Which rationale best supports an older client's risk of complications related to a dysrhythmia? - An older
client is intolerant of decreased cardiac
... [Show More] output which may cause dizziness and falls
In an older client, cardiac output is decreased and a loss of contractility and elasticity reduces systemic
and cerebral blood flow, so dysrhythmias, such as bradycardia or tachycardia is poorly tolerated, and
increases the client's risk for syncope, falls, transient ischemic attacks, and possibly dementia.
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The nurse is assessing an older client and determines that the client's left upper eyelid droops, covering
more of the iris than the right eyelid. Which description should the nurse use to document this finding? -
Ptosis of the left eyelid
Ptosis is the term to describe an eyelid droop that covers a large portion of the iris
astigmatism -- distortion of the lens of the eye, causing decreased visual acuity.
nystagmus - eye makes uncontrolled movements; oculomotor nerve or eyelid muscle disorder that is
characterized by rapid, rhythmic movement of both eyes.
exophthalmos - protrusion of the eyeballs that occurs with hyperthyroidism
The nurse is measuring blood pressure on all four extremities of a child with coarctation of the aorta.
Which blood pressure finding should the nurse expect to obtain? - Lower in the legs than the arms
In coarctation of the aorta, a congenital constriction is found at the aorta near the ductus arteriosus
region that lies past the left subclavian arteries, which perfuses the upper extremities. the child should
have higher blood pressures in the upper extremities than in the legs.
The nurse reviews the CBC findings of an adolescent with acute myelogenous leukemia. The hemoglobin
is 13.8, hematocrit is 36.7 WBC is 8,200 and platelet count is 115,000., Based on these findings, what is
the priority nursing dx for this client's plan of care? - Risk for injury
A client with AML is at risk for anemia, neurtropenia, and thrombocytopenia. These CBC findings
indicate that the platelet count is low (Normal 250,000-400,000) which places this client at an increased
risk for injury, usually manifested as bruising or bleeding.
hemoglobin: 12-16 female
14-18 male
hematocrit: 37-47 female
42-52 male
WBC: 5,000-10,000
Platelets: 250,000-400,000
A nurse is planning to teach self-care measures to a female client about prevention of yeasts infections.
Which instructions should the nurse provide? - Avoid-tight fitting clothing do not use bubble-bath or
bath salts
A common genital tract infection in females is cadidiasis, which is an overgrowth of the normal vaginal
flora of Candida albicans that thrives in an environment that is warm and moist and perpetuated by
tight-fitting clothing, underwear, or pantyhose made of nonabsorbant materials. The client should wear
clothing that is loose fitting and absorbent, such as cotton underwear, and avoid using bubble-bath or
bath salts which further irritate sensitive genital tissue
A client with asthma receives a rx for high blood pressure during a clinic visit. Which rx should the nurse
anticipate the client to receive that is least likely to exacerbate asthma? - Metoprolol tartrate (lopressor)
The best antihypertensive agent for clients with asthma is lopressor a beta blocking agent which is also
cardioselective and less likely to cause bronchocontriction.
Which signs and symptoms are associated with arterial insufficiency? - Pallor, intermittent claudication
Pallor and intermittent claudication are signs related to stage II of PVD, which results in arterial
insufficiency. Arterial insufficiency causes impaired perfusion resulting in hypoxic pain or intermittent
claudication (pain in legs when working out bc not enough blood flow)
Pedal edema, brown pigmentation are signs related to venous insufficiency
Blanched skin, lower extremity ulcers are not specific to arterial disease
Peripheral neuropathy may be related to complications of diabetes mellitus resulting in poor circulation
A man who was recently diagnosed with huntington's disease asks the nurse if his adolescent son should
be tested for the disease. What response is best for the nurse to provide? - Testing is needed bc there is
a 50% risk of passing the gene to each offspring
Huntingdon's disease, a progressively incapacitating, fatal neuromuscular disease, is an autosomal
dominant inherited disease that has a 50% risk of developing in each child of those who have the
disorder. The risk of autosomal dominant inheritance should be explained and emphasized.
