Chapter 1: The Cell in Health and Illness
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. Which statement regarding the sodium-potassium pump is correct?
1. The cell’s plasma membrane is more soluble to sodium ions than potassium ions.
2. The concentration of sodium ions should be higher inside the cell compartment.
3. The concentration of potassium ions should be higher outside the cell compartment.
4. The active transport involves pumping out three sodium ions and pumping in two
potassium ions.
2. What is the process in which glucose is used to create energy?
1. Autolysis
2. Glycolysis
3. Heterolysis
4. None of the above
3. How many adenosine triphosphates (ATPs) are produced in aerobic energy metabolism?
1. 2
2. 3
3. 34
4. None of the above
4. Which cell organelles are believed to have once been self-sustaining and independent?
1. Ribosomes
2. Mitochondria
3. Ribonucleic acid
4. Deoxyribonucleic acid
5. Why is more energy produced when a person is exercising?
1. There is an increase in the synthesis of protein.
2. There is an increase in the production of pyruvic acid in the cells.
3. There is an increase in the conversion of pyruvic acid to lactic acid.
4. There is an increase in the production of mitochondria in the muscle cells.
6. When does ribosomal protein synthesis cease?
1. During endoplasmic reticulum (ER) stress
2. During the synthesis of ATP
3. During severe hypoxic state
4. During the processing of prohormone
7. The cellular organelle responsible for propelling mucous and inhaled debris out of the lungs is
1. cilia.
2. microfilament.
3. secretory vesicle.
4. endoplasmic reticulum.
8. Which are the key proteins in the contractile units of the muscle cells?
1. Actin and myosin
2. Myosin and tubulin
3. Tubulin and actin
4. None of the above
9. Which deficiency causes Tay-Sach’s disease?
1. Proteasome
2. Peroxisome
3. Macrophage
4. Lysosomal enzymes
10. Adrenoleukodystrophy is characterized by
1. Accumulation of ganglioside.
2. Cessation of ribosomal protein synthesis.
3. Acceleration of cellular proteasome activity.
4. Accumulation of long chain fatty acid s in the nervous system.
11. Which statement regarding endoplasmic reticulum (ER) stress is correct?
1. During ER stress, proteins are rapidly degraded.
2. During ER stress, lipids cannot travel to their proper intracellular locations.
3. During ER stress, accumulation of long chain fatty acids occurs in the nervous system.
4. During ER stress, accumulation of non-degraded substances occurs in the cells.
12. Which is referred to as the protein factory of the cell?
1. Ribosome
2. Mitochondria
3. Golgi apparatus
4. Endoplasmic reticulum
13. Which acts as a blue print for the construction of proteins?
1. Transfer RNA
2. Ribosomal RNA
3. Messenger RNA
4. Mitochondrial DNA
14. A hiker experiences muscle pain and acidosis as he or she ascends a mountain during a long, steep climb.
What is the reason for these symptoms?
1. Cellular hypoxia
2. Autolysis
3. Heterolysis
4. Cellular edema
15. Which factor provides DNA the unique molecular ability to replicate?
1. The precise pairing of the nitrogenous bases
2. The presence of pyrimidines bases
3. The presence of nucleotides
4. The nitrogenous base and phosphate bond
16. How many nitrogenous bases compose a single codon?
1. 2
2. 3
3. 4
4. None of the above
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17. The DNA is a polymer of
1. Nucleotides.
2. Amino acids.
3. Fatty acids.
4. Phosphates.
18. What is the function of ribosomal ribonucleic acid during protein synthesis?
1. It transports genetic information from the DNA for protein synthesis.
2. It gathers and joins the amino acids for specific proteins.
3. It is directly involved in the formation of ribosomes.
4. None of the above.
19. Tetracycline antibiotic was given to a 30 year old client with Chlamydia infection. What is the mechanism of
action of the drug?
1. It prevents the replication of bacteria.
2. It alters the configuration of bacterial cytoplasm.
3. It interferes with the function of bacterial ribosomes.
4. It inhibits the functions of bacterial mitochondria.
20. Where does the conversion of a prohormone into a hormone take place?
1. Ribosome
2. Golgi apparatus
3. Secretory granule
4. Endoplasmic reticulum
21. Which is the cell’s “master mind”?
1. Nucleus
2. Ribosome
3. Golgi apparatus
4. Endoplasmic reticulum
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
22. Which statements regarding the microtubules are true? Select all that apply.
1. Microtubules are solid.
2. Microtubules are flexible.
3. Microtubules are composed of tubulin.
4. Microtubules are called actin filaments.
5. Microtubules comprise of centrioles and mitotic spindle.
23. Which structures are found in microtubules? Select all that apply.
1. Cilia
2. Centrioles
3. Mitotic spindle
4. Actin filaments
5. Secretory vesicles
24. What are the characteristics of ribonucleic acid? Select all that apply.
1. Presence of ribose pentose sugar
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2.
3.
4.
5.
Presence of single stranded helix
Presence of double stranded helix
Presence of deoxyribose pentose sugar
Presence of uracil and cytosine as pyrimidine base
25. Which are the purine bases found in deoxyribonucleic acid and ribonucleic acid? Select all that apply.
1. Uracil
2. Adenine
3. Guanine
4. Thymine
5. Cytosine
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Chapter 1: The Cell in Health and Illness
Answer Section
MULTIPLE CHOICE
1. ANS: 4
Chapter: Chapter 1, The Cell in Health and Illness
Page: 4
Objective: N/A
Difficulty: Moderate
Heading: The Sodium Potassium Pump
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Cellular Regulation
1
2
3
4
Feedback
The plasma membrane of the cell is less soluble to sodium ions and more soluble to
potassium ions.
The concentration of sodium ions should be higher outside the cell compartment.
The concentration of potassium ions should be higher inside the cell compartment.
In active transport, for every three sodium ions pumped out, there are two potassium
ions pumped in.
PTS: 1
CON: Cellular Regulation
2. ANS: 2
Chapter: Chapter 1, The Cell in Health and Illness
Page: 5
Objective: N/A
Difficulty: Easy
Heading: Mitochondria
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Cellular Regulation
1
2
3
4
Feedback
Autolysis is the process in which the lysosome releases digestive enzymes to destroy
cell parts when a cell dies.
Glycolysis is the process in which glucose is used to create energy.
Heterolysis is the process in which the lysosomes digest foreign matter ingested by
macrophages.
Glycolysis is the process in which glucose is broken down and used for energy.
PTS: 1
3. ANS: 3
CON: Cellular Regulation
PRIMEXAM.COM
Chapter: Chapter 1, The Cell in Health and Illness
Page: 5
Objective: N/A
Difficulty: Easy
Heading: Mitochondria
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Cellular Regulation
1
2
3
4
Feedback
In anaerobic energy metabolism, two ATPs and pyruvic acid are produced.
In active transport, three sodium ions are pumped out. This takes place in the plasma
membrane.
The process of aerobic energy requires oxygen and provides maximum amount of
energy for cellular function. The process yields 34 ATPs.
The answer option none of the above is incorrect. Aerobic energy metabolism produces
34 ATPs.
PTS: 1
CON: Cellular Regulation
4. ANS: 2
Chapter: Chapter 1, The Cell in Health and Illness
Page: 5
Objective: N/A
Difficulty: Easy
Heading: Mitochondria
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Cellular Regulation
1
2
3
4
Feedback
Ribosomes are small, spherical shaped organelles of the ribosomal ribonucleic acid.
They have not likely evolved from self-sustaining or independent organisms.
Mitochondria are cellular organelles that have their own DNA. They are believed to
have once been independent and self-sustaining but, over the course of evolution, they
were incorporated into human cells.
Ribonucleic acid is single stranded and can travel to sites outside the nucleus, but
ribonucleic acid is not likely evolved from self-sustaining or independent organisms.
Deoxyribonucleic acid contains double stranded helical chains containing various
sequences of nucleotides. Deoxyribonucleic acid is not thought to have evolved from
self-sustaining organisms.
PTS: 1
CON: Cellular Regulation
5. ANS: 4
Chapter: Chapter 1, The Cell in Health and Illness
Page: 5
PRIMEXAM.COM
Objective: N/A
Difficulty: Moderate
Heading: Mitochondria
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Cellular Regulation
1
2
3
4
Feedback
Protein synthesis is the function of ribosomes. An increase in the synthesis of proteins
does not yield energy and is not directly related to exercise.
In aerobic energy metabolism, two adenosine triphosphate and pyruvic acid are
produced. The increase in the production of pyruvic acid does not produce more energy.
Conversion of pyruvic acid to lactic acid in cellular hypoxia is noxious to cells and does
not create energy.
Exercise stimulates an increase in the number of mitochondria formed in the muscle
cells. This process leads to the conversion of oxygen into energy.
PTS: 1
CON: Cellular Regulation
6. ANS: 3
Chapter: Chapter 1, The Cell in Health and Illness
Page: 6
Objective: N/A
Difficulty: Moderate
Heading: Ribosomes
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Cellular Regulation
1
2
3
4
Feedback
Ribosomal protein synthesis does not cease during endoplasmic reticulum stress.
ATP is synthesized in the energy metabolism. It does not interfere with protein
synthesis.
When the cells are deprived of adequate oxygen supply, the ribosomal protein synthesis
ceases.
The processing of prohormones to hormones does not cease the process of protein
synthesis.
PTS: 1
CON: Cellular Regulation
7. ANS: 1
Chapter: Chapter 1, The Cell in Health and Illness
Page: 7
Objective: N/A
Difficulty: Easy
Heading: Microtubules and Microfilaments
Integrated Processes: Nursing Process
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Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Cellular Regulation
1
2
3
4
Feedback
The cilia are responsible for propelling the mucous and inhaled debris out of the lungs
using a sweeping motion.
Microfilaments help in changing the shape of the certain cells, such as macrophages,
and also help with contraction of muscle.
Secretory vesicles store substances, such as hormones, that are secreted by cells before
they are released into the extracellular space.
The endoplasmic reticulum aids in the transport of the synthesized protein from the
ribosomes to the Golgi apparatus.
PTS: 1
CON: Cellular Regulation
8. ANS: 1
Chapter: Chapter 1, The Cell in Health and Illness
Page: 7
Objective: N/A
Difficulty: Easy
Heading: Microtubules and Microfilaments
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Cellular Regulation
1
2
3
4
Feedback
Actin and myosin are the key proteins in the contractile unit of the muscle cells.
Myosin and tubulin are not the key elements in the contractile units of the muscle cells
because tubulin is associated with microtubules formation.
Tubulin and actin are not the key proteins in the contractile units of the muscle cells.
Microtubules are hollow filaments composed of tubulin. So tubulin is associated with
microtubules formation.
The answer option none of the above is incorrect. Actin and myosin are the key proteins
in the contractile unit of the muscle cells.
PTS: 1
CON: Cellular Regulation
9. ANS: 4
Chapter: Chapter 1, The Cell in Health and Illness
Page: 6
Objective: N/A
Difficulty: Easy
Heading: Lysosomes
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Cellular Regulation
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1
2
3
4
Feedback
A deficiency of proteasome in the cell does not cause Tay-Sach’s disease. Proteasome is
an organelle, which contains digestive enzymes similar to lysosomes. Proteasomes
degrade polypeptide chains and proteins.
A deficiency of peroxisomes in the cell does not cause Tay-Sach’s disease. Peroxisomes
contain digestive enzymes such as lysosomes. Peroxisomes break down the long chain
fatty acids and free radicals.
A deficiency of macrophages in the body does not cause Tay-Sach’s disease.
Macrophage is the major defensive white blood cells of the body. Macrophages contain
a large number of lysosomes.
Lysosomes contain digestive enzymes such as lysozyme, proteases, and lipases to
degrade the ingested foreign substances and cellular debris. Tay-Sach’s disease is a rare
genetic disorder that is caused by the deficiency of lysosomal enzymes. It results
because of the buildup of lipids in the brain and spinal cord.
PTS: 1
CON: Cellular Regulation
10. ANS: 4
Chapter: Chapter 1, The Cell in Health and Illness
Page: 6
Objective: N/A
Difficulty: Easy
Heading: Proteasomes and Peroxisomes
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Cellular Regulation
1
2
3
4
Feedback
The deficiency of lysosomal enzymes causes the accumulation of ganglioside in the
central nervous system. Tay-Sach’s disease is characterized by the accumulation of
ganglioside in the central nervous system.
Ribosomes are responsible for the synthesis of cellular proteins. In severe hypoxic
states ribosomal protein synthesis ceases, resulting in decreased synthesis of protein.
Cachexia or wasting of body mass is associated with accelerated proteasome activity. It
is often seen in conditions such as cancer.
Adrenoleukodystrophy is a disorder associated with the dysfunction of the
peroxisomes. The disease is characterized by the accumulation of long chain fatty acids
in the nervous system. The disease causes the deterioration of the nervous system and
eventually leads to death.
PTS: 1
CON: Cellular Regulation
11. ANS: 1
Chapter: Chapter 1, The Cell in Health and Illness
Page: 6
Objective: N/A
Difficulty: Moderate
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Heading: Endoplasmic Reticulum
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Cellular Regulation
1
2
3
4
Feedback
Proteins are rapidly degraded during ER stress.
Proteins cannot travel to their exact intracellular locations during ER stress.
Accumulation of long chain fatty acids in the nervous system is not associated with ER
stress.
Accumulation of non-degraded substances in the cells occurs because of the lack of
lysosomal enzymes, but not as a result of ER stress.
PTS: 1
CON: Cellular Regulation
12. ANS: 1
Chapter: Chapter 1, The Cell in Health and Illness
Page: 6
Objective: N/A
Difficulty: Easy
Heading: Ribosomes
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Cellular Regulation
1
2
3
4
Feedback
Ribosomes are known as the protein factories of the cell. Different types of cells
produce different types of proteins. For example, the ribosomes in thyroid cells
manufacture proteins that build thyroxine.
Mitochondria are known as the power house of the cell. Mitochondria produce the
energy that is required by the cell for performing various functions.
The Golgi apparatus is not the protein factory of the cell. The Golgi apparatus is
responsible for processing and secreting the proteins once they are made in the
ribosomes. Hormones are stored in Golgi apparatus until they are secreted by the
glands.
The endoplasmic reticulum is a network of tubules that act as a transport system within
the cell. For example, endoplasmic reticulum helps in the transport of proteins.
PTS: 1
CON: Cellular Regulation
13. ANS: 3
Chapter: Chapter 1, The Cell in Health and Illness
Page: 6
Objective: N/A
Difficulty: Easy
Heading: Ribosomes
Integrated Processes: Nursing Process
PRIMEXAM.COM
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Cellular Regulation
1
2
3
4
Feedback
Transfer RNA (tRNA) plays an important role in the assembly of proteins.
Ribosomal RNA (rRNA) is associated with the assembly and function of ribosomal
particle.
Messenger RNA (mRNA) acts as a blueprint for the construction of proteins.
Mitochondrial DNA enables the mitochondria to reproduce on their own within the
cells when there is an increased need for ATP formation.
PTS: 1
CON: Cellular Regulation
14. ANS: 1
Chapter: Chapter 1, The Cell in Health and Illness
Page: 5
Objective: N/A
Difficulty: Difficult
Heading: Mitochondria
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Cellular Regulation
1
2
3
4
Feedback
Muscle cramping and acidosis occur when the cells are deprived of adequate oxygen
supply during energy metabolism. The oxygen level decreases slightly as the hiker
climbs up the mountain into higher altitudes.
Autolysis is the process in which lysosomes release digestive enzymes to destroy the
parts of the dead cells. This process does not cause muscle cramping and acidosis in a
hiker.
Heterolysis is the process in which the lysosomes are used to digest the foreign bodies
ingested by the macrophage. This process does not cause muscle cramping and acidosis
in a hiker.
When the plasma membrane configuration is altered because of diseases, excess fluids
enter the cell’s internal environment and cause swelling, resulting in cellular edema.
PTS: 1
CON: Cellular Regulation
15. ANS: 1
Chapter: Chapter 1, The Cell in Health and Illness
Page: 7
Objective: N/A
Difficulty: Moderate
Heading: The Nucleus
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
PRIMEXAM.COM
Concept: Cellular Regulation
1
2
3
4
Feedback
The pairing of nitrogenous bases provides the DNA with the unique molecular ability to
replicate. For example, adenine always binds with thymine.
DNA nucleotides contain nitrogenous bases that are either purines or pyrimidines.
DNA consists of long, double stranded helical chains containing variable sequences of
nucleotides. Nucleotides consist of a nitrogenous base and a phosphate group attached
to a sugar molecule. The presence of nucleotides does not provide DNA molecules the
unique ability to replicate.
Nitrogenous bases and phosphate groups are parts of the nucleotide. The presence of
nitrogenous bases and phosphate groups do not provide DNA molecules with the
unique ability to replicate.
PTS: 1
CON: Cellular Regulation
16. ANS: 2
Chapter: Chapter 1, The Cell in Health and Illness
Page: 9
Objective: N/A
Difficulty: Easy
Heading: The Nucleus
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Cellular Regulation
1
2
3
4
Feedback
A codon contains three nitrogenous bases instead of just two.
Three nitrogenous bases form a codon. Codons are interpreted by the ribosomes during
protein synthesis to form specific proteins to meet the cell’s need.
A codon is not made of three nitrogenous bases instead of four.
The option, none of the above is incorrect because a codon is made of three nitrogenous
bases.
PTS: 1
CON: Cellular Regulation
17. ANS: 1
Chapter: Chapter 1, The Cell in Health and Illness
Page: 7
Objective: N/A
Difficulty: Easy
Heading: The Nucleus
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Cellular Regulation
Feedback
PRIMEXAM.COM
1
2
3
4
The DNA is a polymer of nucleotides.
The DNA is not a polymer of amino acids.
The DNA is not a polymer of fatty acids
The DNA is not a polymer of phosphate.
PTS: 1
CON: Cellular Regulation
18. ANS: 3
Chapter: Chapter 1, The Cell in Health and Illness
Page: 6
Objective: N/A
Difficulty: Easy
Heading: Ribosomes
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Cellular Regulation
1
2
3
4
Feedback
Messenger RNA, not ribosomal RNA, transports the message from the DNA to the
ribosomes for protein synthesis.
Transfer RNA, not ribosomal RMA, gathers and joins the exact amino acids that will
form the protein designated by the messenger RNA.
The r-RNA is involved in the formation of ribosomes.
The answer option is incorrect because ribosomal RNA is involved in the formation of
ribosomes.
