Nursing III Exam III
Chapter 65
The nurse is caring for a client who has sustained multiple injuries from a motor vehicle
accident. The nurse realizes
... [Show More] that the client will have a release of stress hormones that are
useful for all of the following EXCEPT:
Preventing ingestion of food
The nurse is planning care for a client diagnosed with acute respiratory distress syndrome
(ARDS)? Which of the following is not included in the management of this disorder?
Promoting urine output
The nurse, caring for a client diagnosed with shock, realizes that the stage in which the body
attempts to remedy the problem by initiating the homeostatic mechanism would be?
Compensatory stage
A client experiences a bee sting, complains of difficulty breathing, and shows sign of hypoxia
and hypotension. The nurse realizes these are signs of anaphylactic shock, and she should do
which of the following first?
Give epinephrine intravenously or via endotracheal tube
A client is diagnosed with failure of the left ventricle to provide adequate delivery of oxygen to
the body tissues due to a weakened forward pumping function of the heart. The nurse realizes
this client is experiencing:
cardiogenic shock
To assess if the renal system in a client diagnosed with multisystem failure is functioning
properly, the nurse would expect to see urine output of:
30 mL per hour
The nurse realizes that a client, diagnosed with neurogenic shock, is at risk for developing:
deep vein thrombosis
A client is diagnosed with septic shock. The nurse realizes that the major cause of this type of
shock is:
gram-negative bacteria
A client is diagnosed with cardiogenic shock. The nurse should plan interventions to address
which of the following potential complications of this disorder?
Myocardial infarction
The nurse is concerned that a client will develop neurogenic shock when which of the following
is assessed?
Spinal cord injury at T1
The nurse is planning care for a client diagnosed with disseminated intravascular coagulation.
Which of the following should be included in this plan of care?
Avoid intramuscular injections
A firefighter is brought to the emergency department with complaints of headache, weakness,
shortness of breath, cough, and chest pain. During the assessment of this client, the nurse
realizes the client should be evaluated for:
Cyanide poisoning
The nurse is assessing a client for the acute phase of the inflammatory immune response.
Which of the following are considered cardinal signs of this response? (Select all that apply.)
Rubor
Tumor
Dolor
Calor
The nurse is determining if a client is experiencing chronic inflammation. Which of the following
are indications for this type of inflammation? (Select all that apply.)
Chronic elevation of white blood cells
Low-grade fever
Pain
Scar formation
The nurse is assessing a client for systemic inflammatory response syndrome (SIRS). Which of
the following disease processes are associated with this syndrome? (Select all that apply.)
Infection
Pancreatitis
Ischemia
Trauma
Massive transfusions
A client is experiencing symptoms associated with distributive shock. What types of shock are
included in this category? (Select all that apply.)
Neurogenic
Anaphylactic
Septic
The nurse is caring for a client experiencing hypovolemic shock. Which of the following
interventions would be appropriate for this client? (Select all that apply.)
Monitor intravenous fluid replacement
Monitor vital signs
Assess for manifestations of fluid overload
Monitor white blood cell count and hemoglobin and hematocrit levels
Position for comfort
Chapter 24
A client is learning about cholesterol. The nurse explains that the good cholesterol transports
plasma cholesterol away from plaques and to the liver for metabolism. This type of cholesterol is
called:
high-density lipoprotein
A client has a blood pressure of 124/78 mmHg and a triglyceride level of 160 mg/dL. Based on
these results, the nurse knows that the client has:
a prehypertensive blood pressure and a borderline high triglyceride level
The nurse measures a client's blood pressure to be 158/92 mmHg. The nurse recognizes that
this blood pressure is classified as:
stage I hypertension
A client is complaining of chest pain that occurs during exercise. This pain is relieved when the
client rests. The nurse realizes that this client is experiencing which type of angina?
Stable angina
A client diagnosed with stable angina is undergoing a 12-lead electrocardiogram. Which of the
following results is not expected?
ST segment elevation
A client is scheduled for a cardiac angiogram. Which of the following should the nurse instruct
the client about this diagnostic test?
Contrast dye is injected
When planning the care of a client diagnosed with stable angina, which of the following would
be considered a goal of treatment?
Decrease in ischemia and episodes of angina
A client is prescribed a beta-blocker for treatment of coronary artery disease. Which of the
following is the client most likely going to be prescribed?
Atenolol
A client tells the nurse that using nitroglycerin tablets causes a tingling sensation and a
headache. The nurse knows that this is:
Expected
A nurse is considering contraindications to fibrinolytic therapy. Which of the following patients is
an appropriate candidate for fibrinolytic therapy?
A patient with a history of a motor vehicle accident 1 year ago
A client is participating in cardiac rehabilitation and is currently engaging in supervised exercise,
counseling, and education. The nurse realizes this client is in which phase of cardiac
rehabilitation?
Phase III
A client tells the nurs..............................................................................................................CONTINUED [Show Less]