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 nurse that he ingests an NSAID when the angina pain gets really bad, and it eliminates the pain. The nurse suspects the client is experiencing:
Musculoskeletal pain
A client is prescribed nicotinic acid as part of treatment for coronary artery disease. Which of the following should the nurse instruct the client regarding this medication?
Ingest an aspirin 30 minutes before taking the medication and after eating
The nurse is assessing the pain of a client experiencing angina. Which of the following should be included in this assessment? (Select all that apply.)
Precipitating event Quality
Radiation Severity Timing
A client is at risk for coronary artery disease. Which of the following should the nurse instruct as modifiable risk factors for this health condition? (Select all that apply.)
Alcohol consumption Diabetes mellitus Low daily fruit intake Psychosocial index
A client is diagnosed with angina after describing the type of pain she experiences. Which of the following are characteristics of anginal pain? (Select all that apply.)
Pressure Heavy Squeezing
Demonstrates a clenched fist over the sternum
A client is experiencing a sudden onset of chest pain. Which of the following will the nurse do to manage this chest pain?
Administer intravenous morphine as prescribed Provide oxygen
Administer nitroglycerin as prescribed Administer aspirin as prescribed
Which of the following will the nurse instruct a client being discharged to home after experiencing an acute myocardial infarction? (Select all that apply.)
Understand cardiac condition How to manage chest pain Activity level
Medications Risk factors
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