PTS: 1
CON: Cellular Regulation
19. ANS: 3
Chapter: Chapter 1, The Cell in Health and Illness
Page: 7
Objective: N/A
Difficulty: Moderate
Heading: Ribosomes
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Cellular Regulation
1
2
3
4
Feedback
Tetracycline antibiotic does not prevent the replication of bacteria.
Tetracycline antibiotic does not alter the configuration of bacterial cytoplasm.
Tetracycline interferes with the functions of bacterial ribosomes. It inhibits bacterial
protein synthesis.
Tetracycline antibiotic does not interfere with functions of bacterial mitochondria.
PTS: 1
20. ANS: 2
CON: Cellular Regulation
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Chapter: Chapter 1, The Cell in Health and Illness
Page: 7
Objective: N/A
Difficulty: Easy
Heading: Golgi Apparatus
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Cellular Regulation
1
2
3
4
Feedback
Protein is initially manufactured in the ribosome. Protein is referred to as preprohormone, which consists of a single peptide.
The conversion of prohormone into hormone takes place in the Golgi apparatus. The
prohormone is processed and then converted into the actual hormone. The actual
hormone is secreted by the endocrine gland’s cells.
The secretory granule is present in the Golgi apparatus. The completed hormone is
stored in the secretory granule.
The pre-prohormone consists of a single peptide, which directs its transfer to the
endoplasmic reticulum. The single peptide of the pre-prohormone is removed when it is
transferred from ribosome to endoplasmic reticulum.
PTS: 1
CON: Cellular Regulation
21. ANS: 1
Chapter: Chapter 1, The Cell in Health and Illness
Page: 7
Objective: N/A
Difficulty: Easy
Heading: The Nucleus
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Cellular Regulation
1
2
3
4
Feedback
The nucleus is the master mind of a cell. It consists of the body’s genetic material,
which regulates all cell structures and functions.
Ribosomes are spherical, small organelles composed of ribosomal ribonucleic acid.
They are called as the “protein factories” of the cell.
The synthesized proteins from ribosomes are transported to Golgi apparatus through
endoplasmic reticulum. Proteins are processed, packaged, and secreted by the Golgi
apparatus.
The endoplasmic reticulum is a network of tubules within the cell, which acts as a
transport system. Lipid production takes place in endoplasmic reticulum.
PTS: 1
CON: Cellular Regulation
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MULTIPLE RESPONSE
22. ANS: 3, 5
Chapter: Chapter 1, The Cell in Health and Illness
Page: 7
Objective: N/A
Difficulty: Moderate
Heading: Microtubules and Microfilaments
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Cellular Regulation
1.
2.
3.
4.
5.
Feedback
This is incorrect. Microtubules are rigid.
This is incorrect. Microtubules are stiff.
This is correct. Microtubules are composed of protein subunits called tubulin.
This is incorrect. Microfilaments are called as actin filaments.
This is correct. Microtubules comprises of cell structures involved in cell division such as
centrioles and mitotic spindle.
PTS: 1
CON: Cellular Regulation
23. ANS: 2, 3
Chapter: Chapter 1, The Cell in Health and Illness
Page: 7
Objective: N/A
Difficulty: Easy
Heading: Microtubules and Microfilaments
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Cellular Regulation
1.
2.
3.
4.
5.
Feedback
This is incorrect. Cilia are cellular projections whose movement propels substances along
the outside of the cells. Cilia contain microfilaments.
This is correct. Centriole is a structure present in the microtubules which are involved in
cell division.
This is correct. Mitotic spindle is a structure present in the microtubules, which are
involved in cell division.
This is incorrect. Microfilaments are referred to as act in filaments. They help the cell
change shape.
This is incorrect. Secretory vesicles are formed by the endoplasmic reticulum-Golgi
apparatus system. They store substances released by cells prior to their release.
PTS: 1
24. ANS: 1, 2, 5
CON: Cellular Regulation
PRIMEXAM.COM
Chapter: Chapter 1, The Cell in Health and Illness
Page: 8
Objective: N/A
Difficulty: Easy
Heading: The Nucleus
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Cellular Regulation
1.
2.
3.
4.
5.
Feedback
This is correct. The pentose sugar present in ribonucleic acid is ribose.
This is correct. Ribonucleic acid consists of a single stranded helix and can travel to sites
outside the nucleus.
This is incorrect. Double stranded helix is present in deoxyribonucleic acid.
This is incorrect. The pentose sugar present in deoxyribonucleic acid is deoxyribose.
This is correct. The pyrimidine base thymine in deoxyribonucleic acid is replaced with
uracil in ribonucleic acid.
PTS: 1
CON: Cellular Regulation
25. ANS: 2, 3
Chapter: Chapter 1, The Cell in Health and Illness
Page: 7
Objective: N/A
Difficulty: Easy
Heading: The Nucleus
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Cellular Regulation
1.
2.
3.
4.
5.
Feedback
This is incorrect. Uracil is a pyrimidine base present in ribonucleic acid.
This is correct. Adenine is a purine base present in deoxyribonucleic acid and ribonucleic
acid.
This is correct. Guanine is a purine base present in deoxyribonucleic acid and ribonucleic
acid.
This is incorrect. Thymine is a pyrimidine base present in deoxyribonucleic acid.
This is incorrect. Cytosine is a pyrimidine base present in deoxyribonucleic acid and
ribonucleic acid.
PTS: 1
CON: Cellular Regulation
PRIMEXAM.COM
Chapter 2: Cellular Injury, Adaptations, and Maladaptive Changes
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. How does oxidative stress occur?
1. In cells that undergo transient ischemia and subsequent resumption of circulation
2. When estrogen stimulation results in mitotic division of breast gland cells
3. When a blood clot that obstructs a coronary artery causes cardiac muscle ischemia
4. When a cell’s environment cannot support its metabolic requirements
2. A client is diagnosed with a condition in which the brain cells cannot withstand low oxygen delivery long
enough for cell reversible changes to happen. Identify the condition.
1. Organelle disruption
2. Hypoxia
3. Xanthelasma
4. Ischemic-reperfusion injury
3. What is the process whereby newly growing cells acquire the specialized structure and function of the cells
they replace?
1. Apoptosis
2. Differentiation
3. Oxidative phosphorylation
4. Atherosclerosis
4. What is kwashiorkor?
1. A condition seen in individuals suffering from severe protein starvation
2. A condition where blood pressure within the aorta and systemic arterial circulation is
elevated
3. A condition where prostate gland cells increase in number because of testosterone
stimulation
4. A condition that causes defective cholesterol metabolism
5. What are the unique histological findings that represent distinct disease processes?
1. Histology
2. Biopsy
3. Autopsy
4. None of the above
6. A client is diagnosed with failure of the thyroid gland due to increase in apoptotic cell death. Which condition
is the client most likely to have?
1. Xanthomas
2. Hashimoto’s thyroiditis
3. Peptic ulcer
4. Anthracosis
7. Which field involves harvesting of embryonic stem cells and performing nuclear transfer on these cells?
1. Reproductive cloning
2. Restoration with stem cells
3. Transplantation
PRIMEXAM.COM
4. Therapeutic cloning
8. A nurse observes that a client has developed a foul odor in the spots where necrosis of tissue has developed.
What organism causes the emission of this foul odor?
1. Streptococcus
2. Helicobacter pylori
3. Clostridium perfringens
4. Human papilloma virus
9. A client is diagnosed with cellular apoptosis. Which disease can this condition lead to?
1. Cancer
2. Degenerative neurological diseases
3. Necrosis
4. Infarction
10. A client is suffering from prolonged ischemia and tissue death. Which term can be used to refer to such tissue
death?
1. Gangrene
2. Infarction
3. Necrosis
4. Apoptosis
11. A client comes in with persistently uncontrolled hypertension. The nurse informs the client’s spouse that one
of the consequences of prolonged raised blood pressure is a weakened area in the wall of the cerebral artery,
located on the Circle of Willis. What is this condition known as?
1. Xanthelasma
2. Infarction
3. Berry aneurysm
4. Ischemia
12. While conducting an endoscopic examination on a client, it is found that the client has acid reflex. Which
condition is associated with the gastroesophageal reflux disease (GERD) in which cell injury is reversible?
1. Parkinson’s disease
2. Myocardial infarction
3. Barrett’s esophagus
4. Hashimoto’s thyroiditis
13. Which body part contains pluripotent stem cells?
1. Umbilical cord
2. Skeletal muscle
3. Cardiac muscle
4. None of the above
14. A client has an abnormal thickening of the lining of the uterus due to an increase in estrogen levels. How can
such a condition be reversed?
1. Restoration of blood circulation
2. Hormone therapy to counteract the effects of excessive estrogen
3. Surgical removal
4. Acid suppression treatment
15. Which organ is most susceptible to damage and death due to prolonged ischemia?
1. Brain
PRIMEXAM.COM
2. Skeletal muscles
3. Heart
4. None of the above
16. A genetically programmed cell death is a process that can destroy cells that are no longer needed. What is the
best method to do this?
1. Necrosis
2. Apoptosis
3. Infarction
4. Gangrene
17. Which is the most prevalent method to replace permanently injured tissues and organs?
1. Stem cell restoration
2. Therapeutic cloning
3. Reproductive cloning
4. Transplantation
18. Arteriosclerosis is the thickening and hardening of arterial walls. Which condition acts as an initiator of
arteriosclerosis?
1. Apoptosis
2. Endothelial cell injury
3. Necrosis
4. Infarction
19. What is the weakened area in an arterial wall called?
1. Neoplasia
2. Aneurysm
3. Hypertrophy
4. Metaplasia
20. The increase in size of a weightlifter’s muscles is due to muscular
1. Hypertrophy
2. Metaplasia
3. Atrophy
4. Dysplasia
21. A client reports an itchy, bumpy scar around an old wound that is identified as a keloid. This occurs due to the
increase in the number of cells in a tissue or organ. Which term best describes this condition?
1. Neoplasia
2. Hyperplasia
3. Dysplasia
4. Metaplasia
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
22. Which vitamins are fat-soluble? Select all that apply.
1. Vitamin A
2. Vitamin C
3. Vitamin D
PRIMEXAM.COM
4. Vitamin K
5. Vitamin B6
23. When does physiological apoptosis occur? Select all that apply.
1. During the embryonic development of the hand
2. During menopause in female adult ovaries
3. When cells die because of stressors
4. When cells have completed their function and need elimination
5. When the liver gets exposed to excessive amounts of alcohol
24. Which components of the serum level should be measured to confirm myocardial infarction? Select all that
apply.
1. Epinephrine
2. Troponin
3. Lysosomal enzyme
4. Acetylcholine
5. CPKmb
25. A client is suffering from atherosclerosis. What are directly detrimental to the client’s condition? Select all
that apply.
1. Depletion of endothelial nitric oxide
2. Helicobacter pylori infection
3. Low-density lipoprotein (LDL) deposition
4. Inflammatory changes of the endothelium
5. Acid reflux
PRIMEXAM.COM
Chapter 2: Cellular Injury, Adaptations, and Maladaptive Changes
Answer Section
MULTIPLE CHOICE
1. ANS: 1
Chapter: Chapter 2, Cellular Injury, Adaptations, and Maladaptive Changes
Page: 18
Objective: N/A
Difficulty: Moderate
Heading: Free Radical Injury
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Cellular Regulation
1
2
3
4
Feedback
Oxidative stress is a form of cell injury that occurs when free radical generation
exceeds the mechanisms of removal. Oxidative stress commonly occurs in cells that
undergo transient ischemia and subsequent resumption of circulation.
Hormonal stimulation of hyperplasia occurs in pregnancy. It occurs when estrogen
stimulation results in mitotic division of breast gland cells.
Ischemic reperfusion injury occurs when a blood clot obstructs a coronary artery and
results in cardiac muscle ischemia.
Atrophy occurs when a cell’s environment cannot support its metabolic requirements.
The smaller size of the cells allows for less metabolic demand and more efficient
functioning that is compatible with survival.
PTS: 1
CON: Cellular Regulation
2. ANS: 2
Chapter: Chapter 2, Cellular Injury, Adaptations, and Maladaptive Changes
Page: 17
Objective: N/A
Difficulty: Moderate
Heading: Hypertension Hypoxic Cell Injury
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Applying [Application]
Concept: Oxygenation
1
2
Feedback
Organelles are a number of specialized structures within a living cell. Prolonged stress
can cause irreversible cell damage resulting in organelle disruption.
Hypoxia is a condition in which the body or a part of the body is deprived of adequate
oxygen. Brain cells cannot withstand hypoxia for more than 6 minutes, whereas skeletal
muscle can tolerate hypoxia for prolonged periods.
PRIMEXAM.COM
3
4
Xanthelasma are raised skin lesions that develop because of intracellular accretion of
excess cholesterol within epithelial cells.
Ischemic-reperfusion injury is tissue damage. It occurs when the blood supply returns
to the tissue after a period of ischemia or lack of oxygen.
PTS: 1
CON: Cellular Regulation
3. ANS: 2
Chapter: Chapter 2, Cellular Injury, Adaptations, and Maladaptive Changes
Page: 15
Objective: N/A
Difficulty: Easy
Heading: Neoplasia
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Comprehension [Understanding]
Concept: Cellular Regulation
1
2
3
4
Feedback
Apoptosis is an organized process that eliminates unnecessary or damaged cells without
causing inflammation or any adverse effects on surrounding tissue.
Differentiation is the process whereby newly growing cells acquire the specialized
structure and function of the cells that are replaced.
Oxidative phosphorylation is a process through which cells generate energy in the
mitochondria.
Atherosclerosis is the change in metabolic processes associated with diabetes mellitus.
PTS: 1
CON: Cellular Regulation
4. ANS: 1
Chapter: Chapter 2, Cellular Injury, Adaptations, and Maladaptive Changes
Page: 19
Objective: N/A
Difficulty: Easy
Heading: Nutritional Imbalances
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Knowledge [Remembering]
Concept: Nutrition
1
2
3
4
Feedback
Kwashiorkor is a form of malnutrition caused by protein deficiency in the diet.
Hypertension is a condition in which blood pressure within the aorta and systemic
arterial circulation is elevated.
Benign prostatic hyperplasia is a condition in which prostate gland cells increase in
number because of testosterone stimulation.
Hypercholesterolemia is a condition that is caused by an excess of cholesterol in the
bloodstream.
PRIMEXAM.COM
PTS: 1
CON: Cellular Regulation
5. ANS: 4
Chapter: Chapter 2, Cellular Injury, Adaptations, and Maladaptive Changes
Page: 11-12
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts of Cellular Adaptations and Maladaptive Changes
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Knowledge [Remembering]
Concept: Cellular Regulation
1
2
3
4
Feedback
Histology is the microscopic study of tissues and cells, and it yields important
diagnostic information for the clinician.
Biopsy extracts a cell sample from an organ or mass of tissue to allow for histological
examination.
Autopsy is an examination of the tissues and organs of a deceased individual that
allows for a study of the cause of death.
The unique histological findings that represent distinct disease processes are referred to
as pathognomonic changes. For instance, an inflamed, craterlike breach in the
gastrointestinal mucosa is pathognomonic for peptic ulcer disease.
PTS: 1
CON: Cellular Regulation
6. ANS: 2
Chapter: Chapter 2, Cellular Injury, Adaptations, and Maladaptive Changes
Page: 22
Objective: N/A
Difficulty: Moderate
Heading: Apoptosis
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Applying [Application]
Concept: Cellular Regulation
1
2
3
4
Feedback
Xanthomas are yellow, raised skin lesions that develop due to intracellular
accumulation of excess cholesterol within epithelial cells.
Hashimoto’s thyroiditis is a common autoimmune disease that causes gradual failure of
the thyroid gland because of increased apoptotic cell death.
Peptic ulcers are caused by Helicobacter pylori, which is a bacterium that erodes the
gastric mucosa.
Anthracosis is a benign deposition of coal dust within the lungs from inhalation of
sooty air.
PTS: 1
7. ANS: 4
CON: Cellular Regulation
PRIMEXAM.COM
Chapter: Chapter 2, Cellular Injury, Adaptations, and Maladaptive Changes
Page: 24
Objective: N/A
Difficulty: Easy
Heading: Interventions to Treat Permanent Cell Injury
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Comprehension [Understanding]
Concept: Cellular Regulation
Feedback
1
Reproductive cloning is the deliberate production of genetically identical individuals
and it involves the production of a genetic duplicate of an existing organism.
2
The regeneration of the cells that are incapable of regeneration, such as brain, neuron,
and heart muscle cells, are referred to as restoration with stem cells.
3
Transplantation is the most prevalent method to replace permanently injured tissues or
organs.
4
Therapeutic cloning is a field that involves harvesting of embryonic stem cells and
performing nuclear transfer on these cells.
PTS: 1
CON: Cellular Regulation
8. ANS: 3
Chapter: Chapter 2, Cellular Injury, Adaptations, and Maladaptive Changes
Page: 22-23
Objective: N/A
Difficulty: Medium
Heading: Gangrene
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Cellular Regulation
1
2
3
4
Feedback
Streptococcus bacteria distinctly alter cells. They cause inflammation and swelling. For
example, the etiology of sore throats is usually streptococcus bacteria.
Helicobacter pylori is a bacterium that erodes the mucosal lining of the gastrointestinal
tract. It causes gastric acids to damage the stomach lining and leads to peptic ulcers.
Clostridium perfringens is an anaerobic bacterium that multiplies in exposed necrotic
tissue. This bacterium produces gas that becomes trapped in the infected tissue and
emits a distinct foul odor related to gangrene.
Human papilloma virus (HPV) is a virus that is sexually transmitted. It can cause
cancerous cell changes within the cervix.
PTS: 1
CON: Cellular Regulation
9. ANS: 1
Chapter: Chapter 2, Cellular Injury, Adaptations, and Maladaptive Changes
Page: 22
Objective: N/A
PRIMEXAM.COM
Difficulty: Moderate
Heading: Cell Degeneration and Death
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Cellular Regulation
1
2
3
4
Feedback
Certain cancers arise when cells lose the ability to program their own destruction, a
process known as apoptosis, and go on to have an abnormally prolonged life span.
These cells begin to divide uncontrollably and invade other tissues.
Degenerative neurological diseases are caused when the cells, due to dysfunctional
apoptosis, die excessively and prematurely. For example, spinal muscular atrophy
develops when nerve cells undergo increased apoptotic rates and die prematurely.
