lymphocyte cells

Question 206

The family of a 68-year-old man who is in the end stages of small-cell lung
cancer are distraught at his visible body wasting that has worsened in recent
weeks. Which phenomena best accounts for the client’s anorexia and cachexia?

Answer 206

Products of the tumor itself as well as a hypermetabolic state cause cachexia.

Question 207

The nurse caring for a lung cancer client with metastasis to the brain suspects
the client has developed a paraneoplastic syndrome known as Syndrome of
Inappropriate Antidiuretic Hormone (SIADH) secretion. Which laboratory result in
this client who has gained 3 lb in a day would alert the nurse to the possibility of
SIADH?

Answer 207

Serum sodium of 115 mEq/L (115 mmol/L)

Question 208

A 60-year-old man has presented to a clinic and is requesting screening for
tumor markers after reading about them in a magazine. What can the clinician
most accurately tell the man about the clinical use of tumor markers?

Answer 208

“Tumor markers alone aren’t enough to confirm whether you have cancer or not,
so they’re not a very useful screening tool.”

Question 209

A 51-year-old female has been found to have metastatic lesions in her lung but
her oncologist is unsure of the primary tumor site. Which procedure is most likely
to aid in this determination?

Answer 209

Immunohistochemistry

Question 210

A client with malignant melanoma has been prescribed alpha interferon, a
biologic response modifier. Since this drug prolongs the cell cycle, increasing the
percentage of cells in the G0 phase, and stimulates NK cells and T-lymphocyte killer
cells, the nurse can anticipate that they may experience which common side
effects?

Answer 210

Fever, chills, and fatigue

Question 211

An oncology nurse who has worked for many years providing care for children
with cancer has taken a job on an adult oncology unit of a hospital. What
differences might the nurse anticipate in this new job?

Answer 211

There will be a greater number of cancers that are epithelial in origin.

Question 212

A 26-year-old man who survived childhood acute lymphocytic leukemia (ALL),
one of the most common childhood cancers, now complains of weakness, fatigue,
and shortness of breath. His treatment for ALL likely included anthracyclines. What
is the most likely cause of his symptoms?

Answer 212

Heart failure resulting from childhood chemotherapy

Question 213

The mother of an 18-month-old child is concerned that her child is lethargic and
not eating foods that he normally enjoys. She takes him to the pediatrician for a
check-up. Which clinical manifestations lead the health care provider to suspect the
child may have a neuroblastoma? Select all that apply.

Answer 213

• Large, protruding abdomen
• Weight loss
• Crying when joints/position changed

Question 214

The nurse is planning care for a client who is receiving antimetabolite
chemotherapy. What should the nurse include in the plan of care? Select all that
apply.

Answer 214

• Falls prevention protocol
• Daily weights
• Monitor bowel movements closely.

Question 215

The daughter of a client with metastatic cancer is confused as to why the client
is receiving radiation therapy and asks the nurse, “Why are we still treating the
cancer? The plan was only for comfort care.” What is the nurse’s best response?

Answer 215

“In this case, the radiation is being used to help alleviate the bone pain your
family member is experiencing.”

Question 216

The nurse is caring for a client with small cell lung carcinoma who has
developed syndrome of inappropriate antidiuretic hormone (SIADH). What should
the nurse incorporate into the plan of care? Select all that apply.

Answer 216

• Daily weights
• Maintenance of fluid restriction
• Frequent repositioning

Question 217

The family member of a client with terminal metastatic cancer who is
experiencing cachexia-related weight loss asks the nurse why the client is losing
weight despite taking in a large amount of calories per day. What is the nurse’s
best response?

Answer 217

“This weight loss is related to the cancer itself and occurs despite an intake of
adequate calories.”

Question 218

During a discussion with a client recently diagnosed with stage IV kidney
cancer, which statement is most accurate?

Answer 218

“Many times, kidney cancer goes completely undetected until a metastatic lesion
is found in the lung.”

Question 219

A client overheard the provider discussing the case and mentioning a “mutation
in the TP53 gene.” The client asks the nurse, “What does that mean?” Which
response is the most appropriate for this client?

Answer 219

“The TP53 gene is a group of tumor suppressor genes associated with lung,
breast and colon cancer.”

