Patho
Which of the following is NOT a portal of entry?
a. Penetration
b. Airborne
c. Direct contact
d. Ingestion
e. Inhalation
b. Airborne
We are worried about stress levels of _____ because prolonged stress can suppress growth hormone, insulin-like growth factor 1, and other growth factors, because stress exerts a chronically inhibitory effect on growth.
a. older adults
b. healthcare workers
c. immunosuppressed people
d. children
c. immunosuppressed people
A nurse is planning care for a client with hypokalemia. Which interventions should be included in the plan of care? Select all that apply.
A. Ensure adequate fluid intake.
B. Implement safety measures to prevent falls
C. Encourage low fiber foods to prevent diarrhea.
D. Instruct the client about foods that contain
potassium.
E. Encourage the client to obtain assistance to
ambulate.
Answer: A,B, D, and E
Rationale:
Clients with hypokalemia will need instruction on potassium-rich foods, and all clients should maintain adequate hydration, Safety is also a priority because hypokalemia may cause muscle weakness, resulting in falls and injury. Hypokalemia is associated with constipation, not diarrhea, owing to decreased peristalsis.
The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select?
a. Roast beef, gelatin salad, green beans, and peach pie
b. Chicken salad sandwich, coleslaw, French fries, ice cream
c. Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie
d. Pork chop, creamed potatoes, corn, and coconut cake
C
Rationale: Egg yolks, wheat bread, carrots, raisins, and green, leafy vegetables are all high in iron, which is an important mineral for this client. Roast beef, cabbage, and pork chops are also high in iron, but the side dishes accompanying these choices are not
It is important that nurses include a discussion about teratogens in their prenatal discussions to help prevent deformities or abnormalities. Which substances would the nurse include as teratogens? (SATA)
a. certain medications
b. caustic chemicals
c. alcohol
d. multivitamin supplements
a., b., c.
What do we call mild, brief, and controllable periods of stress that can be perceived as positive stimuli to emotional and intellectual growth and development?
Eustress
The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which cardiovascular manifestation would the nurse expect to note?
A. Hypotension
B. Increased heart rate
C. Bounding peripheral pulses
D. Shortened QT interval on electrocardiography
(ECG)
Answer: A
Rationale:
Cardiovascular manifestations that occur with hypocalcemia include decreased heart rate, diminished peripheral pulses, and hypotension. On the electrocardiogram (ECG), the nurse would note a prolonged ST interval and a prolonged QT interval.
Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend?
a. A family vacation in the Rocky Mountains
b. Chaperoning the local boys club on a snow-skiing trip
c. Traveling by airplane for business trips
d. A bus trip to the Museum of Natural History
D
Rationale: Taking a trip to the museum is the only answer that does not pose a threat. A family vacation in the Rocky Mountains at high altitudes, cold temperatures, and airplane travel can cause sickling episodes and should be avoided
Congenital disorders refer to conditions that are present at birth. These disorders may be inherited and caused by environmental factors or maternal malnutrition. Toxic exposures have the greatest effect on development between 15 and 60 days of gestation. For the nurse to be able to conduct a complete assessment of the newly pregnant client, she should understand the significance of exposure to known human teratogens. These include(Select all that apply):
a. Infections.
b. Radiation.
c. Maternal conditions.
d. Drugs.
e. Chemicals.
A., B., C., D., E.
A disabling syndrome caused by chronic activation of the stress response as a result of experiencing a significant traumatic event.
Post Traumatic Stress Disorder (PTSD)
True or False:
The major difference between humoral and cell-mediated immunity is that humoral immunity produces antigen-specific antibodies, whereas cell-mediated immunity does not.
True
The nurse is teaching the client with polycythemia vera about prevention of complications of the disease. Which of the following statements by the client indicates a need for further teaching?
a. "I will drink 500mL of fluid or less each day."
b. "I will wear support hose when I am up."
c. "I will use an electric razor for shaving."
d. "I will eat foods low in iron.