Necrosis is the death of cells in a tissue or organ through injury or disease. It is
irreversible.
Infarction is the death of tissue due to prolonged restriction of blood flow to it.
PTS: 1
CON: Cellular Regulation
10. ANS: 2
Chapter: Chapter 2, Cellular Injury, Adaptations, and Maladaptive Changes
Page: 22
Objective: N/A
Difficulty: Moderate
Heading: Cell Degeneration and Death
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Cellular Regulation
1
2
3
4
Feedback
Gangrene is a condition that occurs when tissues endure prolonged ischemia,
experience infarction and necrosis, and then are exposed to bacteria such as Clostridium
perfringens that proliferate in the decaying tissue.
Infarction is the death of tissue due to prolonged insufficient blood supply (ischemia).
Necrosis is the death of cells in a tissue or organ through injury or disease. It is
irreversible.
Apoptosis is the cell’s genetically programmed degeneration.
PTS: 1
CON: Cellular Regulation
11. ANS: 3
Chapter: Chapter 2, Cellular Injury, Adaptations, and Maladaptive Changes
Page: 20
Objective: N/A
Difficulty: Difficult
Heading: Significance of Endothelial Cell Injury
Integrated Processes: Nursing Process
PRIMEXAM.COM
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Cellular Regulation
1
2
3
4
Feedback
Xanthelasma is a yellowish deposit of cholesterol underneath the skin cells, commonly
on or around the eyelids.
Infarction is tissue death due to prolonged obstruction of blood supply to the tissue.
Berry aneurysm is a small berry-like bulge that is caused by a weakened area in the
wall of the cerebral artery at or near the Circle of Willis in the brain.
Ischemia is the lack of sufficient blood flow to tissues that leads to cell injury.
Prolonged ischemia leads to infarction or death of tissue.
PTS: 1
CON: Cellular Regulation
12. ANS: 3
Chapter: Chapter 2, Cellular Injury, Adaptations, and Maladaptive Changes
Page: 14
Objective: N/A
Difficulty: Difficult
Heading: Clinical Interventions to Reverse Cell Injury
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Cellular Regulation
1
2
3
4
Feedback
Parkinson’s disease causes gradual, progressive neurological deterioration where
specific brain cells undergo degeneration and die. It is irreversible.
Myocardial infarction is the irreversible damage caused by prolonged lack of blood
supply to the myocardial muscle.
Barrett's esophagus is a serious complication of gastroesophageal reflux disease. In
GERD, the lower esophageal squamous epithelial cells can undergo a metaplastic
change into columnar stomach-like cells. This condition develops into Barrett’s
esophagus.
Hashimoto’s thyroiditis is an autoimmune disorder in which the body’s immune system
attacks the thyroid gland. This causes cell injury that is irreversible.
PTS: 1
CON: Cellular Regulation
13. ANS: 1
Chapter: Chapter 2, Cellular Injury, Adaptations, and Maladaptive Changes
Page: 24
Objective: N/A
Difficulty: Easy
Heading: Interventions to Treat Permanent Cell Injury
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
PRIMEXAM.COM
Concept: Cellular Regulation
1
2
3
4
Feedback
Stem cells obtained from the umbilical cord during the birthing process are capable of
developing into other cell types and are, therefore, referred to as pluripotent stem cells.
Skeletal muscle stem cells are adult stem cells that are capable of generating only new
skeletal muscle tissue.
Cardiac muscle stem cells are adult stem cells that are capable of regeneration of only
the host tissue or cardiac muscle tissue.
Umbilical cord stem cells are pluripotent, which means that they are capable of
developing into any tissue in the body.
PTS: 1
CON: Cellular Regulation
14. ANS: 2
Chapter: Chapter 2, Cellular Injury, Adaptations, and Maladaptive Changes
Page: 23
Objective: N/A
Difficulty: Moderate
Heading: Clinical Interventions to Reverse Cell Injury
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Cellular Regulation
1
2
3
4
Feedback
Restoration of blood circulation has no bearing on hyperplasia of the uterine
endometrium. This is because hyperplasia of the uterine endometrium is caused by an
increase in the uterine endometrial cells brought on by excessive estrogen.
Hyperplasia of the uterine endometrium is caused by an overproduction of estrogen.
Hormone therapy to counter the effects of excessive estrogen helps reverse the
condition.
Surgical removal of the hyperplastic uterine endometrium is an irreversible treatment
option.
Acid suppression treatment can resolve the metaplasia of Barrett’s esophagus.
PTS: 1
CON: Cellular Regulation
15. ANS: 1
Chapter: Chapter 2, Cellular Injury, Adaptations, and Maladaptive Changes
Page: 22
Objective: N/A
Difficulty: Moderate
Heading: Cell Degeneration and Death
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Cellular Regulation
PRIMEXAM.COM
1
2
3
4
Feedback
The brain is the organ that is most sensitive to reduction in its blood supply. The brain
undergoes infarction and cell death within minutes.
Skeletal muscles can tolerate lack of blood circulation for a few hours.
Cardiac ischemia occurs when the heart muscle or myocardium receives insufficient
blood flow. In such condition, cell death can occur within minutes but generally not as
quickly as the brain.
The brain is the organ that is most susceptible to damage and death due to prolonged
ischemia.
PTS: 1
CON: Cellular Regulation
16. ANS: 2
Chapter: Chapter 2, Cellular Injury, Adaptations, and Maladaptive Changes
Page: 21
Objective: N/A
Difficulty: Moderate
Heading: Cell Degeneration and Death
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Cellular Regulation
1
2
3
4
Feedback
Necrosis is the death of living tissue due to ischemia, physical injury, radiation, or
chemicals. It is not reversible.
In multicellular organisms, cells that are no longer needed or are a threat to the
organism are destroyed by a programmed cell death called apoptosis. An example of
this process is when an embryonic, paddle-shaped hand forms indentations to shape the
individual fingers.
Infarction is the death of tissue as a result of continued disruption of blood supply. For
example, when there is a lack of adequate coronary artery blood supply to the
myocardial muscle, ischemic necrosis occurs.
Gangrene is a potentially life-threatening condition that can occur when tissues suffer
prolonged ischemia and undergo necrosis. Clostridium perfringens thrives on the
decaying necrotic tissue and causes gangrene.
PTS: 1
CON: Cellular Regulation
17. ANS: 4
Chapter: Chapter 2, Cellular Injury, Adaptations, and Maladaptive Changes
Page: 24
Objective: N/A
Difficulty: Easy
Heading: Interventions to Treat Permanent Cell Injury
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Cellular Regulation
PRIMEXAM.COM
1
2
3
4
Feedback
Stem cells are capable of developing into any specialized tissue and organ and are,
therefore, used to treat and regenerate injured tissues and cells. However, it is not the
most prevalent method.
Therapeutic cloning involves harvesting of embryonic stem cells and performing
nuclear transfer on these cells. With this method, it could be theoretically possible for
individuals in need of organ transplant to obtain exact tissue matches of their organs.
However, this is still a nascent technology with extensive ongoing research.
Reproductive cloning is the creation of a genetic duplicate of an existing organism.
Currently, reproductive cloning is performed among livestock and other animals like
cats, mice, rabbits, and mules.
Transplantation is the most prevalent method to replace permanently injured tissues or
organs, such as kidneys. It is a complex process involving many stages that include
solicitation of donors, harvesting of organs, matching of donor organs and recipients,
surgical implantation, and interventions to avoid organ rejection.
PTS: 1
CON: Cellular Regulation
18. ANS: 2
Chapter: Chapter 2, Cellular Injury, Adaptations, and Maladaptive Changes
Page: 20
Objective: N/A
Difficulty: Moderate
Heading: Significance of Endothelial Cell Injury
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Cellular Regulation
1
2
3
4
Feedback
Apoptosis is also known as programmed cell death. In multicellular organisms, cells
that are unwanted or a threat to the organism are eliminated through a programmed
sequence of events. Too little or too much apoptosis is dangerous.
Endothelial cell injury acts as an initiator of arteriosclerosis. The most significant
injurious agents of the endothelial cells are hypertension, diabetic hyperglycemia, free
radicals, persistent secretion of angiotensin II, and low-density lipoprotein cholesterol.
Necrosis is cell death caused by ischemia, physical injury, chemicals, or radiation,
which is irreversible and may adversely affect neighboring tissues or the organ as a
whole.
Infarction is the death of tissue due to a lack of oxygen or absence of blood supply to
tissues.
PTS: 1
CON: Cellular Regulation
19. ANS: 2
Chapter: Chapter 2, Cellular Injury, Adaptations, and Maladaptive Changes
Page: 20
Objective: N/A
PRIMEXAM.COM
Difficulty: Easy
Heading: Hypertension
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Cellular Regulation
1
2
3
4
Feedback
Neoplasia means new growth and usually refers to disorganized, uncoordinated,
uncontrolled proliferative cell growth that can be cancerous or benign.
Aneurysm is referred to as a weakened area in an arterial wall.
Hypertrophy is an increase in individual cell size, resulting in an enlargement of
functioning tissue mass.
Metaplasia is the replacement of one cell type by another cell type.
PTS: 1
CON: Cellular Regulation
20. ANS: 1
Chapter: Chapter 2, Cellular Injury, Adaptations, and Maladaptive Changes
Page: 12
Objective: N/A
Difficulty: Moderate
Heading: Basic Concepts of Cellular Adaptations and Maladaptive Changes
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Cellular Regulation
1
2
3
4
Feedback
Hypertrophy is the increase in size of an organ or tissue due to the enlargement of its
component cells. Muscle growth is due to physiological hypertrophy, which is caused
by angiogenesis.
Metaplasia is the replacement of one cell type by another cell type. It could be due to a
cell’s genetic programming because of a change in environment, or more commonly it
could be in response to chronic inflammation.
Atrophy is a wasting or decrease in size of a body organ, tissue, or part due to disease,
injury, or lack of use.
Dysplasia is abnormal cellular growth within a specific tissue, often as a result of
chronic inflammation or a precancerous condition.
PTS: 1
CON: Cellular Regulation
21. ANS: 2
Chapter: Chapter 2, Cellular Injury, Adaptations, and Maladaptive Changes
Page: 13
Objective: N/A
Difficulty: Difficult
Heading: Basic Concepts of Cellular Adaptations and Maladaptive Changes
Integrated Processes: Nursing Process
PRIMEXAM.COM
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Evaluation [Evaluating]
Concept: Critical Thinking
1
2
3
4
Feedback
Neoplasia means new growth and usually refers to disorganized, uncoordinated,
uncontrolled proliferative cell growth that can be cancerous or benign.
Hyperplasia is the increase in the number of cells in a tissue or organ, which only
occurs in tissues such as the epithelium and glandular tissue.
Dysplasia is abnormal cellular growth within a specific tissue, often as a result of
chronic inflammation or a precancerous condition.
Metaplasia is the replacement of one cell type by another cell type.
PTS: 1
CON: Critical Thinking
MULTIPLE RESPONSE
22. ANS: 1, 3, 4
Chapter: Chapter 2, Cellular Injury, Adaptations, and Maladaptive Changes
Page: 19-20
Objective: N/A
Difficulty: Easy
Heading: Nutritional Imbalances
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Knowledge [Remembering]
Concept: Cellular Regulation
1.
2.
3.
4.
5.
Feedback
This is correct. Fat-soluble vitamins are vitamins A, D, E, and K. Fat is necessary for
storage of these vitamins in the body.
This is incorrect. Individuals can counteract free radical injury through consumption of
antioxidants such as vitamin C.
This is correct. Fat-soluble vitamins are vitamins A, D, E, and K. Fat is necessary for
storage of these vitamins in the body.
This is correct. Fat-soluble vitamins are vitamins A, D, E, and K. Fat is necessary for
storage of these vitamins in the body.
This is incorrect. Individuals can counteract free radical injury through consumption of
antioxidants such as vitamin E and beta-carotene.
PTS: 1
CON: Cellular Regulation
23. ANS: 1, 2, 4
Chapter: Chapter 2, Cellular Injury, Adaptations, and Maladaptive Changes
Page: 21
Objective: N/A
Difficulty: Moderate
Heading: Apoptosis
PRIMEXAM.COM
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Cellular Regulation
1.
2.
3.
4.
5.
Feedback
This is correct. Apoptosis of select cells occurs within the paddle-shaped hand plate to
form indentations to shape the individual fingers. The apoptotic cells disintegrate in a
stepwise manner without disrupting other cells.
This is correct. Physiological apoptosis also occurs in female adult ovaries during
menopause.
This is incorrect. Cell necrosis occurs when cells die because of stressors or insults that
overwhelm the cell’s ability to survive.
This is correct. Cells such as the white blood cells undergo apoptosis when they become
exhausted after participation in immune reactions.
This is incorrect. Intracellular accumulation can occur in the liver when exposed to
excessive amounts of alcohol.
PTS: 1
CON: Cellular Regulation
24. ANS: 2, 3, 5
Chapter: Chapter 2, Cellular Injury, Adaptations, and Maladaptive Changes
Page: 22
Objective: N/A
Difficulty: Moderate
Heading: Cell Necrosis
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Cellular Regulation
1.
2.
3.
4.
5.
Feedback
This is incorrect. Blood constituents such as norepinephrine and epinephrine are produced
by the adrenal glands, and each constituent affects the vasculature’s function differently
and may have detrimental effects.
This is correct. Blood levels of CPKmb and troponin are measured to confirm myocardial
infarction.
This is correct. Blood level of the lysosomal enzyme is measured to confirm myocardial
infarction.
This is incorrect. Acetylcholineare is a vasodilating substance produced by the endothelial
cells and may have detrimental effects.
This is correct. Blood level of the lysosomal enzyme, CPKmb, is measured to confirm
myocardial infarction.
PTS: 1
CON: Cellular Regulation
25. ANS: 1, 3, 4
Chapter: Chapter 2, Cellular Injury, Adaptations, and Maladaptive Changes
Page: 21
PRIMEXAM.COM
Objective: N/A
Difficulty: Moderate
Heading: Significance of Endothelial Cell Injury
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Cellular Regulation
1.
2.
3.
4.
5.
Feedback
This is correct. Depletion of endothelial nitric oxide can impede the dilatory capacity of
arteries, thus affecting blood flow. Restriction of coronary artery blood flow to the heart
can have a serious negative effect on cardiac health.
This is incorrect. Helicobacter pylori is a bacterium that causes peptic ulcers in the
gastrointestinal system.
This is correct. LDL cholesterol accumulates to form atherosclerotic plaque along the
artery walls and directly impacts cardiac health.
This is correct. Endothelial injury causes inflammation, which in turn causes diminished
vasodilatory capacity of the artery. This results in LDL cholesterol deposition and clot
formation in coronary arteries, resulting in a detrimental effect on cardiac health.
This is incorrect. Acid reflux irritates the lower esophageal cells, causing inflammation of
the esophagus. Prolonged irritation and lack of treatment could lead to a condition known
as Barrett’s esophagus.
PTS: 1
CON: Cellular Regulation
PRIMEXAM.COM
Chapter 3: Genetic Basis of Disease
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. Which is a test primarily used to diagnose fetal chromosome problems?
1. Cordocentesis
2. Amniocentesis
3. Maternal serum screening
4. Chorionic villus sampling
2. Which is an inherited connective-tissue disorder?
1. Marfan syndrome
2. Neurofibromatosis
3. Familial hypercholesterolemia
4. Familial adenomatous polyposis
3. Familial hypercholesterolemia is a genetic disorder characterized by high cholesterol level. Which statement
is true regarding the condition?
1. Children are at the risk for early acute myocardial infarction.
2. Untreated men develop symptoms by the fifth decade of life.
3. Untreated women develop symptoms by the fourth decade of life.
4. Homozygous familial hypercholesterolemia is less severe than the heterozygous form.
4. A client presents with less strength, high elastic skin, and joints that are hypermobile. Which condition can be
diagnosed in the client based on these characteristics?
1. Down syndrome
2. Turner syndrome
3. Klinefelter syndrome
4. Ehlers-Danlos syndrome
5. An adult client is diagnosed with Marfan syndrome after presenting with joint pain and weakness or
numbness in the legs. What other clinical finding would be a treatment priority for this client?
1. Scoliosis
2. Pneumothorax
3. Pectus excavatum
4. Heart valve problems
6. A client presents to the hospital with difficulty in speaking, excessive salivation, and ataxia. What finding
would lead to a diagnosis of Wilson disease?
1. Hepatic dysfunction
2. Grand mal seizures
3. Skeletal rigidity
4. Psychiatric symptoms
7. A client presents with thrombocytopenia and bony fractures. A scan reveals splenomegaly. How would a
diagnosis of Gaucher disease be made in the client?
1. Presence of mutation in gene that codes for glucocerebrosidase
2. Cellular analysis
3. Predisposition to bone fractures
PRIMEXAM.COM
4. Presence of splenomegaly
8. A client, an Ashkenazi Jew, presents with complaints of fever and lymphadenopathy. The client also has a
protuberant abdomen. What finding would lead to a diagnosis of Niemann Pick disease?
1. Massive enlargement of spleen
2. Generalized lymphadenopathy
3. Gastrointestinal problems and fever
4. Biochemical assay
9. A client presents with lethargy and muscle flaccidity. The client’s family members report cognitive
impairment in the client. What finding would the nurse look for if Tay Sachs disease is suspected?
1. Cherry-red spot on the retina on ophthalmologic examination
2. Epicanthic folds around the eyes
3. Flapping of eyes
4. Light-colored ring in the iris of the eye
10. A 19-year-old male client presents with rheumatoid arthritis. The client has a tall, lanky body, sparse facial
hair. He complains of decreased physical endurance. How could a diagnosis of Klinefelter syndrome be
confirmed in the client?
1. Confirm absence of pubertal changes
2. Evaluate muscle weakness
3. Assess distribution of adipose tissue
4. Perform genetic testing and hormone analysis
11. A karyotype is the overall picture of
1. all the chromosomal pairs in an individual.
2. all the chromosomal pairs of a species.
3. all the normal chromosomal pairs in an individual.
4. all the abnormal chromosomal pairs in an individual.
