module 1
The nurse is providing care for a client who recently had a colon polyp removed. What information indicates the polyp is benign? Select all that apply.
A.Examined cells resemble the cells of the tissue of origin
B.Examined cells have spread to the colon from other parts of the body
C.Examined cells are poorly differentiated
D.Examined cells are lined up in an orderly fashion
E.Examined cells display contact inhibition
A, D, E
Benign cells resemble normal cells, have well-defined borders, do not metastasize, and display contact inhibition (stop growing when they touch another cell).
Malignant cells look different than their tissue of origin, are misshapen, grow on top of each other, have poorly defined borders, and will metastasize (move to another location).
The nurse is reviewing the pathophysiology of obesity and adipokines. The nurse is aware that some adipokines are “good” and others are “bad.” Which function(s) related to “good” adipokines should the nurse include? Select all that apply.
A.Protect against arteriosclerosis
B.Act as major vasoconstrictors
C.Promote the process of lipolysis
D.Enhance cellular sensitivity to insulin
E.Reduce triglyceride levels
A, D, E
Adiponectin (good adipokine) is a plasma protein that protects against the formation of arteriosclerosis. Leptin and adiponectin also enhance cellular sensitivity to insulin and reduce triglyceride levels to inhibit fat accumulation.
Bad adipokines increase vasoconstriction (which ultimately leads to hypertension). Bad adipokines also promote lipolysis, which causes the formation of free fatty acids which have negative effects on the body.
A nurse is assessing a client with hives, localized edema, and erythema to their lower left arm after a bee sting. What will the nurse monitor to identify a life-threatening progression of the reaction?
A.Watch for signs of swelling in the left upper arm
B.Observe the client’s respiratory status
C.Keep track of the client’s body temperature
D.Inspect the rash for signs of blanching
B
The client is experiencing a Type I hypersensitivity reaction to the bee sting that could progress to anaphylaxis. The nurse would monitor the client's respiratory status - looking for signs of airway swelling.
Body temperature is not indicative of an anaphylactic reaction.
Progression of the rash does not mean it is life threatening. A blanchable rash is expected in an allergic response.
The nurse is assessing a client with an electrolyte imbalance. The nurse documents a positive Trousseau’s sign. Which electrolyte imbalance does the client have?
A.Hyperkalemia
B.Hypocalcemia
C.Hyponatremia
D.Hypermagnesemia
B
Trousseau's and Chovstek's signs are positive indications of muscle excitability. Low calcium levels (hypocalcemia) cause muscles to be "twitchy".
The nurse is explaining the final pathway in the coagulation cascade. Which statement(s) about the final pathway should the nurse include? Select all that apply.
A.It converts fibrinogen to fibrin
B.Calcium and vitamin K are required for proper functioning of the coagulation cascade
C.It occurs after factor X and cofactor V combine
D.It is measured by the international normalized ratio (INR)
E.It is measured by activated partial thromboplastin time (aPTT)
A, B, C
The coagulation cascade is a sequence of coagulation factors, synthesized by the liver, that form a clot. Two different pathways can activate the coagulation cascade, the intrinsic and the extrinsic pathway, both of which end in a final common pathway that stimulates prothrombin to form thrombin and fibrinogen to form fibrin. Calcium and vitamin K are required for proper function of the total coagulation cascade, including the final pathway. The final pathway commences after factor X and cofactor V combine. The intrinisic pathway is measured by aPTT and the extrinsic pathway is measured by PT/INR. The final pathway time is not measured.
The nurse is caring for a client with paraplegia after a spinal cord injury. The muscle cells in the client’s legs are smaller in size than normal. Which term best describes the condition of the cells?
A.Dysplasia
B.Neoplasia
C.Malignant
D.Atrophy
D
Atrophy is an adaptive change by the cells - they revert to smaller size due to reduction in metabolic demand.
Dysplasia is deranged cellular growth and occurs with neoplasia (new growth) and malignant cells.
An overweight client recently diagnosed with Rheumatoid Arthritis (RA) asks the nurse about nonpharmacological treatments. Which interventions should the nurse include? Select all that apply.