Question 220

Which breakfast diet contains chemicals that likely can contribute to a higher
rate of cancer risk?

Answer 220

Sausage fried in reused grease and biscuits and gravy.

Question 221

When educating a client who has tested positive for human T-cell leukemia
virus-1 (HTLV-1), what mode(s) of transmission should the nurse discuss to
prevent the spread? Select all tht apply.

Answer 221

• sexual intercourse
• blood by sharing needles
• infants through breast milk

Question 222

A client has stage IV cancer but further testing is needed to determine the site
of origin of this metastatic tumor. Which form of testing will the health care
provider be discussing with this client?

Answer 222

immunohistochemistry

Question 223

The nurse is educating a client who is undergoing gamma knife radiosurgery for
a brain metastasis. What advantage to this procedure should the nurse share when
comparing it to other conventional treatments?

Answer 223

less cognitive dysfunction

Question 224

A community health nurse is discussing preventative vaccines with a group of
primigravda women. Which cancer-causing virus(es) should the nurse discuss that
have a vaccine to prevent developing the disease? Select all that apply,

Answer 224

hepatitis B

meningitis

Question 225

As part of preoperative teaching for clients who are about to undergo a coronary
artery bypass graft, a nurse is performing an education session with a group of
surgical candidates. Which teaching point best conveys an aspect of the human
circulatory system?

Answer 225

“The blood pressure varies widely between arteries and veins, and between
pulmonary and systemic circulation.”

Question 226

In which situation would blood most likely be rapidly relocated from central
circulation to the lower extremities?

Answer 226

A client is helped out of bed and stands up.

Question 227

Which statement most accurately captures a principle of blood flow?

Answer 227

With constant pressure, a small increase in vessel radius results in an
exponential increase in blood flow.

Question 228

A 72-year-old female has been told by her physician that she has a new heart
murmur that requires her to go visit a cardiologist. Upon examination, the
cardiologist informs the client that she has aortic stenosis. After the cardiologist has
left the room, the client asks, “What caused this [aortic stenosis] to happen now?”
The clinic nurse responds:

Answer 228

“Heart murmurs result from tumultuous flow through a diseased heart valve that
is too narrow and stiff. This flow causes a vibration called a murmur.”

Question 229

A physician is teaching a group of medical students about the physiologic basis
for damage to the circulatory and neurologic systems that can accompany
hypotension. Which response by a student would warrant correction by the
physician?

Answer 229

“Tension and vessel thickness increase proportionately.”

Question 230

During an automobile accident where the client is bleeding heavily, which
vascular component is the most distensible and can store large quantities of blood
that can be returned to the circulation at this time of need?

Answer 230

Veins

Question 231

A pathologist is examining histological (tissue) samples from a client with an autoimmune disease. Which characteristic of muscle samples would signal the
pathologist that the samples are cardiac rather than skeletal muscle?

Answer 231

The muscle cells are arranged as an interconnecting lattice-work.

Question 232

An 81-year-old female client of a long-term care facility has a history of
congestive heart failure. The nurse practitioner caring for the client has positioned
her sitting up at an angle in bed and is observing her jugular venous distention.
Why is jugular venous distention a useful indicator for the assessment of the
client’s condition?

Answer 232

Blood backs up into the jugular vein because there are no valves at the point of
entry into the heart.

Question 233

As part of their orientation to a cardiac care unit, a group of recent nursing
graduates is receiving a refresher in cardiac physiology from the unit educator.
Which teaching point best captures a component of cardiac function?

Answer 233

“The diastolic phase is characterized by relaxation of ventricles and their filling
with blood.”

Question 234

A client is experiencing impaired circulation secondary to increased systemic
arterial pressure. Which statement is the most relevant phenomenon?

Answer 234

High afterload because of backpressure against the left ventricle

Question 235

In the ICU, the nurse hears an emergency cardiac monitor go off. The nurse
looks at the telemetry and notices the client has gone into ventricular tachycardia.
The nurse will likely assess for signs/symptoms of:

Answer 235

decreasing cardiac output due to less ventricular filling time.

Question 236

A nurse is taking a manual measure of a client’s blood pressure. The nurse
knows that which factors related to blood flow underlies the ability to hear blood
pressure by auscultation (listening)?