12. What defines translation in protein synthesis?
1. Process of RNA synthesis
2. Process of DNA synthesis
3. Process of ribosome formation
4. Process of protein synthesis from RNA
13. Similar to sickle cell anemia, which other genetic disorder offers protection against malaria?
1. Turner syndrome
2. G6PD deficiency
3. Wilson disease
4. Tay Sachs disease
14. What is a characteristic clinical manifestation of Wilson disease?
1. Tremor
2. Excessive salivation
3. Difficulty in speaking
4. Corneal Kayser-Fleischer rings
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
PRIMEXAM.COM
15. What aspects of polymerase chain reaction make it so useful in research? Select all that apply.
1. Requires mitotic cells
2. Used for diagnostic testing
3. Used for genetic analysis in cancer
4. Can be applied to a very small sample of DNA
5. Reduces the segment for further study in the laboratory
16. Prenatal diagnosis is testing for disease or conditions in a fetus. Which statements are true regarding prenatal
diagnoses? Select all that apply.
1. Prenatal sex discernment
2. Early detection of birth defects
3. Genetic problems are unidentified
4. Identify disorders such as neural tube defects and Down syndrome
5. Testing procedures exclude amniocentesis and percutaneous umbilical cord blood
sampling.
17. Chorionic villus sampling is performed during pregnancy. What are the characteristics of chorionic villus
sampling? Select all that apply.
1. Performed after 10 weeks of pregnancy
2. Offered if an inherited genetic problem is identified
3. Used to diagnose 99% of fetal chromosome abnormalities
4. Offered when a woman is at a maternal age below 35 years
5. Used to diagnose chromosome abnormalities and some inherited disorders
18. Amniocentesis is a medical procedure that can give physicians essential information about the fetus. Which
statements are true regarding amniocentesis? Select all that apply.
1. It is used to detect abnormalities by removing a large amount of amniotic fluid.
2. It is used to diagnose fetal chromosome problems.
3. It is used to study the fetal chromosomes.
4. It is performed on the amniotic fluid before 16 weeks of pregnancy.
5. It is used to detect fetal disorders by inserting a thin needle through the mother’s abdomen
into the amniotic sac.
19. Marfan syndrome is an inherited connective tissue disorder. What are the signs and symptoms that can lead a
physician to diagnose a client with Marfan syndrome? Select all that apply.
1. Short stature
2. Low back pain
3. Visual problems
4. Burning sensation
5. Ligament hypermobility
20. Gene therapy is an experimental technique that uses genes to treat or prevent disease. What are some of the
characteristics of gene therapy? Select all that apply.
1. Insertion of a normal gene
2. Used to treat or prevent any disease
3. Used to treat a disorder using drugs or surgery
4. Insertion of a 47th artificial chromosome into the target cells
5. Insertion of the artificial chromosome would affect the function of the standard 46
chromosomes
PRIMEXAM.COM
21. A five-year-old child presents with inguinal freckling and bowed legs. What clinical criteria can be used to
further confirm the diagnosis of neurofibromatosis? Select all that apply.
1. Optic nerve tumor
2. Long-bone abnormalities
3. Two or less tumors in the iris
4. Two or less café-au-lait spots
5. Irregularly shaped raised lesions appear over time in older children
22. Which clinical manifestations are associated with Ehlers-Danlos syndrome? Select all that apply.
1. Skin is less elastic
2. Joints are hypermobile
3. Easy bruising and poor wound healing
4. Treatment includes high dose of vitamin C
5. Caused by abnormalities in the synthesis of collagen
23. Which are lysosomal storage diseases? Select all that apply.
1. Tay Sachs disease
2. Niemann-Pick disease
3. Gaucher disease
4. Wilson disease
5. Klinefelter syndrome
24. How is Gaucher disease treated? Select all that apply.
1. Bone marrow transplantation
2. Genetic testing and counseling
3. Enzyme replacement therapy
4. Antibiotics
5. Vaccine
25. A client presents with excessive salivation and hepatic dysfunction. A diagnosis of Wilson disease is made
through liver biopsy and urine copper levels. What are the treatment options available for the client? Select all
that apply.
1. Antibiotics
2. Preventive vaccines
3. Chelating agents
4. Liver transplant
5. Antivirals
PRIMEXAM.COM
Chapter 3: Genetic Basis of Disease
Answer Section
MULTIPLE CHOICE
1. ANS: 2
Chapter: Chapter 3, Genetic Basis of Disease
Page: 37
Objective: N/A
Difficulty: Easy
Heading: Prenatal Diagnosis of Genetic Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Cellular Regulation
1
2
3
4
Feedback
Cordocentesis is a diagnostic test that examines blood from the fetal umbilical cord to
detect fetal abnormalities.
Amniocentesis is a test primarily used to diagnose fetal chromosome problems. It
detects about 99% of fetal chromosome abnormalities.
Maternal serum screening tests are performed on a pregnant woman’s blood for
determining if her developing fetus has an increased risk of an open neural tube defect.
Chorionic villus sampling is a diagnostic procedure performed during pregnancy to
diagnose chromosome abnormalities and some inherited disorders.
PTS: 1
CON: Cellular Regulation
2. ANS: 1
Chapter: Chapter 3, Genetic Basis of Disease
Page: 39
Objective: N/A
Difficulty: Easy
Heading: Pathophysiology of Selected Genetic and Chromosomal Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Cellular Regulation
1
2
3
4
Feedback
An inherited connective-tissue disorder transmitted as an autosomal dominant trait is
known as Marfan syndrome.
A genetic disorder with cutaneous, neurological, and orthopedic manifestations is
known as neurofibromatosis.
An autosomal dominant disorder that causes severe elevations in total cholesterol and
low-density lipoprotein cholesterol is known as familial hypercholesterolemia.
The early onset of hundreds to thousands of adenomatous polyps throughout the colon
PRIMEXAM.COM
is called familial adenomatous polyposis.
PTS: 1
CON: Cellular Regulation
3. ANS: 1
Chapter: Chapter 3, Genetic Basis of Disease
Page: 38
Objective: N/A
Difficulty: Moderate
Heading: Pathophysiology of Selected Genetic and Chromosomal Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Cellular Regulation
1
2
3
4
Feedback
Children are at risk for early acute myocardial infarction.
Untreated men are likely to develop symptoms of familial hypercholesterolemia by the
fourth decade of their life.
Untreated women are likely to develop symptoms of familial hypercholesterolemia by
the fifth decade of their life.
Homozygous familial hypercholesterolemia is a more severe disease than the
heterozygous form.
PTS: 1
CON: Cellular Regulation
4. ANS: 4
Chapter: Chapter 3, Genetic Basis of Disease
Page: 40
Objective: N/A
Difficulty: Difficult
Heading: Pathophysiology of Selected Genetic and Chromosomal Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Cellular Regulation
1
2
3
4
Feedback
Down syndrome is a condition that refers to a chromosomal disorder in humans and is
the most common cause of intellectual disability.
Turner syndrome is a condition that results from a complete or partially missing X
chromosome in the female.
Klinefelter syndrome is a condition that is associated with the most common male
chromosomal genetic diseases. Males commonly have a 47, XXY karyotype. However,
an extra X or Y can be present in some variants of the disease.
A group of disorders that involve diminished strength and integrity of the skin, joints,
and other connective tissues is known as Ehlers-Danlos syndrome.
PTS: 1
CON: Cellular Regulation
PRIMEXAM.COM
5. ANS: 4
Chapter: Chapter 3, Genetic Basis of Disease
Page: 39
Objective: N/A
Difficulty: Moderate
Heading: Pathophysiology of Selected Genetic and Chromosomal Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Cellular Regulation
1
2
3
4
Feedback
Clients with Marfan syndrome may have scoliosis, but this is not the priority treatment
since it is not life-threatening.
Pneumothorax is a finding that would be treated with a chest tube to perform suction.
This treatment would be performed after heart-related issues are addressed.
Pectus excavatum is the most common congenital deformity associated with Marfan
syndrome. It requires surgical repair but is not a priority treatment.
Heart valve problems are a priority in treatment for clients with Marfan syndrome.
Preventive procedures such as valve replacement and medications are necessary for
cardiovascular disease.
PTS: 1
CON: Cellular Regulation
6. ANS: 1
Chapter: Chapter 3, Genetic Basis of Disease
Page: 42
Objective: N/A
Difficulty: Difficult
Heading: Pathophysiology of Selected Genetic and Chromosomal Disorders
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Metabolism
1
2
3
4
Feedback
More than half clients with Wilson disease present with hepatic dysfunction and have
initial presentation of cirrhosis.
Grand mal seizures are a late manifestation of the disease, therefore, it cannot be the
most common symptom.
Skeletal rigidity is a late manifestation in the disease process, therefore, it cannot be the
most common symptom.
Psychiatric symptoms may or may not be present in clients with Wilson disease.
PTS: 1
CON: Metabolism
7. ANS: 2
Chapter: Chapter 3, Genetic Basis of Disease
Page: 41
PRIMEXAM.COM
Objective: N/A
Difficulty: Difficult
Heading: Pathophysiology of Selected Genetic and Chromosomal Disorders
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Evaluation [Evaluating]
Concept: Cellular Regulation
1
2
3
4
Feedback
It is not possible to diagnose Gaucher disease based on one single genetic test, as more
than 150 mutations of the gene exist.
Cells that have accumulated glucocerebrosidase, known as Gaucher cells, are found
throughout the body in Gaucher disease and confirm the diagnosis.
Several factors can dispose a client to bone fractures, not just Gaucher disease.
While splenomegaly is a symptom of Gaucher disease, it is also found in several other
medical conditions.
PTS: 1
CON: Cellular Regulation
8. ANS: 4
Chapter: Chapter 3, Genetic Basis of Disease
Page: 41
Objective: N/A
Difficulty: Difficult
Heading: Pathophysiology of Selected Genetic and Chromosomal Disorders
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Assessment
1
2
3
4
Feedback
While there is enlargement of the spleen in clients with Niemann-Pick disease, it is also
seen in other conditions so this finding alone would not lead to a positive diagnosis.
Generalized lymphadenopathy is seen in several medical conditions, and is not specific
to Niemann-Pick disease.
Gastrointestinal problems and fever are common symptoms of a variety of diseases,
therefore, they are not specific to Niemann-Pick disease.
A biochemical assay via a biopsy of liver or bone marrow showing the accumulation of
sphingomyelinase is diagnostic for Niemann-Pick disease.
PTS: 1
CON: Assessment
9. ANS: 1
Chapter: Chapter 3, Genetic Basis of Disease
Page: 41
Objective: N/A
Difficulty: Moderate
Heading: Pathophysiology of Selected Genetic and Chromosomal Disorders
Integrated Process: Nursing Process
PRIMEXAM.COM
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
1
Feedback
A cherry-red spot on the retina is the characteristic feature of Tay Sachs disease.
2
Epicanthic folds around the eyes are characteristic for Down syndrome.
3
Flapping of eyes and avoidance of eye contact is seen in Fragile X syndrome.
4
A light-colored ring in the iris of the eye is characteristic for familial
hypercholesterolemia.
PTS: 1
CON: Assessment
10. ANS: 4
Chapter: Chapter 3, Genetic Basis of Disease
Page: 43
Objective: N/A
Difficulty: Moderate
Heading: Klinefelter Syndrome
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaption
Cognitive Level: Analysis [Analyzing]
Concept: Assessment
1
2
3
4
Feedback
Absence of pubertal changes is not restricted to Klinefelter syndrome alone, as reduced
testosterone levels are possible even in the absence of Klinefelter syndrome.
Weak muscles and reduced strength could be a symptom of more than one medical
condition and are not specific to Klinefelter syndrome alone.
Some male clients with Klinefelter syndrome may have a feminine distribution of fat
tissue on their body, but this finding alone cannot lead to an accurate diagnosis of the
condition.
Only genetic testing for an extra X chromosome and associated reduction in
testosterone can confirm Klinefelter syndrome.
PTS: 1
CON: Assessment
11. ANS: 1
Chapter: Chapter 3, Genetic Basis of Disease
Page: 28
Objective: N/A
Difficulty: Easy
Heading: Molecular Analysis of Genetic Disorders
Integrated Process: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Knowledge [Remembering]
Concept: Cellular Regulation
PRIMEXAM.COM
Feedback
1
2
3
4
Each individual has a fixed number of chromosomes and gene patterns. This overall
picture is a karyotype.
A karyotype is the overall picture of all chromosomes in the cell of an individual and
not an arm of a chromosome. The upper arm of a chromosome, however, is called the
“p” arm.
The lower arm of a chromosome is called the “q” arm; however, a karyotype is the
entire picture of all the chromosomes in an individual.
While the extra chromosome when present can form part of the karyotype of an
individual, the extra chromosome alone does not form a karyotype because the latter is
the overall picture of all chromosomes, normal and abnormal, in an individual.
PTS: 1
CON: Cellular Regulation
12. ANS: 4
Chapter: Chapter 3, Genetic Basis of Disease
Page: 29
Objective: N/A
Difficulty: Easy
Heading: Regulation of Gene Expression
Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Cellular Regulation
1
2
3
4
Feedback
The process of RNA synthesis is transcription, not translation.
The process of DNA synthesis is not translation.
Ribosome formation is an intracellular process, not translation.
The process of protein synthesis from RNA at ribosomes is called translation.
PTS: 1
CON: Cellular Regulation
13. ANS: 2
Chapter: Chapter 3, Genetic Basis of Disease
Page: 42
Objective: N/A
Difficulty: Easy
Heading: G6PD Deficiency
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Cellular Regulation
1
2
3
Feedback
Turner syndrome does not offer any protection from malaria.
G6PD deficiency, like sickle cell anemia, confers protection against malaria.
Wilson disease does not confer any protection against malaria.
PRIMEXAM.COM
4
Tay Sachs disease does not confer any protection against malaria.
PTS: 1
CON: Cellular Regulation
14. ANS: 4
Chapter: Chapter 3, Genetic Basis of Disease
Page: 42
Objective: N/A
Difficulty: Easy
Heading: Wilson Disease
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Sensory Perception
1
2
3
4
Feedback
Tremor is a physical manifestation of several medical conditions and not specific to
Wilson disease.
Excessive salivation is not particular to a genetic disorder. It can be due to several
reasons.
Difficulty in speaking does not necessarily have an underlying genetic link.
On a clinical eye examination, corneal Kayser-Fleischer rings are characteristically seen
in clients who have Wilson disease.
PTS: 1
CON: Sensory Perception
MULTIPLE RESPONSE
15. ANS: 2, 3, 4
Chapter: Chapter 3, Genetic Basis of Disease
Page: 36
Objective: N/A
Difficulty: Difficult
Heading: Molecular Analysis of Genetic Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Evaluation [Evaluating]
Concept: Cellular Regulation
1.
2.
3.
4.
Feedback
This is incorrect. The polymerase chain reaction does not require mitotic cells as it occurs
in karyotyping.
This is correct. The polymerase chain reaction procedure can be used for diagnostic testing.
It can be used to diagnose various types of infectious disease.
This is correct. The polymerase chain reaction is commonly used for the detection of
infectious disease, forensics, research, and genetic analysis in cancer.
This is correct. The polymerase chain reaction makes it possible to produce a million
copies of DNA sequence in a test tube in a few hours. This procedure can be applied even
PRIMEXAM.COM
5.
to a very small sample of DNA.
This is incorrect. The polymerase chain reaction amplifies, instead of reduces, the segment
for further study in the laboratory.
PTS: 1
CON: Cellular Regulation
16. ANS: 1, 2, 4
Chapter: Chapter 3, Genetic Basis of Disease
Page: 36
Objective: N/A
Difficulty: Moderate
Heading: Prenatal Diagnosis of Genetic Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Cellular Regulation
1.
2.
3.
4.
5.
Feedback
This is correct. Prenatal screening can also be used for prenatal sex discernment.
This is correct. Birth defects are detected earlier using prenatal diagnosis or prenatal
screening.
This is incorrect. Genetic testing is offered to couples at risk for a particular genetic
problem.
This is correct. Disorders such as neural tube defects, Down syndrome, and chromosome
abnormalities can be identified using prenatal diagnoses.
This is incorrect. Amniocentesis and percutaneous umbilical cord blood sampling are
common testing procedures that are included.
PTS: 1
CON: Cellular Regulation
17. ANS: 2, 3, 5
Chapter: Chapter 3, Genetic Basis of Disease
Page: 37
Objective: N/A
Difficulty: Moderate
Heading: Genetic Assessment
Integrated Processes: Caring
Client Need: Physiological Integrity: Basic Care and Comfort
Cognitive Level: Application [Applying]
Concept: Cellular Regulation
1.
2.
3.
4.
Feedback
This is incorrect. Chorionic villus sampling is performed between 10 and 12 weeks of
pregnancy.
This is correct. Chorionic villus sampling may be offered to a woman if an inherited
genetic problem is identified in the family.
This is correct. Chorionic villus sampling can be used to diagnose approximately 99% of
fetal chromosome abnormalities.
This is incorrect. Chorionic villus sampling is offered when a woman is at an advanced
PRIMEXAM.COM
5.
maternal age around 35 years and older at the time of delivery.
This is correct. Chorionic villus sampling is performed during pregnancy to diagnose
chromosome abnormalities, some inherited disorders, and certain birth defects in a fetus.
PTS: 1
CON: Cellular Regulation
18. ANS: 2, 3, 5
Chapter: Chapter 3, Genetic Basis of Disease
Page: 37
Objective: N/A
Difficulty: Difficult
Heading: Genetic Assessment
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Evaluation [Evaluating]
Concept: Cellular Regulation
1.
2.
3.
4.
5.
Feedback
This is incorrect. A small amount of amniotic fluid is removed in amniocentesis.
This is correct. Amniocentesis is a test used to diagnose fetal chromosome problems.
This is correct. As the fetus grows and sheds cells, those cells can be found in the amniotic
fluid, which is used to study the fetal chromosome.
This is incorrect. Amniocentesis is performed on the amniotic fluid usually between 16 and
18 weeks of pregnancy.
This is correct. A thin needle is inserted through the mother’s abdomen into the amniotic
sac under ultrasound guidance.
PTS: 1
CON: Cellular Regulation
19. ANS: 2, 3, 4
Chapter: Chapter 3, Genetic Basis of Disease
Page: 39
Objective: N/A
Difficulty: Moderate
Heading: Pathophysiology of Selected Genetic and Chromosomal Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Cellular Regulation
1.
2.
3.
4.
5.
Feedback
This is incorrect. Clients with Marfan syndrome have tall stature with elongated arms and
fingers.
This is correct. Clients with Marfan syndrome have low back pain near the tailbone.
This is correct. Visual problems including the loss of vision is diagnosed in clients with
Marfan syndrome.
This is correct. Burning sensation and numbness or weakness in the legs is diagnosed in
clients with Marfan syndrome.
