The nurse is assessing a client admitted from the emergency room with
gastrointestinal bleeding related to peptic ulcer disease (PUD).
... [Show More] Which
physiological factors can produce ulceration? (Select all that apply.)
A) Vagal stimulation.
B) An increased level of stress.
C) Decreased duodenal inhibition.
D) Hypersecretion of hydrochloric acid.
E) An increased number of parietal cells. - Correct selections are (A, C, D, and E).
Hypersecretion of gastric juices (D) and an increased number of parietal cells (E)
that stimulate secretion are most often the causes of ulceration. Vagal stimulation
(A) and decreased duodenal inhibition (C) also increase the secretion of caustic
fluids. An increased stress level is not physiologic and is not a direct cause of
ulceration (B).
The healthcare provider prescribes high-protein, high-fat, low-carbohydrate diet
with limited fluids during meals for a client recovering from gastric surgery. The
client asks the nurse what the purpose is for this type of diet. Which rationale
should be included in the nurse's explanation to this client?
A) It is quickly digested.
B) It does not cause diarrhea.
C) It does not dilate the stomach.
D) It is slow to leave the stomach. - This type of diet is slowly digested and is
slow to leave the stomach (D). Because of its density from proteins and fats, and
the reduction of fluids with the meal, the possibility of dumping syndrome is
reduced. (A, B, and C) are incorrect rationales.
Which preexisting diagnosis places a client at greatest risk of developing superior
vena cava syndrome?A) Carotid stenosis.
B) Steatosis hepatitis.
C) Metastatic cancer.
D) Clavicular fracture. - Superior vena cava syndrome occurs when the superior
vena cava (SVC) is compressed by outside structures, such as a growing tumor that
impedes the return blood flow to the heart. Superior vena cava syndrome is likely
to occur with metastatic cancer (C) from a primary tumor in the upper lobe of the
right lung that compresses the superior vena cava. (A, B, and D) do not result in
SVC syndrome.
The nurse should explain to a client with lung cancer that pleurodesis is performed
to achieve which expected outcome?
A) Prevent the formation of effusion fluid.
B) Remove fluid from the intrapleural space.
C) Debulk tumor to maintain patency of air passages.
D) Relieve empyema after pneumonectomy. - Instillation of a sclerosing agent to
create pleurodesis (adherence of the parietal and visceral pleura) is aimed at
preventing the formation of pleural effusion fluid (A). (B) refers to thoracentesis.
(C) is achieved by surgical resection. (D) is treated by closed-chest drainage.
A client with a markedly distended bladder is diagnosed with hydronephrosis and
left hydroureter after an IV pyelogram. The nurse catheterizes the client and
obtains a residual urine volume of 1650 ml. This finding supports which
pathophysiological cause of the client's urinary tract obstruction?
A) Obstruction at the urinary bladder neck.
Feedback: CORRECT
B) Ureteral calculi obstruction.
Feedback: INCORRECTC) Ureteropelvic junction stricture.
Feedback: INCORRECT
D) Partial post-renal obstruction due to ureteral stricture. - Hydroureter (dilation of
the renal pelvis), vesicoureteral reflux (backward movement of urine from the
lower to upper urinary tracts), and hydronephrosis (dilation or enlargement of the
renal pelvis and calyces) result from post-renal obstruction which can consequently
result in chronic pyelonephritis and renal atrophy. Ascending urinary reflux occurs
when normal ureteral peristaltic pressure is met with an increase in urinary
pressure occurring during bladder filling if the urinary bladder neck is obstructed
(A). A large residual urine does not occur with (B, C, and D) because the urine can
not get to the bladder.
A client is admitted to the hospital with a traumatic brain injury after his head
violently struck a brick wall during a gang fight. Which finding is most important
for the nurse to assess further?
A) A scalp laceration oozing blood.
B) Serosanguineous nasal drainage.
C) Headache rated 10 on a 0-10 scale.
D) Dizziness, nausea and transient confusion. - Any nasal discharge should be
evaluated (B) to determine the presence of cerebral spinal fluid which indicates a
tear in the dura making the client susceptible to meningitis. The scalp is highly
vascular and results in blood oozing from wounds (A). Pain is expected and can be
treated after further assessment of the presence of nasal discharge (C). Dizziness,
nausea, and transient confusion (D) are expected manifestations following a
traumatic brain injury and need ongoing monitoring, but (B) is most important.
A male client with sickle cell anemia, who has been hospitalized for another health
problem, tells the nurse he has had an erection for over 4 hours. What action
should the nurse implement first?A) Notify the client's healthcare provider.
Feedback: CORRECT
B) Document the finding in the client record.
Feedback: INCORRECT
C) Prepare a warm enema solution for rectal instillation.
Feedback: INCORRECT
D) Obtain a large bore needle for aspiration of the corpora cavernosa. - Priapism, a
urologic emergency, is common during sickle cell crisis due to sickle cells
clogging the microcirculation in the penis, causing a reduction of blood flow and
oxygenation to the penis, so the healthcare provider should be notified immediately
(A). Documentation (B) is not the first action that should be taken. Treatment may
consist of noninvasive measures such as applying ice to the penis, instilling a warm
solution enema to increase outflow in the corpora cavernosa (C) and giving pain
medications, but (A) has priority. If noninvasive measures do not work, (D) is
implemented by the healthcare provider. [Show Less]