Answer 236

Pressure pulsation that exceeds the velocity of blood flow is audible and
coincides with systolic BP.

Question 237

Analysis has shown that a client’s right atrial pressure is 30 mm Hg. What is the
most likely conclusion that the client’s care team will draw from this piece of data?

Answer 237

The pressure is excessive given that the right atrium should be at atmospheric
pressure.

Question 238

An emergency department client arrives after two days of “chest pressure” and
“tightness” that was unrelieved with antacids. Following angioplasty for a massive
myocardial infarction (MI), the client asks why so much muscle was damaged if only the left circumflex vessel was blocked. Which response by the nurse is most
accurate?

Answer 238

“If a major artery like the circumflex is occluded, the smaller vessels supplied by
that vessel cannot restore the blood flow.”

Question 239

When explaining to a client why there was only minimal muscle damage
following 99% occlusion of the left anterior descending artery, the nurse will explain
that this is primarily due to:

Answer 239

development of collateral circulation that build channels between some of the
smaller arteries, usually when the flow is decreased gradually.

Question 240

Which individual is most likely to be experiencing vasodilation?

Answer 240

A 51-year-old man with a history of hypertension who is taking a medication that blocks the effect of the renin–angiotensin–aldosterone system

Question 241

When trying to explain to a client on dialysis the movement of substances
through the capillary pores, the nurse will explain that in the kidneys, the
glomerular capillaries have:

Answer 241

Small openings that allow large amounts of smaller molecular substances to filter through the glomeruli.

Question 242

A 51-year-old client with a history of alcohol abuse and liver disease has low
serum levels of albumin, and presents with ascites (excess fluid in his peritoneal
space) and jaundice. A health care professional would recognize that which process
is most likely underlying his health problems?

Answer 242

Low albumin is contributing to excess hydrostatic pressure and inappropriate
fluid distribution.

Question 243

While intubated for surgery, a client has inadvertently had his vagus nerve
stimulated. What effect would the surgical team expect to observe?

Answer 243

Decreased heart rate as a result of parasympathetic innervation of the heart

Question 244

A client in the emergency department is experiencing a massive stroke with
extremely low blood flow to the brain exhibited by a BP <60 mm Hg. The nurse
suddenly notes there is a sharp rise in the BP to 250 mm Hg. This high BP lasts
about 5 minutes and then the BP drops sharply again. The pathophysiologic
principle behind this is likely due to the:

Answer 244

CNS ischemic response.

Question 245

The nurse is assessing heart sounds on a client and detects a previously
undocumented murmur. What diagnostic test should the nurse prioritize
requesting an order for related to this finding?

Answer 245

Hemoglobin

Question 246

The nurse is caring for a client with small veins. The nurse can improve the
chance of successfully drawing a blood sample by applying the principle of critical
closing pressure and:

Answer 246

using minimal negative pressure when drawing the sample into the syringe.

Question 247

The nurse is caring for a client with angina. If wanting to reduce the Frank–
Starling effect on myocardial oxygen consumption, what type of medication would
the nurse expect to be prescribed?

Answer 247

A venous vasodilator

Question 248

The nurse is caring for a client with peripheral edema. When elevating the client’s legs to the level of the heart, what will the nurse expect to occur? Select all
that apply.

Answer 248

• Reduction in the venous hydrostatic pressures of the legs
• Increase in urine output
• Increase in blood pressure

Question 249

A client with uncontrolled hypertension has reviewed the echocardiogram report
prior to visiting the health care provider. The client asks, “What does it mean when my ejection fraction is measured as only 30%? I want to know how to get this back
to normal.” Which response by the provider is most accurate?

Answer 249

“Most likely, your low ejection fraction is caused by your uncontrolled high blood
pressure.”

Question 250

If a virus has caused inflammation resulting in endothelial dysfunction, an
excessive amount of endothelins in the blood can result in:

Answer 250

contraction of the underlying smooth muscles within the vessels.

Question 251

A nursing instructor is explaining the role of vascular smooth muscle cells in relation to increases in systemic circulation. During discussion, which
neurotransmitter is primarily responsible for contraction of the entire muscle cell layer, thus resulting in decreased vessel lumen radius?