This is incorrect. Clients with Marfan syndrome have ligament hypermobility of the hips,
PRIMEXAM.COM
knees, ankles, arches, wrists, and fingers.
PTS: 1
CON: Cellular Regulation
20. ANS: 1, 2, 4
Chapter: Chapter 3, Genetic Basis of Disease
Page: 37
Objective: N/A
Difficulty: Moderate
Heading: Gene Therapy
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Cellular Regulation
1.
2.
3.
4.
5.
Feedback
This is correct. Insertion of a normal gene into the genome of a target cell to replace a
nonfunctional or mutated gene is a procedure under investigation.
This is correct. Gene therapy is an experimental technique used for treating or preventing
any disease.
This is incorrect. A gene is inserted into a client’s cells instead of using drugs or surgery to
treat a disorder.
This is correct. Insertion of a 47th artificial human chromosome would be a larger vector
capable of carrying a substantial amount of correct genetic code into the cells.
This is incorrect. The artificial normal chromosome will exist along with the standard 46
chromosomes and not affect their function.
PTS: 1
CON: Cellular Regulation
21. ANS: 1, 2, 5
Chapter: Chapter 3, Genetic Basis of Disease
Page: 39-40
Objective: N/A
Difficulty: Difficult
Heading: Pathophysiology of Selected Genetic and Chromosomal Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Comprehension [Understanding]
Concept: Cellular Regulation
1.
2.
3.
4.
5.
Feedback
This is correct. A client with neurofibromatosis may have an optic nerve tumor.
This is correct. Long-bone abnormalities can be diagnosed in a client with
neurofibromatosis.
This is incorrect. Two or more tumors in the iris can be diagnosed by an ophthalmologist.
This is incorrect. Six or more café-au-lait spots are diagnosed in a client with
neurofibromatosis.
This is correct. Cutaneous neurofibromas are irregularly shaped, darkly pigmented, raised
lesions that appear in older children, adolescents, and adults.
PRIMEXAM.COM
PTS: 1
CON: Cellular Regulation
22. ANS: 3, 4, 5
Chapter: Chapter 3, Genetic Basis of Disease
Page: 40
Objective: N/A
Difficulty: Moderate
Heading: Pathophysiology of Selected Genetic and Chromosomal Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Cellular Regulation
1.
2.
3.
4.
5.
Feedback
This is incorrect. Clients with Ehlers-Danlos syndrome have highly elastic skin.
This is incorrect. The joints are hypermobile in clients with Ehlers-Danlos syndrome.
This is correct. Persons with Ehlers-Danlos syndrome may experience easy bruising and
poor wound healing.
This is correct. Treatment for Ehlers-Danlos syndrome is symptomatic and high doses of
vitamin C have been used.
This is correct. Ehlers-Danlos syndrome is caused by abnormalities in the synthesis of
collagen and other connective tissue proteins.
PTS: 1
CON: Cellular Regulation
23. ANS: 1, 2, 3
Chapter: Chapter 3, Genetic Basis of Disease
Page: 41
Objective: N/A
Difficulty: Easy
Heading: Pathophysiology of Selected Genetic and Chromosomal Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Metabolism
1.
2.
3.
4.
5.
Feedback
This is correct. Tay Sachs disease is caused by the deficiency of the lysosomal enzyme
hexosaminidase.
This is correct. Niemann-Pick disease is caused by the deficiency of the lysosomal enzyme
sphingomyelinase.
This is correct. Gaucher disease is caused by the deficiency of the lysosomal enzyme
glucocerebrosidase.
This is incorrect. Wilson disease is related to copper metabolism.
This is incorrect. Klinefelter syndrome is a male chromosomal genetic disease; it is not
related to liposomal enzyme.
PTS: 1
CON: Metabolism
PRIMEXAM.COM
24. ANS: 1, 3
Chapter: Chapter 3, Genetic Basis of Disease
Page: 41
Objective: N/A
Difficulty: Moderate
Heading: Pathophysiology of Selected Genetic and Chromosomal Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Metabolism
1.
2.
3.
4.
5.
Feedback
This is correct. Bone marrow transplantation is one option to treat Gaucher disease when
bone marrow is involved with symptoms of thrombocytopenia.
This is incorrect. Genetic counseling can prevent the incidence of the disease when
combined with family planning, but it cannot treat the disease.
This is correct. Enzyme replacement therapy to make up for the lack of glucocerebrosidase
in Gaucher disease is another option to treat the disease.
This is incorrect. Gaucher disease is not a bacterial disease, therefore, it cannot be treated
with antibiotics.
This is incorrect. Being a genetically inherited disease, vaccines cannot be used to treat it.
PTS: 1
CON: Metabolism
25. ANS: 3, 4
Chapter: Chapter 3, Genetic Basis of Disease
Page: 42
Objective: N/A
Difficulty: Difficult
Heading: Pathophysiology of Selected Genetic and Chromosomal Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Metabolism
1.
2.
3.
4.
5.
Feedback
This is incorrect. Wilson disease is not a bacterial disease, therefore, it cannot be treated
with antibiotics.
This is incorrect. Wilson disease in an inherited disease and cannot be treated with
preventive vaccines.
This is correct. The main treatment for Wilson disease involves elimination of excess
copper through chelating agents since the urine copper levels are elevated and excess
copper must be removed from the client’s system.
This is correct. Wilson disease damages the liver, so liver transplantation is an option for
those with liver damage.
This is incorrect. Wilson disease is not a viral disease, therefore, antivirals cannot cure it.
PTS: 1
CON: Metabolism
PRIMEXAM.COM
Chapter 4: Stress, Exercise, and Immobility
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. Which is an example of eustress?
1. Job promotion
2. Death of a friend
3. Unemployment
4. Divorce
2. A client is scheduled for a heart valve replacement. Which strategic action of the primary healthcare provider
enhances the client’s adaptive ability and coping mechanism to reduce stress?
1. Encouraging a family member to stay with the client in the pre-operative setting
2. Permitting a family member to stay in the operation theater
3. Administering epinephrine to reduce stress
4. Restricting the family members from talking to the client in the pre-operative setting
3. In which stage of Hans Selye’s general adaptation syndrome is the sympathetic nervous system (SNS)
activated?
1. Alarm stage
2. Resistance stage
3. Exhaustion stage
4. Homeostasis
4. What is polysomnography?
1. A diagnostic test to examine sleep patterns
2. A diagnostic test to examine eye movement
3. A diagnostic test to examine respiratory functions
4. A diagnostic test to examine electrical activity of the brain
5. Which problem is a 55-year-old client most likely to exhibit as a result of prolonged benzodiazepine use?
1. Unstable gait
2. Bradycardia
3. Dyspnea
4. Anuria
6. A client who has been taking an antidepressant for 10 days complains of depression and does not find the
medication to be effective. Which is the best response by the nurse?
1. “I will increase the drug dosage after informing the physician”
2. “The medication will take at least 3 weeks to be effective.”
3. “I will change the medication after informing the physician.”
4. “Stop taking the medication.”
7. Which is the most commonly used over-the-counter sleep aid?
1. Diphenhydramine (Benadryl)
2. Phenylephrine (Neo-Synephrine)
3. Pseudoephedrine (Sudafed)
4. Acetylcholine (Miochol)
PRIMEXAM.COM
8. A registered nurse is explaining the effects of exercise on cardiovascular system to a student nurse. Which
statement by the student nurse indicates effective teaching?
1. “Exercise prevents thrombus formation.”
2. “Exercise increases fibrinogen levels.”
3. “Exercise prevents angiogenesis.”
4. “Exercise increases the heart’s efficiency by decreasing cardiac muscle mass.”
9. A client is on long-term bed rest. Which condition might the client develop due to immobility?
1. Orthostatic hypotension
2. Venous stasis
3. Hypertension
4. Dyspnea
10. A bedridden client has frequent gastrointestinal reflux. Which condition might the client develop due to
gastrointestinal reflux?
1. Aspiration pneumonia
2. Hypotension
3. Hyperthermia
4. Constipation
11. A nurse is providing care for a client, who is on bed rest due to immobility. Which measure does the nurse
adopt in order to counteract the ill effects of immobility?
1. Assess the client’s skin for erythema.
2. Place the client in prone position.
3. Avoid seating the client on a chair.
4. Change the position of the client every 4 hours.
12. A client was hospitalized due to immobility. The blood report after one month of hospitalization shows that
the client has developed septicemia. Which factor could have caused septicemia?
1. Erythema
2. Decubitus ulcer
3. Antibacterial drugs
4. Excessive exercise
13. A client, who is on prolonged bed rest, has developed kidney stones. Which factor could have caused kidney
stones?
1. Change in the levels of glucose
2. Change in the levels of growth hormone
3. Change in the levels of thyroid hormone
4. Change in the levels of parathyroid hormone
14. Which statement is correct regarding the effects of exercise?
1. Enlarges the muscle fibers
2. Decreases the rate of breathing
3. Increases the risk of colon cancer
4. Decreases the number of mitochondrial enzymes
15. What is the effect of physical activity on gastrointestinal system?
1. Increases constipation
2. Improves peristaltic movement
3. Increases the risk of diverticulosis
PRIMEXAM.COM
4. Increases the risk of inflammatory bowel diseases
16. Which condition commonly found in inactive clients results in edema?
1. Venous stasis
2. Pulmonary embolism
3. Hypertension
4. Orthostatic hypotension
17. What is the result of decreased cardiac output in a client, who is on a prolonged bed rest?
1. Increase in stroke volume
2. Increase in heart rate
3. Increase in venous returns
4. Increase in diastolic volume
18. What happens when nitric-oxide dependent vasodilation occurs in the coronary arteries?
1. Increase in platelet activation
2. Increase in thrombus formation
3. Increase in myocardial perfusion
4. Increase in endothelial inflammation
19. What is the physiological change that occurs in stage 5 of the sleep cycle?
1. Heart rate decreases
2. Breathing becomes rapid
3. Breathing becomes regular
4. None of the above
20. Which stage of sleep makes it difficult to wake someone?
1. Stage 1
2. Stage 2
3. Stage 3
4. Stage 5
NARRBEGIN: Exhibit
Exhibit
NARREND
21. A nurse is assessing the sleep history of different clients for obstructive sleep apnea (OSA). Which signs
could indicate that the client has OSA?
Client 1
Excessive daytime
sleepiness, snoring, and
repetitive pauses in
breathing during sleep
Client 2
Drowsiness during
daytime, able to sleep
only 6 hours at night,
snoring, and leg cramps
at night
Client 3
Difficulty getting back
to sleep after waking
during the night,
hallucinations when
awake, and jerking of
the legs during sleep
1. Client 1
2. Client 2
3. Client 3
PRIMEXAM.COM
Client 4
Sleepwalking,
nightmares, and leg
cramps at night
4. Client 4
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
22. A client is on prolonged bed rest. What are the psychological changes the client would exhibit? Select all that
apply.
1. Increased anxiety
2. Increased mood swings
3. Altered tactile responses
4. Increased levels of concentration
5. Increased problem solving ability
23. What gastrointestinal changes are seen in clients on bed rest? Select all that apply.
1. Slowed peristalsis
2. Diminished appetite
3. Increased diaphragm strength
4. Increased rate of intestinal absorption
5. Decreased abdominal and pelvic muscle strength
24. Which nutritional advice given by a nurse to a client under stress is appropriate? Select all that apply.
1. “Eat a heavy meal before bedtime.”
2. “Consume more soy products.”
3. “Drink a glass of milk before going to bed.”
4. “Add peanuts and brown rice to your diet.”
5. “Add spinach and green vegetables to your diet.”
Completion
Complete each statement.
PRIMEXAM.COM
25. A 50-year-old male client is scheduled for a cardiac exercise stress test. The predicted maximal heart rate in
beats/minute is
Chapter 4: Stress, Exercise, and Immobility
Answer Section
MULTIPLE CHOICE
1. ANS: 1
Chapter: Chapter 4, Stress, Exercise, and Immobility
Page: 55
Objective: N/A
Difficulty: Easy
Heading: Stress, Exercise, and Immobility
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Stress
1
2
3
4
Feedback
Eustress is the stress that motivates an individual positively. A job promotion is an
example of eustress as it gives positive feelings.
Distress is defined as the stress that induces negative sentiments and adverse reactions.
Unemployment does not motivate an individual and the situation evokes negative
feelings.
Divorce is generally stressful and individuals may suffer from depression during the
separation or divorce.
PTS: 1
CON: Stress
2. ANS: 1
Chapter: Chapter 4, Stress, Exercise, and Immobility
Page: 56
Objective: N/A
Difficulty: Easy
Heading: The Effects of Stress
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Stress
1
2
3
Feedback
The primary healthcare provider can improve the client’s adaptive ability and coping
mechanism by encouraging the client’s family members to stay with the client in the
pre-operative setting and also during the recovery phase.
The primary health care provider should not allow the family members to stay in the
operation theater.
Epinephrine is administered by the primary healthcare provider to the client during
PRIMEXAM.COM
4
emergency conditions such as severe allergic reactions.
The primary healthcare provider should encourage the family members to talk with the
client in the pre-operative setting to improve the adaptive ability of the client.
PTS: 1
CON: Stress
3. ANS: 1
Chapter: Chapter 4, Stress, Exercise, and Immobility
Page: 56
Objective: N/A
Difficulty: Easy
Heading: The Effects of Stress
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Stress
1
2
3
4
Feedback
In the alarm stage, the sympathetic nervous system (SNS) is activated. The SNS
releases the catecholamine norepinephrine which increases alertness and stimulates the
vascular responses and cardio-respiratory responses.
In the resistance stage, the body attempts to stave off the effects of stress through
continual hormone secretion.
In the exhaustion stage, the body’s resources are exhausted and signs of systemic
dysfunction occur. Stress overwhelms the body’s ability to defend itself in this stage.
Homeostasis is a condition of equilibrium when various physiological parameters such
as heart rate, blood pressure, respiration rate, blood glucose, and so on are within
normal range.
PTS: 1
CON: Stress
4. ANS: 1
Chapter: Chapter 4, Stress, Exercise, and Immobility
Page: 61
Objective: N/A
Difficulty: Easy
Heading: Treatment of Stress
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Basic Care and Comfort
Cognitive Level: Knowledge [Remembering]
Concept: Sleep, Rest, and Activity
1
2
3
4
Feedback
Polysomnography is a diagnostic test used to diagnose sleep patterns.
Eye movements are examined in a polysomnography; however, this is not the main
purpose of the test
Respiratory functions will be assessed in a polysomnography; however, this is not the
main purpose of the test.
Electrical activities of the brain will be analyzed in a polysomnography; however, this
PRIMEXAM.COM
is not the main purpose of the test.
PTS: 1
CON: Sleep, Rest, and Activity
5. ANS: 1
Chapter: Chapter 4, Stress, Exercise, and Immobility
Page: 64
Objective: N/A
Difficulty: Moderate
Heading: Treatment of Stress
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Medication
1
2
3
4
Feedback
If a client takes sedatives on a long-term basis it might result in an unstable gait.
Bradycardia is abnormally slow heart rate. Long term use of sedatives does not result in
abnormally slow heart rate.
Dyspnea is difficulty breathing or labored breathing. Using sedatives for a long time
does not result in labored breathing.
Taking sedatives for a long period of time does not affect urine formation. It will not
cause anuria.
PTS: 1
CON: Medication
6. ANS: 2
Chapter: Chapter 4, Stress, Exercise, and Immobility
Page: 64
Objective: N/A
Difficulty: Difficult
Heading: Treatment of Stress
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Medication
1
2
3
4
Feedback
The nurse cannot increase the drug dosage. Only the physician can increase or decrease
the prescribed drug dosage.
Antidepressants generally require at least 3 weeks to reach the therapeutic level in the
blood. Once the therapeutic blood level is attained, the effects of the medications can be
seen. Ten days is too soon to assess the effectiveness of the medication.
The nurse cannot change the medication. Only the physician can change the
medication.
The nurse cannot advise the client to stop the medication without notifying the
physician and getting information from the physician.
PTS: 1
CON: Medication
PRIMEXAM.COM
7. ANS: 1
Chapter: Chapter 4, Stress, Exercise, and Immobility
Page: 64
Objective: N/A
Difficulty: Easy
Heading: Treatment of Stress
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Knowledge [Remembering]
Concept: Medication: Sleep, Rest, and Activity
1
2
3
4
Feedback
The most commonly used over-the-counter-sleep aid is diphenhydramine (Benadryl).
Phenylephrine (Neo-Synephrine) is a decongestant. However, insomnia is a common
side effect of this medication.
Pseudoephedrine (Sudafed) is also used to relieve congestion caused by cold and
allergies, but this medication can interfere with sleep.
Acetylcholine (Miochol is a neurotransmitter released by nerves. It is not a sleep aid.
PTS: 1
CON: Medication: Sleep, Rest, and Activity
8. ANS: 1
Chapter: Chapter 4, Stress, Exercise, and Immobility
Page: 65
Objective: N/A
Difficulty: Difficult
Heading: The Beneficial Effects of Exercise
Integrated Processes: Teaching/Learning: Client Need: Safe and Effective Care Environment: Management of
Care
Cognitive Level: Evaluation [Evaluating]
Concept: Clotting
1
2
3
4
Feedback
Exercise prevents thrombus formation. Exercise improves vascular endothelial
function. The vascular endothelium responds to exercise by producing vasodilator
compounds, which widen the arterial blood vessels and prevents thrombus formation.
Exercise lowers fibrinogen levels. Fibrinogen is an indicator of active clot formation.
Therefore, exercise is believed to have anti-atherogenic effect on the endothelium,
which prevents clot formation.
Exercise stimulates angiogenesis. Angiogenesis is the growth of collateral blood
vessels.
Exercise increases heart’s efficiency by promoting cardiac muscle mass and growth of
coronary vessel branches.
PTS: 1
CON: Clotting
9. ANS: 2
Chapter: Chapter 4, Stress, Exercise, and Immobility
Page: 67
PRIMEXAM.COM
Objective: N/A
Difficulty: Moderate
Heading: The Harmful Effects of Physical Inactivity and Immobility
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Clotting: Sleep, Rest, and Activity
1
2
3
4
Feedback
Orthostatic hypotension might occur when a client tries to resume to upright position
after a prolonged period of bed rest. The symptoms of orthostatic hypotension are
dizziness and tachycardia, among others.
Clients on bed rest might develop venous stasis. Venous stasis is the risk of forming
blood clots in the veins of the legs.