A client with aortic valve stenosis develops HF. Which pathophysiological finding occurs in the
myocardial cells as a result of the increased cardiac workload? - Increase in size
Hypertension and incompetent or stenotic heart valves cause an increase in the workload of the heart
by increasing afterload which requires an increase in teh force of contraction to pump blood out of the
heart. Myocardial hypertrophy results bc the cells increase in surface area or size by increasing the
amount of contractile proteins, but the quantity of fibers remains constant. As myocardial hypertrophy
progresses, the heart becomes ineffective as a pump bc the ventricular wall cannot develop enough
tension to cause effective contraction, which causes myocardial irritability due to hypoxia.
While the nurse obtains a male client's history, review of systems, and physical exam, the client tells the
nurse that his breasts drain fluid secretions from the nipple. The nurse should seek further evaluation of
which endocrine gland function? - Hypothalamus and anterior pituitary
Breast fluid and milk production are induced by the presence of prolactin secreted from the anterior
pituitary gland, which is regulated by the hypothalamus' secretion of prolactin-inhibiting hormone in
both men and women. Further evaluation of the hypothalamus and the anterior pituitary gland should
provide additional information about secretions or lactation
Several hours after surgical repair of an AAA, the client develops left flank pain. the nurse determines
the client's urinary output is 20ml/hr for the past 2 hours. The nurse should conclude that these findings
support which complication? - Renal artery embolization
Postop complications of surgical repiar of AAA are related to the location of resection, graft, or stent
placement along the abdominal aorta. Emobolization of a fragment of thrombus or plaque from the
aorta into a renal artery can compromise blood flow in one of the renal arteries, resulting in renal
ischemia that precipitates unilateral flank pain.
hypovolemia can cause acute renal failure which involves both kidneys and would cause bilateral flank
pain
A client with a fractured right radius reports severe, diffuse pain that has not responded to the rx
analgesics. The pain is greater with passive movement of the limb than the active movement by the
client. The nurse recognizes that the client is most likely exhibiting symptoms of which condition? -
acute compartment syndrome
These signs are specific indications of acute compartment syndrome, and should be treated as an
emergency situation.
A client with a markedly distended bladder is dx 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 with pathophysiological cause of client's urinary tract obstruction? - Obstruction at the urinary
bladder neck
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.
The nurse is teaching a client with maple syrup urine disease MSUD, an autosomal recessive disorder,
about the inheritance pattern. Which information should the nurse provide? - Both genes of a pair must
be abnormal for the disorder to continue.
MSUD is a type of Autosomal recessive inheritance disorder in which both genes of a pair must be
abnormal for the disorder to be expressed. MSUD is not an x-linked dominant or recessive disorder or an
autosomal dominant inheritance disorder.
Which reaction should the nurse ID in a client who is responding to stimulation of the sympathetic
nervous system? - Increased heart rate
Any stressor that is perceived as threatening to homeostasis acts to stimulate the sympathetic nervous
system and manifests as a flight-or-fight response, which includes an increase in heart rate.
Pupil constriction, bronchial constriction and decreased blood pressure are responses of the
parasympathetic nervous system
A 26-y/o male client with Hodgkin's disease is scheduled to undergo radiation therapy. The client
expresses concern about the effect of radiation on his ability to have children. What information should
the nurse provide? - Permanent sterility occurs in male clients who receive radiation
Low sperm count and loss of motility are seen in males with Hodgkin's disease before any therapy.
Radiotherapy often results in permanent aspermia, or sterility.
The nurse is assessing a client with a ruptured small bowel and determines that the client has a
temperature of 102.8. Which assessment finding provides the earliest indication that the client is
experiencing septic shock? - Hyperpnea--increased depth of respirations
The interrelated pathophysiologic changes associated with the hypermetabolic state of sepsis and septic
shock produce a pathologic imbalance between cellular oxygen demand, supply, and consumption.