Answer 251

Norepinephrine

Question 252

In which of the following hospital clients would the care team most realistically
anticipate finding normal cholesterol levels?

Answer 252

A 51-year-old male with a diagnosis of hemorrhagic stroke and consequent
unilateral weakness

Question 253

When a 55-year-old client’s routine blood work returns, the nurse notes that the client’s C-reactive protein (CRP) is elevated. The client asks what that means. The
nurse responds:

Answer 253

“This means you have elevated serum markers for systemic inflammation that has been associated with vascular disease.”

Question 254

A client is reading a brochure on atherosclerosis while in the waiting room of
medical clinic. Which excerpt from the educational brochure warrants correction?

Answer 254

“Because smoking causes a permanent increase in your risk of heart disease, it’s
best not to start.”

Question 255

A client arrives at the ED complaining of numbness in left lower leg. Upon
assessment, the nurse finds the lower left leg to be cold to touch, pedal and
posterior tibial pulses non-palpable, and a sharp line of paralysis/paresthesia. The
nurse’s next action is based on the fact that:

Answer 255

acute arterial occlusion is a medical emergency requiring immediate intervention
to restore blood flow.

Question 256

A 70-year-old male client presents to the emergency department reporting pain
in his calf that is exacerbated when he walks. His pedal and popliteal pulses are
faintly palpable and his leg distal to the pain is noticeably reddened. The nurse
knows that the client is likely experiencing which medical diagnosis/possible
treatment plan listed below?

Answer 256

Atherosclerotic occlusive disease necessitating thrombolytic therapy

Question 257

A young woman has been diagnosed by her family physician with primary
Raynaud disease. The woman is distraught, stating, “I’ve always been healthy and I
can’t believe I have a disease now.” What would be her physician’s most
appropriate response?

Answer 257

“If you make sure to keep yourself warm, it will have a fairly minimal effect; I’ll
also give you pills to enhance your circulation.”

Question 258

An older adult client arrives to the health care provider’s office complaining of a
“sore” that won’t heal on the lower leg. Upon assessment, the nurse finds thin, shiny, bluish brown pigmented desquamative skin. It is located medially over the
lower leg. The nurse will educate the client that the usual treatment is:

Answer 258

compression therapy to help facilitate blood flow back to the vena cava.

Question 259

A physician is explaining to a group of medical students the concept of
Virchow’s triad as it applies to venous thrombosis. Which clinical observation of a
50-year-old male client is most likely unrelated to a component of Virchow’s triad?

Answer 259

The man has decreased cardiac output and an ejection fraction of 30%.

Question 260

A 74-year-old man is being assessed by a nurse as part of a weekly basic
health assessment at the long term care facility where he resides. His blood
pressure at the time is 148/97 mm Hg, with a consequent pulse pressure of 51 mm
Hg. The nurse would recognize that which of the following is the most significant
determinant of the resident’s pulse pressure?

Answer 260

the amount of blood that his heart ejects from the left ventricle during each beat

Question 261

The nurse practitioner is working in an overnight sleep lab assessing and
diagnosing clients with sleep apnea. During this diagnostic procedure, the nurse notes that a client’s blood pressure is 162/97 mm Hg. The nurse explains this
connection to the client based on which pathophysiologic principle?

Answer 261

During apneic periods the client experiences hypoxemia, which stimulates chemoreceptors to induce vasoconstriction.

Question 262

A number of older adults have come to attend a wellness clinic that includes
both blood pressure monitoring and education about how to best control blood
pressure. Which teaching point is most accurate?

Answer 262

“Too much alcohol, too little exercise, and too much body fat all contribute to
high blood pressure.”

Question 263

When advising a morbidly obese client about the benefits of weight reduction,
which statement would be most accurate to share?

Answer 263

“A 10-pound loss of weight can produce a decrease in blood pressure.”

Question 264

A physician is providing care for several clients on a medical unit of a hospital.
In which situation would the physician be most likely to rule out hypertension as a
contributing factor?

Answer 264

A 61-year-old man who has a heart valve infection and recurrent fever

Question 265

An autopsy is being performed on a 44-year-old female who died unexpectedly
of heart failure. Which components of the pathologist’s report is most suggestive of
a possible history of poorly controlled blood pressure?