Hypertension does not develop because of immobility.
Dyspnea or difficulty breathing does not develop because of immobility.
PTS: 1
CON: Clotting: Sleep, Rest, and Activity
10. ANS: 1
Chapter: Chapter 4, Stress, Exercise, and Immobility
Page: 69
Objective: N/A
Difficulty: Moderate
Heading: The Harmful Effects of Physical Inactivity and Immobility
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Bowel Elimination: Sleep, Rest, and Activity
1
2
3
4
Feedback
A bedridden client might be at a high risk of gastroesophageal reflux, which can cause
gastric contents to enter into the lungs and result in aspiration pneumonia.
Hypotension is reduced blood pressure. Gastroesophageal reflux does not reduce the
blood pressure of the client.
Hyperthermia is above normal body temperature. Gastroesophageal reflux does not
alter the body temperature of the client.
Gastroesophageal reflux does not cause constipation. However, the antacids that contain
aluminum light cause constipation.
PTS: 1
CON: Bowel Elimination: Sleep, Rest, and Activity
11. ANS: 1
Chapter: Chapter 4, Stress, Exercise, and Immobility
Page: 72
Objective: N/A
Difficulty: Moderate
Heading: Interventions to Counteract Effects of Immobility
Integrated Process: Nursing Process
PRIMEXAM.COM
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Sleep, Rest, and Activity, Skin Integrity, Safety
1
2
3
4
Feedback
The nurse should assess the client’s skin for areas of erythema and irritation
periodically. This can help in preventing the development of decubitus ulcers.
The nurse should not place the client in prone position for a prolonged period, because
it hinders chest excursion. Clients should be turned sideways periodically.
The nurse should seat the client on a chair for a part of the day and ambulate small
distances.
The nurse should change the position of the client every 2 hours. This will help in
preventing skin breakdown and decubitus ulcers.
PTS: 1
CON: Sleep, Rest, and Activity, Skin Integrity, Safety
12. ANS: 2
Chapter: Chapter 4, Stress, Exercise, and Immobility
Page: 72
Objective: N/A
Difficulty: Moderate
Heading: Interventions to Counteract Effects of Immobility
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Skin Integrity: Infection: Mobility: Sleep, Rest, and Activity
1
2
3
4
Feedback
Erythema is redness of the skin. It has to be assessed periodically to prevent decubitus
ulcer.
Decubitus ulcers are vulnerable to bacterial contamination and infection. These
infections can enter the blood stream and cause septicemia.
Antibacterial drugs do not cause septicemia. They are used to treat septicemia.
Excessive exercise does not cause septicemia. Exercise rebuilds muscles, improves
pulmonary function, and makes the bones strong.
PTS: 1
CON: Skin Integrity: Infection: Mobility: Sleep, Rest, and Activity
13. ANS: 4
Chapter: Chapter 4, Stress, Exercise, and Immobility
Page: 71
Objective: N/A
Difficulty: Moderate
Heading: Metabolic and Endocrine System Changes
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Metabolism: Urinary Elimination: Mobility: Sleep, Rest, and Activity
PRIMEXAM.COM
1
2
3
4
Feedback
After 2 weeks of bed rest, peripheral cellular glucose uptake decreases by 50% and
blood glucose levels increase. This forces the increased production of insulin by the
pancreas.
Immobility leads to changes in the levels of growth hormones. Cardiac rhythm and
trough levels of hormones change, which leads to changes in appetite, sleep, and mood.
Changes in thyroid hormone occur due to immobility. Cardiac rhythm and trough levels
of hormones change which leads to changes in appetite, sleep and mood.
Parathyroid hormone levels are increased due to immobility. This stimulates
osteoclastic activity and bone degeneration, which leads to increased amount of calcium
in blood stream. Excess calcium, which reaches kidney precipitates and forms kidney
stones.
PTS: 1
CON: Mobility: Urinary Elimination: Sleep, Rest, and Activity
14. ANS: 1
Chapter: Chapter 4, Stress, Exercise, and Immobility
Page: 66
Objective: N/A
Difficulty: Easy
Heading: The Beneficial Effects of Exercise
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Comprehension [Understanding]
Concept: Sleep, Rest, and Activity
1
2
3
4
Feedback
Exercise enlarges the muscle fibers. With isometric exercise, muscles can hypertrophy,
which will result in increase in the size of the muscles.
Exercise increases the rate and depth of breathing. This in turn increases the blood’s
oxygenation.
Exercise decreases the risk of colon cancer by maintaining the energy balance, hormone
metabolism, and decreasing the time the colon is exposed to potential carcinogens.
Exercise increases the number of mitochondrial enzymes. This would help in improving
the body to generate more energy.
PTS: 1
CON: Sleep, Rest, and Activity
15. ANS: 2
Chapter: Chapter 4, Stress, Exercise, and Immobility
Page: 67
Objective: N/A
Difficulty: Easy
Heading: The Beneficial Effects of Exercise
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Comprehension [Understanding]
Concept: Bowel Elimination: Digestion
PRIMEXAM.COM
1
2
3
4
Feedback
Exercise counteracts constipation by stimulating natural contraction of intestinal
muscles.
Peristaltic movement is the involuntary contraction of smooth gastrointestinal muscles
that causes food to move through the digestive tract. Exercise improves the peristaltic
movement.
Diverticulosis is the condition where pouches are developed on the walls of the colon.
Exercise decreases the risk of developing diverticulosis.
Inflammatory bowel diseases are diseases of colon and small intestine. Exercise
decreases the risk of inflammatory bowel diseases.
PTS: 1
CON: Bowel Elimination: Digestion
16. ANS: 1
Chapter: Chapter 4, Stress, Exercise, and Immobility
Page: 68
Objective: N/A
Difficulty: Easy
Heading: The Harmful Effects of Physical Inactivity and Immobility
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Comprehension [Understanding]
Concept: Clotting, Hematological Regulation, Mobility
1
2
3
4
Feedback
Venous stasis is a condition characterized by the stagnation of venous blood in the
lower extremities of the body. This is mainly due to immobility. It increases the
hydrostatic pressure of the legs which is then transmitted into the capillaries. Fluid is
displaced from the blood into the interstitial tissue forming edema due to the pressure.
Clients who are immobile and have venous insufficiency are at high risk of developing
pulmonary embolism. A venous clot formed due to venous blood stagnation, travels to
the right ventricle. From there it is pumped into the pulmonary artery, resulting in
pulmonary embolism.
Hypertension or increased blood pressure does not result in edema.
Orthostatic hypotension occurs as a client attempts to resume an upright position after a
prolonged period of bed rest. The client experiences a delay in arterial vasoconstriction
and a temporary drop in blood pressure.
PTS: 1
CON: Clotting, Hematological Regulation, Mobility
17. ANS: 2
Chapter: Chapter 4, Stress, Exercise, and Immobility
Page: 68
Objective: N/A
Difficulty: Easy
Heading: The Harmful Effects of Physical Inactivity and Immobility
Cardiovascular System Changes
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
PRIMEXAM.COM
Cognitive Level: Comprehension [Understanding]
Concept: Hematological Regulation: Mobility: Perfusion
1
2
3
4
Feedback
Left ventricular end stroke volume decreases due to prolonged bed rest and contributes
to decreased cardiac output.
Cardiac output decreases due to prolonged bed rest. To compensate for this, the heart
rate increases. The heart beats harder and faster to eject sufficient ventricular blood
supply to the organs with adequate circulation.
Extended periods of bed rest decrease the venous return which in turn diminishes
cardiac filling.
Left ventricular end diastolic volume decreases due to prolonged bed rest and
contributes to decreased cardiac output.
PTS: 1
CON: Hematological Regulation: Mobility: Perfusion
18. ANS: 3
Chapter: Chapter 4, Stress, Exercise, and Immobility
Page: 65
Objective: N/A
Difficulty: Easy
Heading: The Beneficial Effects of Exercise
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Knowledge [Remembering]
Concept: Hematological Regulation: Mobility: Perfusion
1
2
3
4
Feedback
Nitric-oxide dependent vasodilation in the coronary arteries prevents the activation of
platelets.
Nitric-oxide dependent vasodilation in the coronary arteries prevents the formation of
thrombus.
Myocardial perfusion increases when nitric-oxide dependent vasodilation occurs in the
coronary arteries.
Nitric-oxide dependent vasodilation in the coronary arteries prevents endothelial
inflammation.
PTS: 1
CON: Hematological Regulation: Mobility: Perfusion
19. ANS: 2
Chapter: Chapter 4, Stress, Exercise, and Immobility
Page: 62
Objective: N/A
Difficulty: Easy
Heading: Treatment of Stress
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Knowledge [Remembering]
Concept: Oxygenation: Sleep, Rest, and Activity
PRIMEXAM.COM
1
2
3
4
Feedback
The heart rate increase in stage 5 of the sleep cycle.
Breathing becomes more rapid and shallow in stage 5 of the sleep cycle.
Breathing becomes irregular in stage 5 of the sleep cycle.
Breathing becomes rapid in stage 5 of the sleep cycle.
PTS: 1
CON: Oxygenation: Sleep, Rest, and Activity
20. ANS: 3
Chapter: Chapter 4, Stress, Exercise, and Immobility
Page: 62
Objective: N/A
Difficulty: Easy
Heading: Treatment of Stress
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Knowledge [Remembering]
Concept: Sleep, Rest, and Activity
1
2
3
4
Feedback
In stage 1 or drowsiness, brain waves show a 50% reduction in activity between
wakefulness and stage 1 sleep on polysomnography.
Stage 2 of the sleep cycle is a light sleep stage where the polysomnography readings
show periods of muscle tone. Polysomnography readings also show muscle relaxation.
In stage 3 of sleep cycle, delta waves, which are slow brain waves, begin to appear.
There is no eye movement or muscle activity. It is difficult to wake someone in this
stage of sleep.
In stage 5, rapid eye movements occur. Stage 5 is referred to as REM sleep.
PTS: 1
CON: Sleep, Rest, and Activity
21. ANS: 1
Chapter: Chapter 4, Stress, Exercise, and Immobility
Page: 61
Objective: N/A
Difficulty: Difficult
Heading: Treatment of Stress
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Sleep, Rest, and Activity
1
2
Feedback
Client 1 has OSA. Excessive day time sleepiness, snoring, and repetitive pauses in
breathing during sleep are typical symptoms of OSA.
Client 2 does not have OSA. Feeling drowsy during daytime and leg cramps at night are
symptoms of sleep disorders; however, the ability to sleep 6 hours at night is considered
normal.
PRIMEXAM.COM
3
4
Client 3 has a sleep disorder; however, symptoms such as difficulty getting back to
sleep after waking during the night, hallucinations when awake, and jerking of the legs
during sleep do not indicate OSA.
Sleepwalking, nightmares, and leg cramps at night are symptoms of a sleep disorder;
however, these symptoms do not specifically indicate OSA.
PTS: 1
CON: Sleep, Rest, and Activity
MULTIPLE RESPONSE
22. ANS: 1, 2, 3
Chapter: Chapter 4, Stress, Exercise, and Immobility
Page: 72
Objective: N/A
Difficulty: Moderate
Heading: Psychosocial Changes
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Mobility: Sleep, Rest, and Activity
1.
2.
3.
4.
5.
Feedback
This is correct. The client on prolonged bed rest will show increased levels of anxiety.
This is correct. The client on prolonged bed rest will exhibit mood swings while enduring
isolation.
This is correct. The client on prolonged bed rest will exhibit tactile responses.
This is incorrect. The client on prolonged bed rest will exhibit decreased levels of
concentration.
This is incorrect. The client on prolonged bed rest will exhibit decreased problem solving
ability.
PTS: 1
CON: Mobility: Sleep, Rest, and Activity
23. ANS: 1, 2, 5
Chapter: Chapter 4, Stress, Exercise, and Immobility
Page: 67
Objective: N/A
Difficulty: Moderate
Heading: Gastrointestinal System
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Mobility: Sleep, Rest, and Activity
1.
2.
3.
Feedback
This is correct. Clients on bed rest exhibit slowed peristaltic movement.
This is correct. Clients on bed rest exhibit diminished appetite.
This is incorrect. Bed rest causes diminished strength of the diaphragm.
PRIMEXAM.COM
4.
5.
This is incorrect. Bed rest decreases the rate of intestinal absorption.
This is correct. Bed rest causes decreased strength of abdominal and pelvic muscles.
PTS: 1
CON: Mobility: Sleep, Rest, and Activity
24. ANS: 2, 3, 4
Chapter: Chapter 4, Stress, Exercise, and Immobility
Page: 63
Objective: N/A
Difficulty: Moderate
Heading: Treatment of Stress
Integrated Processes: Teaching/Learning
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Sleep, Rest, and Activity: Stress
1.
2.
3.
4.
5.
Feedback
The answer is incorrect. The client under stress should not be advised to eat a heavy meal
before bedtime.
The answer is correct. The client should be advised to consume more soy products because
soy products contain tryptophan, which is the precursor of serotonin. Serotonin helps
individuals to stay calm, relaxed, confident, and promotes the feeling of well-being.
The answer is correct. The client should be advised to drink a glass of milk before bedtime
because drinking milk will relax the body and promote sleep.
The answer is correct. Peanuts and brown rice are dietary sources of tryptophan.
The answer is incorrect. Green vegetables and spinach are rich sources of vitamin K.
However, vitamin K is not associated with stress management.
PTS: 1
CON: Sleep, Rest, and Activity: Stress
COMPLETION
25. ANS:
170
Chapter: Chapter 4, Stress, Exercise, and Immobility
Page: 66
Objective: N/A
Difficulty: Moderate
Heading: The Beneficial Effects of Exercise
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Perfusion: Stress
Feedback: The client who is taking a cardiac exercise stress test is challenged to exercise at various levels
until the maximum heart rate is reached. The target heart rate is estimated by the age of the client. The
predicted maximal heart rate of a client is calculated by subtracting the age of the client from 220, as a
general rule. Therefore, the target heart rate of a 50-year-old client is 220 – 50 = 170 beats/minute.
PRIMEXAM.COM
PTS: 1
CON: Perfusion: Stress
PRIMEXAM.COM
Chapter 5: Obesity and Nutritional Imbalances
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. A client has a pigmented rash on the sun-exposed areas of the client’s skin. Which nutrient deficiency results
in this condition?
1. Folate
2. Niacin
3. Vitamin A
4. Vitamin K
2. Which nutrient deficiency causes beriberi?
1. Thiamine
2. Riboflavin
3. Vitamin B6
4. Vitamin B12
3. A client displays behaviors that involve a desire for perfection and success in academics, and psychiatric
characteristics, such as being socially isolated and emotional, and having a severely restricted diet. Which
disorder could the client possibly have?
1. Anorexia nervosa
2. Bulimia nervosa
3. Binge eating
4. Purging disorder
4. According to the United States Department of Agriculture (USDA), what is the recommended daily allowance
for calcium consumption?
1. 1.7 mg
2. 60 mg
3. 400 mg
4. 1000 mg
5. According to the United States Department of Agriculture (USDA), what is the recommended daily allowance
for potassium consumption?
1. 20 mg
2. 300 mg
3. 2,400 mg
4. 3,500 mg
6. A client reports excessive pain in the hips, knees, and joints. Which condition could be the root cause for the
development of these symptoms?
1. Dumping syndrome
2. Hypogonadism
3. Insulinoma
4. Obesity
7. A client is to undergo gastric bypass surgery. Which part of the intestine should be cut to connect to the
newly-created pouch in the superior portion of the stomach?
1. Omentum
PRIMEXAM.COM
2. Jejunum
3. Duodenum
4. Subcutaneous tissue
8. What is the basal metabolic rate (BMR) for a 28-year-old man who weighs 65 kg and is 170 cm tall?
1. 1,616 calories/day
2. 1,166 calories/day
3. 1,161 calories/day
4. 1,661 calories/day
9. What is the basal metabolic rate (BMR) of a 26-year-old woman who weighs 55 kg and is 163 cm tall?
1. 1,345 calories/day
2. 1,543 calories/day
3. 1,453 calories/day
4. 1,354 calories/day
10. What percentage of body fat is considered to be acceptable in women?
1. 35% to 40%
2. 25% to 31%
3. 21% to 24%
4. 14% to 20%
11. What is the percentage of body fat for a man who is considered to be obese?
1. 30% to 40%
2. 20% to 25%
3. 14% to 17%
4. 6% to 13%
12. What is the lean body mass of a man whose weight is 164 lbs and body fat is 22%?
1. 128 lbs
2. 182 lbs
3. 218 lbs
4. 281 lbs
13. A client is diagnosed with a deficiency of ascorbic acid. Which disease could this condition lead to?
1. Scurvy
2. Megaloblastic anemia
3. Rickets
4. Beriberi
14. An 18-year-old client, who is within a normal weight range, admits to using laxatives and diuretics. The client
displays increased symptoms of depression and reports a sore throat and tooth decay. What question should a
nurse ask the client to evaluate if the client is suffering from bulimia nervosa?
1. “Do you engage in self-induced purging?”
2. “Do you suffer from constipation?”
3. “Do you have hypertension?”
4. “Do you have a habit of starving intentionally?”
15. Which vitamin works in close correlation with the parathyroid hormones to regulate the absorption of
calcium?
1. Vitamin A
2. Vitamin C
PRIMEXAM.COM
3. Vitamin D
4. Vitamin K
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
16. Which statements are true with regard to liposuction? Select all that apply.
1. It does not involve the use of an anesthetic.
2. It is a cosmetic procedure.
3. It is associated with high mortality rates.
4. It promotes weight loss by limiting the amount of food that the client consumes.
5. It requires clients to wear compression garments preoperatively.
17. A 40-year-old client has a body mass index (BMI) of 45. The client wants to undergo gastric bypass surgery.
Which statements of the nurse would justify the advantages of the surgery? Select all that apply.
1. Gastric bypass surgery limits the volume of food consumed to one-half to 1 ounce.
2. Gastric bypass surgery is done by surgically restructuring the upper portion of the
stomach.
3. Gastric bypass surgery usually results in gradual weight loss over a long period of time.
4. Gastric bypass surgery does not involve any complications or surgical risks.
5. Gastric bypass surgery alters the ability of the stomach and small bowel to absorb calories
and nutrients.
18. A client undergoes gastric bypass surgery and reports symptoms postsurgery. Which symptoms can be
interpreted as dumping syndrome? Select all that apply.