A.Adequate rest
B.NSAIDs
C.Weight loss
D.Plasmapheresis
E.Art therapy
A, C, D, E
In RA, joints will be inflamed - swollen and painful. All of these are interventions to help the patient cope with the pain, but NSAIDs are a PHARMACOLOGICAL treatment.
Adequate rest, plasmapheresis (remove client's blood, remove antibodies, return blood), alternative therapies like art or music, and weight loss (especially for those weight bearing joints) are all interventions for RA.
The nurse is reviewing cell-mediated immunity with a student nurse. Which statement about T-lymphocytes by the student nurse indicates a need for further teaching?
A.“T-helper cells, called CD4 cells, are important in recognizing self versus non-self.”
B.“Regulator T-cells help suppress hypersensitivity reactions.”
C.“Cytotoxic T-cells are the messengers of our immune system.”
D.“Natural killer cells are first line defenders in destroying tumor cells.”
C
Cytotoxic T-cells should not be confused with Cytokines. Cytokines are the messengers of our immune system. Cytotoxic T-cells have the ability to destroy cells that are non-self - especially effective when self-cells are infected by parasites, viruses and protozoa.
A client with excess body fluid is given an IV diuretic. The client’s urine output does not increase. Which serum component does the nurse expect to be low?
A.Calcium
B.Angiotensin
C.Albumin
D.Glucose
C
Albumin is a large protein and is responsible for oncotic pressure - the pulling pressure to remove fluid from cells and bring it into circulation. When albumin is low/missing, hydrostatic pressure (pushing pressure from the blood stream to the cells) overtakes oncotic pressure.
The diuretic will act on the kidneys to remove fluid from circulation - but there will be little fluid in circulation if albumin is low.
The nurse is caring for a client with a decreased platelet count. Which signs or symptoms should the nurse monitor for?
A.Hypertension and dyspnea
B.Occult blood and spleen enlargement
C.Prolonged PT/INR and aPTT
D.High levels of D-dimer and jaundice
B
S/S of bleeding include ecchymoses, petechiae, purpura, epistaxis, occult blood, and enlarged spleen.
Hypertension and edema would occur with hypervolemia – low platelets would cause hypovolemia.
Prolonged PT/INR and aPTT are problems with the coagulation cascade, not platelets.
High levels of D-dimer occur with excessive clotting and jaundice is a sign of liver disease/failure.
The nurse is preparing education on ribosomes. Which statement should the nurse include?
A.“Ribosomes are the protein factories of the cell.”
B.“Ribosomes are housed in the smooth endoplasmic reticulum.”
C.“Hypoxia causes increased protein synthesis.”
D.“During DNA replication, transcription occurs in the ribosomes.”
A
Ribosomes are the protein factories. They are housed in the ROUGH (not smooth) endoplasmic reticulum inside a cell. Hypoxia DECREASES protein synthesis - we need that oxygen for lots of cell activities! TransLATION (not tranSCRIPTION) occurs in the ribosomes. Transcription occurs in the nucleus.
A client develops limited range of motion in their right shoulder after a surgical procedure. Which term does the nurse use to describe the complication of abnormal bands of internal scar tissue?
A.Contracture
B.Rupture
C.Adhesion
D.Inflammation
C
Adhesion is internal bands of scar tissue between tissues or organs. it can limit mobility to joints and may require surgery to remove.
Contracture is inflexible shrinkage of a wound where the wound pulls to the center. It can also limit mobility.
Rupture is when a wound reopens - can be a dehiscence or an evisceration (opens or opens and internal organs spill out).
Inflammation is a response to infection or injury.
The nurse is preparing discharge education for a client with Systemic Lupus Erythematosus (SLE). What information is essential for the nurse to include in the education for this client? Select all that apply.
A.Provide information on corticosteroids for treatment of chronic inflammation
B.Talk with the client about the need for a bone marrow transplant
C.Remind the client to wear protective clothing or sunscreen and avoid prolonged exposure to UV light
D.Educate the client on the importance of monitoring body temperature and reporting fever to their provider
E.Include resources for managing gastrointestinal symptoms like GERD and dysphagia
A, C, D
SLE will result is a chronic inflammatory disease process and the client will be on corticosteroids. Fever is the CLASSIC sign of an SLE exacerbation. Photosensitivity is common with SLE, and the client should know how to protect their skin.