Answer 265

“Arterial sclerosis of subcortical brain regions noted.”

Question 266

During a routine physical exam for a client diagnosed with hypertension, the
nurse practitioner will be most concerned if which assessment is found?

Answer 266

Noted hemorrhages and microaneurysms during evaluation of internal eye.

Question 267

A physical assessment of a 28-year-old female client indicates that the blood
pressure in her legs is lower than that in her arms and that her brachial pulse is
weaker in her left arm than in her right. In addition, her femoral pulses are weak
bilaterally. Which possibility would her care provider be most likely to suspect?

Answer 267

Coarctation of the aorta

Question 268

A formerly normotensive woman, pregnant for the first time, develops
hypertension and headaches at 26 weeks’ gestation. Her blood pressure is 154/110
mm Hg and she has proteinuria. What other labs should be ordered for her?

Answer 268

Platelet count; serum creatinine; liver enzymes

Question 269

A physiotherapist is measuring the lying, sitting, and standing blood pressure of
a client who has been admitted to the hospital following a syncopal episode and
recent falls. Which fact about the client best relates to these health problems?

Answer 269

The client is 89 years old and takes a diuretic medication for his congestive heart
failure.

Question 270

A 78-year-old male client has undergone a total knee replacement. He just
doesn’t feel like getting out of bed and moving around. After 3 days of staying in
bed, the physical therapist encourages him to get out of bed to the chair for meals.
He starts to complain of dizziness and lightheadedness. These symptoms are
primarily caused by which pathophysiologic principle? Select all that apply.

Answer 270

• Client is experiencing a reduction in plasma volume.

- Peripheral vasoconstriction mechanism has failed.

Question 271

Which client should the emergency department staff suspect to be high risk for the development of a thoracic aortic aneurysm?

Answer 271

A 66-year-old client with facial edema, a cough, and neck vein distention

Question 272

Which medication will likely be prescribed for a client with elevated LDL and triglyceride levels?

Answer 272

Simvastatin, an HMG-CoA reductase inhibitor or ‘statin’

Question 273

While working triage in the emergency department, which client report should
alert the nurse to imminent danger and, thus, that client should be seen first?

Answer 273

A client holding the abdomen and reporting a tearing and ripping feeling inside.

Question 274

Following physical assessment, which abnormality(ies) leads the health care
provider to suspect the client has metabolic syndrome? Select all that apply.

Answer 274

• Sitting blood pressure reading of 145/96 mm Hg
• Five foot (1.5 meter) tall female with abdominal waist measurement of 45 inches(114 cm)
• Fasting triglyceride level of 230 mg/dL 92.6 mmol/L)

Question 275

In which client situations would a physician be most justified in preliminarily
ruling out pericarditis as a contributing pathology to the client’s health problems?

Answer 275

A 77-year-old with diminished S3 and S4 heart tones, irregular heart rate, and a
history of atrial fibrillation

Question 276

Which teaching point would be most appropriate for a group of older adults who
are concerned about their cardiac health?

Answer 276

“The plaque that builds up in your heart vessels obstructs the normal flow of
blood and can even break loose and lodge itself in a vessel.”

Question 277

Four clients were admitted to the emergency department with severe chest pain.
All were given preliminary treatment with aspirin, morphine, oxygen, and nitrates
and were monitored by ECG. Which client most likely experienced myocardial
infarction?

Answer 277

An 80-year-old woman whose pain started at 6 AM shortly after awakening and
was not relieved by nitrates or rest; the ECG showed ST-segment elevation with
inverted T waves and abnormal Q waves; levels of cardiac markers subsequently
rose

Question 278

A number of clients have presented to the emergency department in the last 32
hours with reports that are preliminarily indicative of myocardial infarction. Which
client is least likely to have an ST-segment myocardial infarction (STEMI)?

Answer 278

A 71-year-old man who has moist skin, fever, and chest pain that is excruciating
when he moves but relieved when at rest

Question 279

The initial medical management for a symptomatic client with obstructive
hypertrophic cardiomyopathy (HCM) would be administering a medication to block
the effects of catecholamines. The nurse will anticipate administering which
medication?