1. Rapid food digestion
2. Abdominal cramps
3. Proximal stomach pouch herniation
4. Severe hypotension
5. Diarrhea
19. A nurse is explaining about the advantages and disadvantages of gastric banding surgery to a client who is
scheduled for the procedure. Which statements made by the nurse with regard to the advantages and
disadvantages of gastric banding surgery are correct? Select all that apply.
1. Gastric banding surgery promotes weight loss by limiting the amount of food that can be
consumed and producing early satiety.
2. Gastric banding surgery is a laparoscopic procedure and does not carry the typical risks
associated with surgery.
3. Gastric banding surgery carries no risk of a ruptured suture line.
4. Gastric banding surgery may cause vomiting.
5. Gastric banding surgery carries the risk of rapid gastric emptying.
20. A nurse is explaining about the risks of dumping syndrome to a client who recently had undergone gastric
bypass surgery. Which statements made by the nurse with regard to the risks of dumping syndrome are
correct? Select all that apply.
1. Dumping syndrome may cause excessive sweating.
2. Dumping syndrome is too severe a complication to be controlled through changes to the
diet and eating habits.
3. Dumping syndrome may place the client at risk for hyperglycemia.
4. Dumping syndrome causes a malabsorption of nutrients.
PRIMEXAM.COM
5. Dumping syndrome may cause diarrhea.
21. Which vitamins are fat-soluble? Select all that apply.
1. Vitamin A
2. Vitamin B
3. Vitamin C
4. Vitamin D
5. Vitamin E
22. Which statements are true about pharmacological interventions for weight loss? Select all that apply.
1. Weight loss medications are very effective.
2. Weight loss is short term.
3. Weight loss medications, such as over-the-counter appetite suppressants, have
sympathomimetic side effects.
4. Weight loss medications are indicated for people who have a body mass index (BMI) of 27
or greater with concurrent obesity-related medical problems.
5. Weight loss medications, such as appetite suppressants, are relatively safe and can be
bought over the counter without a prescription from a primary health-care provider.
23. A client is diagnosed with obesity as a secondary effect. Which disorder could possibly be caused by obesity?
Select all that apply.
1. Hypothyroidism
2. Prader-Willi syndrome
3. Polycystic ovarian syndrome
4. Cushing’s syndrome
5. Leptin receptor gene mutation at 7q31
24. Which statements are true with regard to free fatty acids? Select all that apply.
1. They cause glucose intolerance.
2. They send satiety signals to the brain.
3. They cause cirrhosis.
4. They are created through lipolysis.
5. They cause hypertension.
Completion
Complete each statement.
PRIMEXAM.COM
25. A client comes in for a consultation with a bariatric surgeon to inquire about surgical options to lose weight.
The client’s body mass index (BMI) is checked to see if the client would be a candidate for the bariatric
surgery. A nurse records the client’s height as 5 feet, 4 inches and weight as 258 pounds. What is the client’s
BMI? Record your answer to one decimal point.
Chapter 5: Obesity and Nutritional Imbalances
Answer Section
MULTIPLE CHOICE
1. ANS: 2
Chapter: Chapter 5, Obesity and Nutritional Imbalances
Page: 85
Objective: N/A
Difficulty: Moderate
Heading: Nutritional Imbalances
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Nutrition
1
2
3
4
Feedback
This is incorrect. A deficiency in folate causes megaloblastic anemia.
This is correct. Vitamin B is a water-soluble vitamin; therefore, it is not stored in the
body. Niacin is a component of vitamin B and is also known as vitamin B3. A deficiency
in vitamin B causes pellagra, which is characterized by a pigmented rash on sunexposed areas of the skin.
This is incorrect. A deficiency in vitamin A causes nightblindness.
This is incorrect. A deficiency in vitamin K causes bleeding and elevated prothrombin
time.
PTS: 1
CON: Nutrition
2. ANS: 1
Chapter: Chapter 5, Obesity and Nutritional Imbalances
Page: 85
Objective: N/A
Difficulty: Easy
Heading: Nutritional Imbalances
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Nutrition
1
2
Feedback
This is correct. Thiamine is a B-complex vitamin. A deficiency in thiamine causes
beriberi, which results in neuropathy and muscle weakness.
This is incorrect. Riboflavin is a B-complex vitamin. A deficiency in riboflavin causes
PRIMEXAM.COM
3
4
cheilosis, which results in fissures and irritation at the edges of the mouth.
This is incorrect. A deficiency in vitamin B6 causes neuropathy, depression, and
microcytic anemia.
This is incorrect. A deficiency in vitamin B12 causes megaloblastic anemia.
PTS: 1
CON: Nutrition
3. ANS: 1
Chapter: Chapter 5, Obesity and Nutritional Imbalances
Page: 85
Objective: N/A
Difficulty: Difficult
Heading: Eating Disorders
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Analysis [Analyzing]
Concept: Nutrition
1
2
3
4
Feedback
This is correct. Anorexia nervosa is an eating disorder wherein an individual refuses to
maintain body weight within the minimal normal standards and displays behaviors such
as a desire for perfection and other psychiatric characteristics, including social
isolation.
This is incorrect. Bulimia nervosa is an eating disorder that is characterized by bouts of
extreme overeating, which are followed by fasting or self-induced vomiting.
This is incorrect. Binge eating is an eating disorder that is characterized by the
consumption of large quantities of food in a short period of time or continuously for the
entire day.
This is incorrect. Purging disorder is an eating disorder that is characterized by selfinduced vomiting, laxative and/or diuretic use, or other extreme methods used to
control body weight or shape. Sometimes this condition leads to excessive exercise.
PTS: 1
CON: Nutrition
4. ANS: 4
Chapter: Chapter 5, Obesity and Nutritional Imbalances
Page: 82
Objective: N/A
Difficulty: Easy
Heading: Treatment
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Knowledge [Remembering]
Concept: Nutrition
1
2
Feedback
This is incorrect. The USDA recommends a 1.7 mg daily allowance for riboflavin. This
is based on a 2,000-calorie diet for adults and children who are 4 years of age or older.
This is incorrect. The USDA recommends a 60 mg daily allowance for vitamin C. This
PRIMEXAM.COM
3
4
is based on a 2,000-calorie diet for adults and children who are 4 years of age or older.
This is incorrect. The USDA recommends a 400 mg daily allowance for vitamin D.
This is based on a 2,000-calorie diet for adults and children who are 4 years of age or
older.
This is correct. The USDA recommends a 1,000 mg daily allowance for calcium. This
is based on a 2,000-calorie diet for adults and children who are 4 years of age or older.
PTS: 1
CON: Nutrition
5. ANS: 4
Chapter: Chapter 5, Obesity and Nutritional Imbalances
Page: 82
Objective: N/A
Difficulty: Easy
Heading: Treatment
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Knowledge [Remembering]
Concept: Nutrition
1
2
3
4
Feedback
This is incorrect. The USDA recommends a 20 mg daily allowance for saturated fatty
acids. This is based on a 2,000-calorie diet for adults and children who are 4 years of
age or older.
This is incorrect. The USDA recommends a 300 mg daily allowance for cholesterol.
This is based on a 2,000-calorie diet for adults and children who are 4 years of age or
older.
This is incorrect. The USDA recommends a 2,400 mg daily allowance for sodium. This
is based on a 2,000-calorie diet for adults and children who are 4 years of age or older.
This is correct. The USDA recommends a 3,500 mg daily allowance for potassium.
This is based on a 2,000-calorie diet for adults and children who are 4 years of age or
older.
PTS: 1
CON: Nutrition
6. ANS: 4
Chapter: Chapter 5, Obesity and Nutritional Imbalances
Page: 88
Objective: N/A
Difficulty: Moderate
Heading: Treatment
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Nutrition
1
Feedback
This is incorrect. Dumping syndrome causes malabsorption of important nutrients,
vitamins, and minerals.
PRIMEXAM.COM
2
3
4
This is incorrect. Hypogonadism is characterized by the reduction or absence of
hormone secretion. It is a disorder that causes obesity.
This is incorrect. An insulinoma is a tumor of the pancreas. It is also a disorder that can
cause obesity.
This is correct. Disorders that are associated with obesity include cardiovascular
disease, diabetes mellitus, osteoarthritis, sleep apnea, and diseases that affect the
gallbladder and liver. Osteoarthritis is caused by excessive weight on the knees and
hips.
PTS: 1
CON: Nutrition
7. ANS: 2
Chapter: Chapter 5, Obesity and Nutritional Imbalances
Page: 84
Objective: N/A
Difficulty: Moderate
Heading: Surgical Options
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Nutrition
1
2
3
4
Feedback
This is incorrect. The omentum is the membranous covering of the intestine. It is a
major area of fat storage in the body.
This is correct. Gastric bypass surgery involves the surgical restructure of the upper
portion of the stomach. In the procedure, the jejunum is cut and connected to the newly
created pouch in the superior portion of the stomach. This creates a smaller pouch in
which to intake and digest food.
This is incorrect. The duodenum is a part of the intestine that is located in the lower
portion of the stomach. It is bypassed in gastric bypass surgery.
This is incorrect. Subcutaneous tissue is the membranous covering of the intestine. This
is a major area of fat storage in the body.
PTS: 1
CON: Nutrition
8. ANS: 1
Chapter: Chapter 5, Obesity and Nutritional Imbalances
Page: 83
Objective: N/A
Difficulty: Difficult
Heading: Diet
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Nutrition
Feedback: To calculate BMR, use the following formula:
Men: BMR = 66 + (13.7 x weight in kg) + (5 x height in cm) – (6.8 x age in years)
PRIMEXAM.COM
= 66 + 890.5 + 850 – 190.4
= 1,616 calories/day
PTS: 1
CON: Nutrition
9. ANS: 4
Chapter: Chapter 5, Obesity and Nutritional Imbalances
Page: 83
Objective: N/A
Difficulty: Difficult
Heading: Diet
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Nutrition
Feedback: To calculate BMR, use the following formula:
Women: BMR = 655 + (9.6 x weight in kg) + (1.8 x height in cm) – (4.7 x age in years)
= 655 + 528 + 293.4 – 122.2
= 1,354 calories/day
PTS: 1
CON: Medication
10. ANS: 2
Chapter: Chapter 5, Obesity and Nutritional Imbalances
Page: 81
Objective: N/A
Difficulty: Easy
Heading: Diagnosis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Nutrition
1
2
3
4
Feedback
This is incorrect. In women, a body fat percentage that is above 32% indicates obesity,
according to the American Council on Exercise.
This is correct. In women, a body fat percentage that is above 25% and below 31% is
considered acceptable according to the American Council on Exercise.
This is incorrect. In women, a body fat percentage that is above 21% and below 24% is
considered normal according to the American Council on Exercise.
This is incorrect. In female athletes, a body fat percentage that is above 14% and below
20% is considered normal according to the American Council on Exercise.
PTS: 1
CON: Nutrition
11. ANS: 1
Chapter: Chapter 5, Obesity and Nutritional Imbalances
Page: 81
Objective: N/A
PRIMEXAM.COM
Difficulty: Easy
Heading: Diagnosis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Nutrition
1
2
3
4
Feedback
This is correct. In men, a body fat percentage that is above 26% indicates obesity
according to the American Council on Exercise.
This is incorrect. In men, a body fat percentage that is above 18% and below 25% is
considered acceptable according to the American Council on Exercise.
This is incorrect. In men, a body fat percentage that is above 14% and below 17% is
considered normal according to the American Council on Exercise.
This is incorrect. In male athletes, a body fat percentage that is above 6% and below
13% considered normal according to the American Council on Exercise.
PTS: 1
CON: Nutrition
12. ANS: 1
Chapter: Chapter 5, Obesity and Nutritional Imbalances
Page: 81
Objective: N/A
Difficulty: Difficult
Heading: Diagnosis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Nutrition
Feedback: To calculate BMR, use the following formula:
Men: Lean Body Mass = Weight × (100 – Body Fat)
= 164 x 0.78
=128 lbs
PTS: 1
CON: Nutrition
13. ANS: 1
Chapter: Chapter 5, Obesity and Nutritional Imbalances
Page: 85
Objective: N/A
Difficulty: Moderate
Heading: Nutritional Imbalances
Integrated Process: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Nutrition
Feedback
PRIMEXAM.COM
1
2
3
4
This is correct. Scurvy is a disease that occurs from a severe lack of vitamin C or
ascorbic acid in the diet.
This is incorrect. Megaloblastic anemia is caused by a folate (folic acid) deficiency.
This is incorrect. Rickets is caused by a deficiency in vitamin D.
This is incorrect. Beriberi is caused by a deficiency in vitamin B1 (thiamine). It causes
neuropathy, muscle weakness, and wasting.
PTS: 1
CON: Nutrition
14. ANS: 1
Chapter: Chapter 5, Obesity and Nutritional Imbalances
Page: 87
Objective: N/A
Difficulty: Difficult
Heading: Eating Disorders
Integrated Process: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Evaluate [Evaluating]
Concept: Nutrition
1
2
3
4
Feedback
This is correct. The nurse should ask the client if the client engages in self-induced
purging because purging is a symptom of bulimia nervosa.
This is incorrect. The nurse should not ask the client if the client suffers from
constipation because constipation is a symptom of anorexia nervosa, not bulimia
nervosa.
This is incorrect. The nurse should not ask the client if the client has hypertension
because hypertension is a symptom of binge eating.
This is incorrect. The nurse should not ask the client if the client has a habit of starving
intentionally because intentional starving is a symptom of anorexia nervosa.
PTS: 1
CON: Nutrition
15. ANS: 3
Chapter: Chapter 5, Obesity and Nutritional Imbalances
Page: 85
Objective: N/A
Difficulty: Moderate
Heading: Vitamin and Mineral Deficiencies
Integrated Process: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Knowledge [Remembering]
Concept: Nutrition
1
2
3
Feedback
This is incorrect. Vitamin A is a fat-soluble vitamin that can be stored in the liver and
fat tissue.
This is incorrect. Vitamin C is a water-soluble vitamin that is not stored in the body.
This is correct. Vitamin D is a fat-soluble vitamin that works in close correlation with
PRIMEXAM.COM
4
the parathyroid hormones to regulate the absorption of calcium.
This is incorrect. Vitamin K is a fat-soluble vitamin that plays a key role in helping the
blood to clot, thus preventing excessive bleeding.
PTS: 1
CON: Nutrition
MULTIPLE RESPONSE
16. ANS: 2, 3, 4
Chapter: Chapter 5, Obesity and Nutritional Imbalances
Page: 84
Objective: N/A
Difficulty: Difficult
Heading: Surgical Options
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Nutrition
1.
2.
3.
4.
5.
Feedback
This is incorrect. Liposuction involves the use of an anesthetic.
This is correct. Liposuction is a cosmetic procedure.
This is correct. Liposuction is a procedure that is associated with high mortality rates,
especially among clients who are morbidly obese. This results from fluid shifts that occur
during the procedure.
This is correct. Liposuction promotes weight loss by limiting the amount of food that the
client consumes.
This is incorrect. Liposuction is a procedure where compression garments are to be worn
postoperatively.
PTS: 1
CON: Nutrition
17. ANS: 1, 2, 5
Chapter: Chapter 5, Obesity and Nutritional Imbalances
Page: 84
Objective: N/A
Difficulty: Difficult
Heading: Surgical Options
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Nutrition
1.
2.
Feedback
This is correct. Gastric bypass surgery promotes weight loss by limiting the volume of food
consumed to between one-half and 1 ounce.
This is correct. Gastric bypass surgery is performed by surgically restructuring the upper
portion of the stomach to leave an extremely small pouch in place for food digestion.
PRIMEXAM.COM
3.
4.
5.
This is incorrect. Gastric bypass surgery usually results in significant weight loss in a short
period of time.
This is incorrect. Gastric bypass surgery is not without possible complications and surgical
risks.
This is correct. The connection of the stomach to the small bowel is altered in gastric
bypass surgery. The jejunum is cut and connected to the newly created pouch in the
superior portion of the stomach. The lower portion of the stomach and the duodenum are
bypassed.
PTS: 1
CON: Nutrition
18. ANS: 2, 4, 5
Chapter: Chapter 5, Obesity and Nutritional Imbalances
Page: 84
Objective: N/A
Difficulty: Moderate
Heading: Surgical Options
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Nutrition
1.
2.
3.
4.
5.
Feedback
This is incorrect. Dumping syndrome occurs when the undigested contents of the stomach
are transported or “dumped” into the small intestine too rapidly.
This is correct. Abdominal cramps are a symptom that occurs shortly after eating.
This is incorrect. Proximal stomach pouch herniation and suture line rupture are surgical
complications related to obesity.
This is correct. Tachycardia and severe hypotension can occur hours after eating.
This is correct. Diarrhea can occur hours after eating.
PTS: 1
CON: Nutrition
19. ANS: 1, 4, 5
Chapter: Chapter 5, Obesity and Nutritional Imbalances
Page: 84
Objective: N/A.
Difficulty: Difficult
Heading: Surgical Options
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Nutrition, Perioperative
1.
2.
Feedback
This is correct. Gastric banding surgery involves placing a band around the upper portion
of the stomach to create a small pouch to hold food. The band limits the amount of food a
client can eat by making the client feel full after eating small amounts of food.
This is incorrect. Gastric banding surgery is a laparoscopic procedure, but carries all of the
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3.
4.
5.
typical risks associated with any major surgery. The risks include rupture of the suture line,
infection, and bleeding at the surgical site.
This is incorrect. One of the postoperative risks of gastric banding surgery is the rupture of
the suture line.
This is correct. Vomiting may be a side effect of gastric banding surgery when the banding
is too tight for the client to tolerate.
This is correct. One of the risks of gastric banding surgery is a malabsorption disorder
called rapid gastric emptying or dumping syndrome, where the undigested contents of the
stomach are transported or “dumped” into the small intestine too rapidly.
PTS: 1
CON: Nutrition, Perioperative
20. ANS: 1, 3, 4, 5
Chapter: Chapter 5, Obesity and Nutritional Imbalances
Page: 84
Objective: N/A.
Difficulty: Moderate
Heading: Surgical Options
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment - Management of Care
Cognitive Level: Application [Applying]
Concept: Nutrition: Perioperative
1.
2.
3.
4.
5.
Feedback
This is correct. Dumping syndrome may cause excessive sweating hours after eating.
This is incorrect. Changing diet and eating habits may help control dumping syndrome.
High-sugar foods may exacerbate symptoms.
This is correct. Dumping syndrome may place the client at risk for hypoglycemia or low
blood sugar.