A
Rationale: The client with polycythemia vera is at risk for thrombus formation. Hydrating the client with at least 3L of fluid per day is important in preventing clot formation, so the statement to drink less than 500mL is incorrect. Answers B, C, and D are incorrect because they all contribute to the prevention of complications. Support hose promotes venous return, the electric razor prevents bleeding due to injury, and a diet low in iron is essential to preventing further red cell formation.
The nurse is administering immunizations at a health care clinic. The nurse understands that an immunization will provide:
a. Protection from all disease
b. Innate immunity from disease
c. Natural immunity from disease
d. Artificial immunity from disease
d. artificial immunity from disease
During an assessment of a newly admitted client, the nurse notes that the client's heart rate is 110 beats/minute, his blood pressure shows orthostatic changes when he stands up, and his tongue has a sticky, paste-like coating. The client's spouse tells the nurse that he seems a little confused and unsteady on his feet. Based on these assessment findings, the nurse suspects that the client has which condition?
A. Dehydration
B. Hypokalemia
C. Fluid Overload
D. Hypernatremia
A. Dehydration
When a client is dehydrated, the heart rate increases in an attempt to maintain blood pressure. Blood pressure reflects orthostatic changes caused by the reduced blood volume, and when the client stands, he may experience dizziness because of insufficient blood flow to the brain. Alterations in mental status also may occur. The oral mucous membranes, usually moist, are dry and may be covered with a thick, pasty coating. These findings are not manifestations of the conditions noted in the other options.
Which hormone regulates the salt and water balance of the body by increasing the retention of sodium and water and the excretion of potassium by the kidneys (and to a lesser extent by the skin and intestines).
a. insulin
b. aldosterone
c. testosterone
d. TSH
b. aldosterone
Which of the following is a physiological response experienced during the exhaustion stage of general adaptation syndrome?
a) Increased mental alertness
b) Vasoconstriction
c) The initiation of neuroendocrine activity
d) Decreased blood pressure
Decreased blood pressure
Explanation: The stage of exhaustion is often accompanied by decreased blood pressure and vasodilation. Increased mental alertness and the initiation of neuroendocrine activity are associated with the alarm reaction of the GAS.
What type of immunity passed through breastfeeding from mother to infant?
a. innate immunity
b. passive immunity
c. adaptive immunity
d. active immunity
b. passive immunity
A nurse is caring for a client whose magnesium level is 3.5 mg/dL. Which assessment finding should the nurse most likely expect to note in the client based on this magnesium level?
A. Tetany
B. Twitches
C. Positive Trousseau's sign
D. Loss of deep tendon reflexes
Answer: D
Rationale:
The normal magnesium level is 1.6 to 2.6 mg/dL. A client with a magnesium level of 3.5 mg/dL is experiencing hypermagnesemia. Assessment findings include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes, respiratory insufficiency, bradycardia, and hypotension. Tetany, twitches, and a positive Trousseau's sign are seen in a client with hypomagnesemia.
A client with diarrhea for 3 days and inability to eat or drink well is brought to the emergency department (ED) by her family. She states she has been taking her diuretics for congestive heart failure (CHF). What nursing actions are indicated at this time?
SELECT ALL THAT APPLY.
A. Place the client on bed rest.
B. Evaluate the electrolyte levels.
C. Administer the ordered diuretic.
D. Assess for orthostatic hypotension
E. Initiate cardiac monitoring
A, B, D, E
Which of the following nurses is most likely to experience the greatest amount of stress related to his or her position as a nurse?
a) A graduate nurse working on a telemetry unit
b) A nurse with 1 year of experience working on an oncology unit
c) A nurse who is an editor of a nursing journal
d) A nurse with 10 years of experience working as a nurse educator
A graduate nurse working on a telemetry unit
Explanation: Stress is often greater for new graduate nurses and nurses who work in settings such as an intensive care unit and emergency care.