Answer 279

Propranolol, a beta-adrenergic blocker

Question 280

A 31-year-old female at 30 weeks’ gestation has been diagnosed with peripartum
cardiomyopathy. Which statement best captures an aspect of peripartum
cardiomyopathy?

Answer 280

The diagnosis might be attributable to a disordered immune response, nutritional
factors, or infectious processes.

Question 281

An IV drug abuser walks into the ED telling the nurse, “I am sick.” The client
looks feverish with flushed, moist skin; dehydrated with dry lips/mucous
membranes; and fatigued. The assessment reveals a loud murmur. An
echocardiogram was ordered that shows a large vegetation growing on the client’s
mitral valve. The client is admitted to ICU. The nurse will be assessing this client for
which possible life-threatening complication?

Answer 281

Systemic emboli, especially to brain.

Question 282

A 34-year-old man who is an intravenous drug user has presented to the
emergency department with malaise, abdominal pain, and lethargy. The health care
team wants to rule out endocarditis as a diagnosis. Staff of the department would
most realistically anticipate which set of diagnostics?

Answer 282

Echocardiogram, blood cultures, temperature

Question 283

On a routine physical exam visit, the physician mentions that he hears a new
murmur. The client gets worried and asks, “What does this mean?” The physician
responds:

Answer 283

“One of your heart valves is not opening properly. We need to do an
echocardiogram to see which valve is having problems.”

Question 284

A client has been diagnosed with mitral valve stenosis following his recovery
from rheumatic fever. Which teaching point would be most accurate to convey to
the client?

Answer 284

“Your mitral valve isn’t opening up enough for blood to flow into the part of your
heart that sends blood into circulation.”

Question 285

A nurse who works on a pediatric cardiology unit of a hospital is providing care
for an infant with a diagnosis of tetralogy of Fallot. Which pathophysiologic result
should the nurse anticipate?

Answer 285

Blood outflow into the pulmonary circulation is restricted by pulmonic valve
stenosis.

Question 286

A nurse will be providing care for a female client who has a diagnosis of heart
failure that has been characterized as being primarily right-sided. Which statement
best describes the presentation that the nurse should anticipate? The client:

Answer 286

has pitting edema to the ankles and feet bilaterally, decreased activity tolerance,
and occasional upper right quadrant pain.

Question 287

The nurse working in the ICU knows that chronic elevation of left ventricular
end-diastolic pressure will result in the client displaying which clinical
manifestation?

Answer 287

Dyspnea and crackles in bilateral lung bases.

Question 288

A 77-year-old client with a history of coronary artery disease and heart failure
has arrived in the emergency room with a rapid heart rate and feeling of
“impending doom.” Based on pathophysiologic principles, the nurse knows the rapid
heart rate could:

Answer 288

be a result of catecholamines released from SNS, which could increase the
myocardial oxygen demand.

Question 289

Mr. V. has been admitted for exacerbation of his chronic heart failure (HF).
When the nurse walks into his room, he is sitting on the edge of the bed, gasping
for air, and his lips are dusty blue. Vital signs reveal heart rate 112, respiratory rate
36, and pulse oximeter reading of 81%. He starts coughing up frothy, pink sputum.
The priority intervention is:

Answer 289

Call for emergency assistance utilizing hospital protocol.

Question 290

A nurse is administering morning medications to a number of clients on a
medical unit. Which medication regimen is most suggestive that the client has a
diagnosis of heart failure?

Answer 290

Diuretic, ACE inhibitor, beta-blocker

Question 291

Emergency medical technicians respond to a call to find an 80-year-old man who is showing signs and symptoms of severe shock. Which phenomenon is most
likely taking place?

Answer 291

The man’s alpha- and beta-adrenergic receptors have been activated, resulting
in vasoconstriction and increased heart rate.

Question 292

A 22-year-old male is experiencing hypovolemic shock following a fight in which
his carotid artery was cut with a broken bottle. What immediate treatments are
most likely to benefit the man?

Answer 292

Infusion of normal saline or Ringer’s lactate to maintain the vascular space.

Question 293

A 30-year-old woman presents at a hospital after fainting at a memorial service
and she is diagnosed as being in neurogenic shock. Which signs/symptoms is she
most likely to display?