GI involvement is not common, so education about GI disorders is not essential to the client's education. A bone marrow transplant is not a treatment for SLE - complexes usually deposit in kidneys, not bone.
The nurse is providing emergency care for a client presenting with the symptoms of an ischemic stroke. Which characteristics of the involved clotting pathway does the nurse recognize?
A.The extrinsic pathway is stimulated because of trauma.
B.Injury has occurred at the endothelial lining of a vessel.
C.Diagnostic testing will involve prothrombin time (PT) and international normalized ration (INR).
D.The intrinsic pathway does not result in converting fibrinogen to fibrin.
B
An ischemic stroke stimulates the intrinsic pathway because of tissue damage incurred at the endothelial lining of a vessel. It does not stimulate the extrinsic pathway. The intrinsic pathway clotting time is measured by aPTT, not PT/INR (which measures the clotting time on the extrinsic pathway). Both the intrinsic and extrinsic pathway meet at the final common pathway, where fibrinogen is ultimately converted to fibrin
The nurse is caring for a client with hypercoagulability and venous stasis. What other condition increases the client’s risk for a deep venous thromboembolism?
A.Venous ulcers
B.Vascular damage
C.Varicose veins
D.Venous ablation
B
Virchow's Triad, which indicates an individual’s risk for DVT, includes hypercoagulability, venous stasis, and vascular damage
Venous ulcers result from poor venous return.
Varicose veins result from damage to superficial (not deep) veins.
Venous ablation is a treatment for varicose veins.
The nurse is explaining causes of cellular injury to a community group. Which agent(s) should the nurse include, that can contribute to cellular necrosis and infarction? Select all that apply.
A.Hypoxia
B.Obesity
C.Bacteria
D.Genetic defects
E.Lacerations
A, B, C, D, E
Many things can cause cellular injury. Prolonged exposure to the injurious agent can result in infarction and necrosis (unplanned cell death).
Hypoxia - lack of oxygen - is one of the main ways our cells are damaged.
Genetic defects - if our DNA is altered, the cell is damaged
Obesity - nutritional imbalances cause cellular injury
Lacerations - physical agent - disrupts plasma membrane
Bacteria - infectious agent
A client has recently received a pneumococcal vaccination. The nurse understands that this client has obtained what type of immunity to pneumonia?
A.Artificial active immunity
B.Natural active immunity
C.Artificial passive immunity
D.Natural passive immunity
A
Artifical active immunity - pathogen is acquired artifically (vaccination) but body builds own antiboidies to it.
Natural active immunity - pathogen is acquired naturally (came in contact with someone else with pneumonia) and the body builds own antibodies to it.
Artifical passive immunity - antibodies are acquired from an artificial source (IgG infusions)
Natural passive immunity - antibodies transferred from mom to baby
The nurse is caring for a client with a sodium level of 148 mEq/L with dehydration. Which sign or symptom does the nurse monitor for in the client?
A.Tachycardia
B.Hypertension
C.Weight gain
D.Dyspnea
A
Dehydration is fluid loss - and classic signs/symptoms of dehydration are tachycardia and HYPOtension (especially on standing). Decrease urine output and poor skin turgor would also be seen with dehydration.
Fluid overload would result in hypertension, weight gain, and dyspnea. Edema would also be observed.
A client with a clotting issue asks the nurse about the difference between heparin and warfarin. Which statement(s) should the nurse include when comparing the two medications? Select all that apply.
A.Both heparin and warfarin are administered intravenously and subcutaneously.
B.Both heparin and warfarin are anticoagulant medications.
C.Both heparin and warfarin have bleeding as a side effect.
D.Both heparin and warfarin are neutralized by Vitamin K administration.
Both heparin and warfarin take the same amount of time to reach therapeutic levels
B, C
Both heparin and warfarin are anticoagulant drugs, and as such, both medications have bleeding as a side effect. Only heparin can be administered intravenously. Warfarin is administered PO. Only warfarin is neutralized by Vitamin K. Heparin is counteracted by protamine sulfate (when too therapeutic) or argatroban (when HIT). The two medications take different times to reach therapeutic levels.