Bilateral crackles, mucus production, and weak peripheral pulses are signs of advanced shock
When observing a client for symptoms of a large bowel obstruction, the nurse should assess for which
finding? - Distention of the lower abdomen
Among findings characteristic of a large bowel obstruction is the distention of the lower abdomen
Nausea with profuse vomiting, fluid and electrolyte imbalance, and upper abdominal discomfort are
signs of small bowel obstruction
What histologic finding in an affected area of the body would suggest the presence of chronic
inflammation? - Increase in monocytes and macrophages
A predominance of monocytes and macrophages in an inflamed area indicates the start of a chronic
infection. Macrophages are responsible for "cleaning up" the healing wound through phagocytic and
debridement actions, and monocytes assist in the healing of the wound after neutrophils have entered
the area.
Neutrophils arrive during the acute stage of inflammation rather than the later, chronic stage
The nurse is caring for a client with syndrome of inappropriate ADH, which is manifested by which
symptoms? - loss of thirst, weight gain
SIADH=too much ADH--water retention--not peeing--hyponatremia --increase in fluid volume --
increased sodium loss in urine
SIADH occurs when the posterior pituitary gland releases too much ADH, causing water retention, a
urine output of less than 20ml/hr, and dilutional hyponatriemia. Other indications of SIADH are loss of
thirst, weight gain, irritability, muscle weakness, and decreased LOC.
SIADH leads to hyponatremia
A mother is crying as she holds and rock her child with tetanus who is having muscular spasms and
crying. After administering diazepam (Valium) to the child, what action should the nurse implement? -
Lay the child down and ask the mother to stay near the child in the crib.
Controlling environmental stimulation such as noise, light, or tactile stimuli helps reduce CNS irritability
related to acute tentanus. The mother should be instructed to minimize handling of the child during
episodes of muscle spasticity and to stay calmly near the child. The mother's presence with the child
provides security and support.
A middle-aged male client asks the nurse what findings from his digital rectal exam prompted the
healthcare provider to rx a repeat digital serum prostatic surface antigen level. What information should
the nurse provide? - Stony, irregular nodules palpated on the prostate should be further evaluated.
PSA levels are rx to screen for prostatic cancer which is often detected by DRE and manifested as small,
hard, or stony, irregularly shaped nodules on the surface of the prostate.
A client is brought to the ER after snow-skiing accident. Which intervention is most important for the
nurse to implement? - Review the EKG tracing.
Airway, breathing, and circulation are priorities in client assessment and treatment. Continuous cardiac
monitoring is indicated bc hypothermic clients have an increased risk for dysrhythmias.
Which client is at highest risk for chronic kidney disease secondary to diabetes mellitus? - Type I DM and
retinopathy and mild vision loss
Diabetic retinopathy and nephropathy are related to prolonged hyperglycemia and hypertension which
damage the microvasculature of the eyes and kidneys, so a client with Type I DM and retinopathy is
most likely to develop nephropathy and CKD.
A1c = less than 7% ideal
After talking with the HCP, a male client continues to have questions about the results of prostatic
surface antigen screening test and asks the nurse how the PSA levels become elevated. the nurse should
explain which pathophysiological mechanism? - As prostate gland enlarges, its cells contribute more PSA
in the circulating blood.
PSA is a glycoprotein found in prostatic epithelial cells, and elevations are used as specific tumor
markers. Elevations in PSA are related to gland volume, i.e., benign prostatic hypertrophy, prostatitis,
and cancer of the prostate, indicating (tumor) cell load. PSA levels are also used to monitor response to
therapy
a client is admitted to the ED with a tension pneumothorax. Which assessment should the nurse expect
to ID? - a deviation of the trachea toward the side opposite the pneumothorax [Show Less]