Answer 293

Dry and warm skin

Question 294

All of the following interventions are ordered STAT for a client stung by a bee
who is experiencing severe respiratory distress and faintness. Which priority
intervention will the nurse administer first?

Answer 294

Epinephrine

Question 295

A client in the intensive care unit has a blood pressure of 87/39 mm Hg and has
warm, flushed skin accompanying his sudden decline in level of consciousness. The
client also has arterial and venous dilatation and a decrease in systemic vascular
resistance. What is this client’s most likely diagnosis?

Answer 295

Septic shock

Question 296

A 3-year-old child with right-sided heart failure has been admitted for
worsening of their condition. Which assessment would be considered one of the
earliest signs of systemic venous congestion in this toddler?

Answer 296

Enlargement of liver

Question 297

A pediatrician is teaching a group of medical students about some of the
particularities of heart failure in children as compared with older adults. Which
statement by the physician best captures an aspect of these differences?

Answer 297

“You’ll find that, in pediatric clients, pulmonary edema is more often interstitial
rather than alveolar, so you often won’t hear crackles.”

Question 298

A client has undergone insertion of a drug-eluting stent. Based on clinical trials,
which medications, when taken in combination, have been found effective to
prevent restenosis if taken for up to 1 year after the procedure? Select all that
apply.

Answer 298

• aspirin

- clopidogrel

Question 299

A physician has ordered the measurement of a cardiac client’s electrolyte levels
as part of the client’s morning blood work. Which statement best captures the
importance of potassium in the normal electrical function of the client’s heart?

Answer 299

Potassium is central to establishing and maintaining the resting membrane
potential of cardiac muscle cells.

Question 300

Which statement describes phase 4 of the action potential of cells in the
sinoatrial (SA) node?

Answer 300

A slow depolarization occurs when Na+ is transported out of the cell and K+
moves back in, resulting in resting membrane potential.

Question 301

An ECG technician is placing leads on a client who has presented to the
emergency department with a sudden onset of chest pain. The technician would
recognize which fact about the placement of leads and the achievement of a
clinically accurate ECG?

Answer 301

The chest leads measure electrical activity on the horizontal plane, while limb
leads measure it on the vertical plane.

Question 302

The cardiologist just informed a client that he has a reentry circuit in the
electrical conduction system in his heart. This dysrhythmia is called Wolff-
Parkinson-White (WPW) syndrome. After the physician has left the room, the client asks the nurse to explain this. Which statement most accurately describes what is happening?

Answer 302

“There is an extra, abnormal electrical pathway in the heart that leads to
impulses traveling around the heart very quickly, in a circular pattern, causing the heart to beat too fast.”

Question 303

A 6-year-old boy has been brought to the emergency department by his mother
complaining his heart rate is “so fast I couldn’t even count it.” The child was
determined to be in atrial flutter via ECG. Which points should underlie an
explanation of this event to the mother?

Answer 303

The child is experiencing a reentry rhythm in his right atrium.

Question 304

A medical student is working with a 61-year-old male client in the hospital who has presented with a new onset of atrial fibrillation. Which course of treatment will
the student most likely expect the attending physician to initiate?

Answer 304

Anticoagulants and beta-blockers to control rate

Question 305

A 63-year-old male client has been diagnosed with a bundle branch block. How
will this client’s care team most likely expect his condition to be expressed
diagnostically?

Answer 305

His ECG will show an inordinately wide QRS complex because impulses are
bypassing normal conduction tissue.

Question 306

Which client should the nurse be assessing for long QT syndrome?

Answer 306

32-year-old male admitted for cocaine overdose with long history of illicit drug
abuse

Question 307

A number of clients on an acute cardiac care unit of a hospital have diagnoses of impaired cardiac conduction. Which client is most deserving of immediate medical
attention?

Answer 307

A 69-year-old woman who has entered ventricular fibrillation

Question 308

A 71-year-old man is slated for pacemaker insertion for treatment of a third-
degree AV block. The man’s nurse has been educating him around his diagnosis and

treatment and answering the numerous questions he has about his health problem.
Which teaching point should the nurse include in this client teaching?

Answer 308

“The root problem is that the top chambers of your heart and the bottom
chambers of your heart aren’t coordinating to pump blood efficiently.”