The nurse is preparing to explain arterial injury to a client. Which statement(s) does the nurse include? Select all that apply.
A.“Damage to the artery’s endothelium is the first step in atherosclerosis.”
B.“Endothelial damage starts an inflammatory reaction.”
C.“Arterial damage causes the blood to flow in a laminar pattern.”
D.“Nicotine destroys artery walls and causes increased blood pressure and heart rate.”
E.“High levels of LDL cholesterol are good for the arteries and protects them from damage.”
A, B, D
A, B, and D all explain arterial injury.
Answer C is incorrect because laminar flow is what we want - that is smooth (not turbulent) blood flow. Laminar flow is not a result of arterial injury.
Answer E is incorrect because high levels of LDL (bad cholesterol) cause arterial damage. HDL (good cholesterol) is protective against arterial damage.
The nurse is preparing a presentation for older adult clients regarding the effects of physical inactivity. Which physiological effect of immobility is most harmful to this group of clients?
A.Increases constipation
B.Decreases peristaltic movement
C.Increases the risk of diverticulosis
D.Increases the risk of inflammatory bowel disease (IBD)
B
Peristaltic movement is the involuntary contraction of smooth GI muscles that cause food to move through the digestive tract. Immobility decreases peristaltic movement, which in turn increases constipation, increases the risk for diverticulosis, and increases the risk of IBD.
An increase in constipation is a concern of many older adult clients; however, this is a manifestation with multiple causes and preventative measures, not just immobility.
A nurse reviews an antibody screening and titer that reveals the presence of immunoglobulins (Igs) to the rubella virus. What does the nurse prepare to tell the client?
A.The client is at increased risk for infection.
B.The client is having a hypersensitivity reaction to the test.
C.The client needs a rubella vaccination.
D.The client has been exposed to rubella in the past.
D
An antibody screening and titer is performed to confirm adequate immune protection against a particular antigen. The screening identifies the presence of the Ig and the titer provides a measurement of the amount of Ig. Presence of an Ig indicates the client has been exposed to rubella in the past and their body has made an antibody to it.
Because of the presence of Igs to rubella, the client does not need a rubella vaccination.
An allergy test (not a titer/screen) would reveal an allergic reaction. If the client had no Igs to anything (revealed in an anergy panel), they would be at increased risk for infection.
The nurse is preparing education on fluid homeostasis. Which physiologic mechanisms that work together to maintain fluid homeostasis does the nurse include in the teaching? Select all that apply.
A.Intake and output
B.Electrolytes
C.Thirst sensation
D.Renin-angiotensin-aldosterone system
E.Edema
A, B, C, D
Intake and output, RAAS, serum electrolytes and the thirst sensation all work together to keep the body in fluid balance.
Edema is a sign that the body is out of fluid balance.
A client with hemolytic-uremic syndrome reports fever, abdominal pain, and bloody diarrhea. Which treatment does the nurse expect will be beneficial for the client?
A.Supportive care with dialysis
B.Administer antifibrinolytic agents
C.Increase dietary protein
D.Splenectomy and immuno-modulatory drugs
A
Supportive treatment for hemolytic-uremic syndrome includes plasma exchange early and dialysis as the client’s condition advances to end stage renal disease. Clients with HUS would actually require dietary protein restrictions. Antifibrinolytic agents are used for clients with von Willebrand Disease. Clients with Thrombotic Thrombocytopenic Purpura (TTP) would benefit from a splenectomy and immunomodulatory drugs.
The client’s right foot is pale, with ulcers on the tips of the toes. On assessment, the nurse notes a diminished pedal pulse and delayed capillary refill. Which treatment does the nurse expect?
A.Compression stockings when out of bed
B.Placement of an inferior vena cava filter
C.Administration of antibiotics to prevent infection
D.Elevation of the affected extremity above the level of the heart
C
Because of poor perfusion, a client with an ARTERIAL ulcer will have difficulty healing. The nurse should prepare to administer antibiotics (most likely topical) to prevent infection of the wound.
Compression is contraindicated in arterial deficiency.
An inferior vena cava filter prevents a DVT from becoming a PE.
Elevation is for venous problems, not arterial problems.