Question 309

A 72-year-old woman with a recent onset of syncopal episodes has been
referred to a cardiologist by her family physician. As part of the client’s diagnostic
workup, the cardiologist has ordered her to wear a Holter monitor for 24 hours.
Which statement best captures an aspect of Holter monitoring?

Answer 309

Accurate interpretation of the results requires correlating the findings with activity that the woman was doing at the time of recording.

Question 310

A 31-year-old woman with a congenital heart defect reports episodes of
lightheadedness and syncope, with occasional palpitations. A resting
electrocardiogram reveals sinus bradycardia and she is suspected to have sick sinus
syndrome. Which diagnostic method is the best choice to investigate the suspicion?

Answer 310

Holter monitoring

Question 311

When ablation therapy is added to an electrophysiologic test, the nurse should
be assessing the client for which complication of ablation that may occur
postprocedure?

Answer 311

Sudden onset of dyspnea, tachypnea, and chest pain that is worsened by
breathing.

Question 312

A nurse who provides care on a geriatric subacute medicine unit has noted that a large number of clients receive beta-adrenergic blocking medications (beta-
blockers). Which statement best conveys an aspect of the use of beta-blockers?

Answer 312

They can be used to treat supraventricular dysrhythmias and decrease
automaticity by depressing phase 4 of the action potential.

Question 313

A client who is experiencing some angina associated with atrial tachycardia has
been placed on verapamil, a calcium-channel blocker. Knowing that this medication
blocks the slow calcium channels, thereby depressing phase 4 and lengthening
phases 1 and 2 action potential, the nurse should assess this client for which
adverse reaction?

Answer 313

Bradycardia

Question 314

A client is believed to be in cardiac arrest and defibrillation is being performed.
What is an aspect of the rationale and physiology of defibrillation treatment?

Answer 314

The goal is to depolarize the entire heart during the passage of current.

Question 315

A client with a new automatic implantable cardioverter-defibrillator (AICD) asks
the nurse what happens if he goes into that deadly heart rhythm again. The nurse
will base her response knowing the AICD will:

Answer 315

respond to ventricular tachydysrhythmia by delivering a shock within 10-20
seconds of its onset.

Question 316

Assuming that they have not responded to drug therapy, which client is likely to be the best candidate for surgical cardiac ablation?

Answer 316

A 46-year-old man with unstable angina and a history of myocardial infarction
who is found to have long Q-T syndrome and episodes of frequent ventricular
dysrhythmias

Question 317

The nurse is caring for a client who develops a paroxysmal supraventricular
tachycardia. Which medications should the nurse prepare to administer? Select all
that apply.

Answer 317

• Adenosine
• Diltiazem (Class IV)
• Metoprolol (Class II)

Question 318

The nurse is prioritizing clients based on the risk for falls. Which client would be
at greatest risk for sudden falls and related injury? The client:

Answer 318

with uncontrolled sick sinus syndrome.

Question 319

The nurse has completed an automated blood pressure and pulse reading on a
client with persistent atrial fibrillation. The client’s baseline values are blood
pressure 130/85 mm Hg and heart rate of 80 bpm and irregular. The current result
is blood pressure is 98/47 mm Hg, the heart rate is 77 bpm, and the client denies
feeling differently. What is the nurse’s priority action?

Answer 319

Perform a manual blood pressure and apical heart rate reading.

Question 320

A client arrives reporting feeling “faint and dizzy” when standing and on
telemetry the client’s heart rate is 25 beats/min. On electrocardiogram, the rate is fairly consistent and lacks the normal “P” wave and the QRS is wider than normal.
This client’s heart rhythm is being controlled by which cardiac structure?

Answer 320

Purkinje system

Question 321

Which client on the nurse’s team will be given priority for cardiac monitoring
based on medical history?

Answer 321

Adolescent client resuscitated following drowning in a swimming pool that
required CPR at the scene

Question 322

During a sleep study in the laboratory, the health care provider notices one
client has a prolonged period of asystole. Which term will the nurse use to describe
this event in the documentation?

Answer 322

Sinus arrest

Question 323

A nurse is caring for four clients with the diagnosis of atrial fibrillation. Which
client will likely require cardioversion related to complications?

Answer 323

Newly diagnosed client with atrial fibrillation and has developed pulmonary
edema