This is correct. Dumping syndrome causes a malabsorption of nutrients, vitamins, and
minerals.
This is correct. Dumping syndrome causes diarrhea.
PTS: 1
CON: Nutrition: Perioperative
21. ANS: 1, 4, 5
Chapter: Chapter 5, Obesity and Nutritional Imbalances
Page: 85
Objective: N/A
Difficulty: Easy
Heading: Vitamin and Mineral Imbalances
Integrated Process: Nursing Process
Client Need: Safe and Effective Care Environment - Management of Care
Cognitive Level: Knowledge [Remembering]
Concept: Nutrition
1.
Feedback
This is correct. Vitamin A is a fat-soluble vitamin. Fat-soluble vitamins are absorbed
through the intestinal tract and are stored in the liver and in fatty tissue.
PRIMEXAM.COM
2.
3.
4.
5.
This is incorrect. B vitamins are water-soluble vitamins. Water-soluble vitamins are not
stored in the body, but are readily excreted from the body.
This is incorrect. Vitamin C is a water-soluble vitamin. Water-soluble vitamins are not
stored in the body, but are readily excreted from the body.
This is correct. Vitamin D is a fat-soluble vitamin that dissolves in fat and is accumulated
in the tissues of the body. It is necessary to prevent and treat rickets, weak bones, and bone
loss. Maximum vitamin D intake is obtained through exposure to sunlight.
This is correct. Vitamin E is a fat-soluble vitamin that dissolves in fat and is accumulated
in the tissues of the body.
PTS: 1
CON: Nutrition
22. ANS: 2, 3, 4
Chapter: Chapter 5, Obesity and Nutritional Imbalances
Page: 83
Objective: N/A
Difficulty: Moderate
Heading: Pharmacology
Integrated Process: Nursing Process
Client Need: Safe and Effective Care Environment - Management of Care
Cognitive Level: Application [Applying]
Concept: Nutrition
1.
2.
3.
4.
5.
Feedback
This is incorrect. Weight loss medications are only modestly effective and work best as an
adjunct to lifestyle changes, such as eating a healthy, low-calorie diet and being physically
active.
This is correct. Weight loss medications usually have only a short-term effect. In a large
number of clients, weight is often regained as soon as the treatment is stopped.
This is correct. Weight loss medications have sympathomimetic side effects or those that
mimic the effects of the sympathetic nervous system, affecting the heart by increasing the
heart rate and the circulation by constricting blood vessels.
This is correct. Weight loss medications are indicated for client who have a relatively
“safe” BMI of 27 or greater, but who have concurrent obesity-related medical problems.
This is incorrect. Appetite suppressants are available over the counter or with a
prescription; however, both have side effects. Appetite suppressants obtained with a
prescription should only be used for a short period of time. Over-the-counter appetite
suppressants have sympathomimetic side effects.
PTS: 1
CON: Nutrition
23. ANS: 1, 3, 4
Chapter: Chapter 5, Obesity and Nutritional Imbalances
Page: 78
Objective: N/A
Difficulty: Difficult
Heading: Risk Factors
Integrated Process: Nursing Process
Client Need: Health Promotion and Maintenance
PRIMEXAM.COM
Cognitive Level: Analysis [Analyzing]
Concept: Nutrition
1.
2.
3.
4.
5.
Feedback
This is correct. Hypothyroidism results in a lack of the thyroid hormone, which can cause
obesity. Once hypothyroidism is treated, the weight gain is usually remedied, thus making
this a secondary cause of weight gain.
This is incorrect. Prader-Willi syndrome is a genetic disorder that directly leads to weight
gain because of hyperphagia or excessive hunger.
This is correct. Polycystic ovarian syndrome results in weight gain. Once this syndrome is
controlled, weight gain can be rectified, thus making this a secondary cause of weight gain.
This is correct. Cushing’s syndrome is caused by the overactivity of the adrenal gland. It
also causes weight gain. Treatment of Cushing’s syndrome will rectify the weight gain,
thus making this a secondary cause of weight gain.
This is incorrect. Leptin receptor gene mutation at 7q31 is a genetic condition that causes
obesity.
PTS: 1
CON: Nutrition
24. ANS: 1, 3, 4
Chapter: Chapter 5, Obesity and Nutritional Imbalances
Page: 80
Objective: N/A
Difficulty: Easy
Heading: Adipokines
Integrated Process: Nursing Process
Client Need: Safe and Effective Care Environment - Management of Care
Cognitive Level: Knowledge [Remembering]
Concept: Nutrition
1.
2.
3.
4.
5.
Feedback
This is correct. Excess free fatty acids disturb the pancreas, which leads to a reduced
secretion of insulin and, consequently, glucose intolerance.
This is incorrect. Leptin is released into the blood when fat stores rise in adipocytes,
sending satiety signals to the brain.
This is correct. Excess free fatty acids are deposited in the liver, causing nonalcoholic
steatohepatitis, which leads to cirrhosis.
This is correct. Free fatty acids are created during the process of lipolysis. Lipolysis
involves the hydrolysis of triglycerides into glycerol and free fatty acids.
This is incorrect. There is a clear correlation between high levels of angiotensinogen and
hypertension.
PTS: 1
CON: Nutrition
COMPLETION
25. ANS:
44.3
PRIMEXAM.COM
Chapter: Chapter 5, Obesity and Nutritional Imbalances
Page: 81-82
Objective: N/A.
Difficulty: Difficult
Heading: Diagnosis
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Nutrition
Feedback: Surgical treatments for obesity are offered to clients who have a BMI of 40 or greater, and clients
who have a BMI between 35 and 40 and who have medical problems related to obesity.
Body Mass Index (BMI) = Weight in pounds × 703 / height in inches / height in inches
Height in inches = 5 feet × 12 = 60 inches + 4 inches = 64 inches
Weight in pounds = 258 × 703 = 181,374
BMI = (181,374 / 64) / 64 = 44.3
PTS: 1
CON: Nutrition
PRIMEXAM.COM
Chapter 6: Pain
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. Which statement is related to a simplex reflex arc?
1. Interpretation of the brain is necessary when it occurs in the body.
2. An efferent neuron connects with an interneuron in the substantia gelatinosa.
3. An interneuron connects to an afferent neuron that exits through the ventral horn.
4. An afferent neuron carries sensory impulses into the dorsal horn of the spinal cord.
2. Pain that is dull or aching and that occurs in certain parts of the body is referred to as deep somatic pain.
Explain how somatic pain is different from other pain.
1. Pain that occurs from ligaments, tendons, and bones
2. Pain originating in an amputated part of the body
3. Pain from deep organs resulting from disease processes
4. Pain originating from the chest and left arm
3. Pain is an unpleasant sensation that is associated with disease. The process by which people experience pain
occurs in four phases. Choose the first phase that converts painful stimuli into neuronal impulses.
1. Perception
2. Modulation
3. Transduction
4. Transmission
4. Which statement is related to gate control theory?
1. The first neuron is an interneuron.
2. The second neuron is an afferent neuron.
3. Sensation travels both to and from the brain.
4. The interneuron is influenced by descending nerve tracts from the spinal cord.
5. A 40-year-old client experiences problems such as sleeplessness, fear, irritability, anxiety, and stress. The
client has pain that lasts longer than 6 months. Which type of pain can be diagnosed from the symptoms?
1. Acute pain
2. Chronic pain
3. Neuropathic pain
4. Phantom limb pain
6. What is the process by which the body responds to nonpharmacological treatments to relieve pain?
1. The body responds by secreting inflammatory mediators.
2. The body responds by secreting endothelin-1.
3. Nonpharmacological treatments activate the body’s prostaglandins.
4. Nonpharmacological treatments activate the body’s own endorphins and enkephalins.
7. A client presents with a greater than 3-month history of widespread aches and pains. The client also points to
several tender locations. On further questioning, the client mentions disturbed sleep and feeling fatigued.
Which is the likely diagnosis for the client?
1. Complex regional pain syndrome
2. Fibromyalgia
3. Spinal nerve radiculopathy
PRIMEXAM.COM
4. Trigeminal neuralgia
8. A client presents with symptoms of trigeminal neuralgia and wants the best pain management available.
Which treatment will address the client’s need?
1. Surgery
2. Acupuncture
3. Guided imagery
4. Anticonvulsants
9. A client presents with symptoms of fibromyalgia. Which treatment option can be offered to the client?
1. Curative prescription drugs
2. Relieving and coping therapies
3. Preventive vaccines
4. Surgery
10. A client complains of headaches during morning hours and sleep, and also rhinorrhea and tearing of the eye.
Which type of headache is likely to be diagnosed for the client?
1. Tension headache
2. Migraine
3. Cluster headache
4. Cephalgia
11. Some forms of complex regional pain syndrome have no causes, and in some cases there are precipitating
factors. What is the precipitating factor of complex regional pain syndrome?
1. Injury and surgery
2. Viral infection
3. Brain tumor
4. Radiculitis
12. A client presents with episodic headache associated with muscular tightness in the neck and shoulders. The
client is given a diagnosis of tension headaches based on which symptom?
1. Sharp, stabbing pain in the face with radiation to the jaw
2. Bandlike pain sensation in the head
3. Throbbing headache with associated symptoms of nausea
4. A perception of lights flashing in the visual field
13. A client comes in with symptoms typical of a migraine attack. Which treatment option is the most apt for the
client?
1. Tricyclic antidepressants
2. Beta blockers
3. Sumatriptan
4. Anticonvulsants
14. A client complains of pain in the neck that radiates down the right arm with numbness in the fingers. What
would the client most likely be checked for?
1. Postherpetic neuralgia
2. Fibromyalgia
3. Complex regional pain syndrome
4. Cervical radiculopathy
Multiple Response
PRIMEXAM.COM
Identify one or more choices that best complete the statement or answer the question.
15. What are the characteristics of afferent neurons? Select all that apply.
1. They are motor nerves.
2. They extend to the muscles of the body.
3. They enter the dorsal horn.
4. They exit through the ventral horns.
5. They carry pressure sensations into the spinal cord.
16. Which are the features of A-delta fibers? Select all that apply.
1. Myelinated
2. Persisting dull pain
3. Small in diameter
4. Cause long-lasting pain
5. Conduct impulses slowly
17. The spinothalamic tract is a sensory pathway from the skin to the thalamus. Select the clinical significance of
the spinothalamic tract. Select all that apply.
1. Cross over at the medulla
2. Exit through the ventral horn
3. Descend downward in the spinal cord
4. Direct sensory neuronal impulses to hypothalamus
5. Direct sensory neuronal impulses to the upper regions of the brain cortex
18. A client visits a primary health-care provider and complains of pain. The primary health-care provider
diagnoses the pain as neuropathic pain. Which are the symptoms of neuropathic pain? Select all that apply.
1. Arises as a result of sustained noxious stimuli
2. Is often acute and chronic
3. Is burning, tingling, and shooting in sensation
4. Occurs in the skin, muscles, and bones
5. Leads to conditions such as postherpetic neuralgias and spinal nerve radiculopathy
19. Which steps are necessary to identify the severity of pain in a client? Select all that apply.
1. It is necessary to ask if the pain is aching, throbbing, or stabbing.
2. It is unnecessary to use a 0 to 10 scale.
3. It is necessary to ask the client for a number to describe the severity of pain.
4. It is necessary to ask about the associated symptoms such as depression.
5. It is unnecessary to obtain the history of the client.
20. Which clinical criteria should the physician follow to analyze pain? Select all that apply.
1. Examine the area of pain first.
2. Assess the history of the client.
3. Listen to the client’s complaint of pain.
4. Assess the pain.
5. Allow the client to point to the area of pain after a physical exam.
21. A 35-year-old client presents with colicky pain. When seeking a diagnosis, which conditions are likely to be
causing the pain in the client? Select all that apply.
1. Hyperperistalsis
2. Muscular spasm
3. Cholecystitis
PRIMEXAM.COM
4. Esophagitis
5. Abdominal pain
22. Depression is common in clients with chronic pain. Identify the signs and symptoms than can be observed in
a client with depression. Select all that apply.
1. Increased appetite
2. Restricted activity levels
3. Excess sleep
4. Hyperfocus or concentration
5. Chronic fatigue
23. A client prefers nonpharmacological treatment for regional complex pain syndrome. What treatment options
can be offered to the client? Select all that apply.
1. Counseling
2. Alternative medicine
3. Acupuncture
4. Transcutaneous electrical neural stimulation (TENS)
5. Guided imagery
24. Which statements are true regarding intradiscal electrothermal therapy (IDET)? Select all that apply.
1. It uses thoughts and suggestions to guide the imagination.
2. It uses heat to modify the nerve fibers of a spinal disc.
3. It uses electrodes to deliver electrical current through the skin.
4. It uses a wire called an electrothermal catheter that is placed through an incision into the
spinal disc.
5. It uses thin solid metallic needles.
25. A nursing instructor is educating student nurses on the cause of bone pain in cancer clients. Which statement
by a nurse student indicates effective learning? Select all that apply.
1. “Metastasis of cancer to the bones is one of the reasons for bone pain.”
2. “Entrapment of the spinal nerve in a herniated disc is a reason for bone pain.”
3. “Excess glucose in the nerves leads to structural breakdown of the nerves.”
4. “A tumor within the bone can cause bone pain.”
5. “Enzyme and inflammatory mediators cause bone pain.”
PRIMEXAM.COM
Chapter 6: Pain
Answer Section
MULTIPLE CHOICE
1. ANS: 4
Chapter: Chapter 6, Pain
Page: 94
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts Related to Pain
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Sensory Perception: Neurologic Regulation
1
2
3
4
Feedback
A simple reflex arc occurs in the body without the need for interpretation of the brain.
An afferent neuron connects with an interneuron in the substantia gelatinosa.
An interneuron connects to an efferent neuron that exits through the ventral horn and
enacts motor activity.
An afferent neuron carries sensory impulses into the dorsal horn of the spinal cord.
PTS: 1
CON: Sensory Perception: Neurologic Regulation
2. ANS: 1
Chapter: Chapter 6, Pain
Page: 100
Objective: N/A
Difficulty: Moderate
Heading: Sources of Pain
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Comfort
1
2
3
4
Feedback
Pain that originates from ligaments, tendons, bones, blood vessels, and nerves is known
as deep somatic pain.
Pain originating in an amputated part of the body is known as phantom pain.
Pain from deep organs usually resulting from disease processes is known as visceral
pain.
Pain that occurs when nerve fibers from regions of high sensory input and nerves from
regions of normally low sensory input converge on the same levels of the spinal cord is
known as referred pain. The pain originates from the chest and left arm.
PTS: 1
CON: Comfort
PRIMEXAM.COM
3. ANS: 3
Chapter: Chapter 6, Pain
Page: 97, 98
Objective: N/A
Difficulty: Difficult
Heading: Basic Pathophysiological Concepts Related to Pain
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Evaluation [Evaluating]
Concept: Comfort
1
2
3
4
Feedback
The conscious awareness of the experience of pain is known as perception.
Other neurons that have influence on the afferent neuron in the spinal cord are known
as modulation.
The initial process of converting painful stimuli into neuronal impulses is known as
transduction.
The travel of the impulse along the nerve’s axon is known as transmission.
PTS: 1
CON: Comfort
4. ANS: 3
Chapter: Chapter 6, Pain
Page: 98, 99
Objective: N/A
Difficulty: Easy
Heading: Basic Pathophysiological Concepts Related to Pain
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Comfort
1
2
3
4
Feedback
The first neuron is an afferent neuron. It is stimulated by pain in the periphery and an
impulse travels into the spinal cord.
The second neuron is an interneuron. It is influenced by descending nerve tracts from
the brain.
Neural signals continue up to the brain where interpretation occurs and can also come
down from the brain to the neurons in the spinal cord.
The interneuron is influenced by descending nerve tracts from the brain or ascending
nerve tracts from the spinal cord.
PTS: 1
CON: Comfort
5. ANS: 2
Chapter: Chapter 6, Pain
Page: 99
Objective: N/A
Difficulty: Difficult
PRIMEXAM.COM
Heading: Basic Pathophysiological Concepts Related to Pain
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Comfort
1
2
3
4
Feedback
Acute pain is experienced immediately after tissue injury.
Chronic pain is a prolonged pain sensation that may or may not be related to tissue
injury.
Neuropathic pain is a feeling of pain perpetuated by dysfunctional neurons. It is often
difficult for the client to describe the pain.
Phantom limb pain occurs after a client undergoes an amputation.
PTS: 1
CON: Comfort
6. ANS: 4
Chapter: 6, Pain
Page: 108
Objective: N/A
Difficulty: Easy
Heading: Treatment
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Basic Comfort and Care
Cognitive Level: Comprehension [Understanding]
Concept: Comfort
1
2
3
4
Feedback
Rather than relieving cancer pain, the cancer cells that secrete inflammatory mediators
penetrate and irritate tissues.
Endothelin-1 is a strong vasoconstrictor released by tumors that decreases circulation
and causes pain.
Tumors secrete prostaglandins that cause pain, edema, and constant inflammation.
Nonpharmacological pain interventions are thought to be effective because they
activate the body’s own endorphins and enkephalins that relieve pain.
PTS: 1
CON: Comfort
7. ANS: 2
Chapter: Chapter 6, Pain
Page: 108
Objective: N/A
Difficulty: Difficult
Heading: Selected Clinical Pain Syndromes
Client Need: Physiological Integrity: Basic Comfort and Care
Cognitive Level: Analysis [Analyzing]
Concept: Sleep, Rest, and Activity
Feedback
PRIMEXAM.COM
1
2
3
4
Complex regional pain syndrome will have symptoms of edema and discoloration of
the skin.
Presence of tender points and widespread aches and pain is characteristic of
fibromyalgia.
Spinal nerve radiculopathy either presents as pain in the leg or arm.
Trigeminal neuralgia presents as sharp, stabbing pain in the face.
PTS: 1
CON: Sleep, Rest, and Activity
8. ANS: 1
Chapter: Chapter 6, Pain
Page: 109
Objective: N/A
Difficulty: Difficult
Heading: Selected Clinical Pain Syndromes
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Basic Comfort and Care
Cognitive Level: Analysis [Analyzing]
Concept: Perioperative
1
2
3
4
Feedback
Persistent trigeminal neuralgia that is not relieved by other measures leaves no choice
but surgery to relieve pressure on the trigeminal nerve.
Acupuncture has been found to be effective for some pain, but not pain caused by
trigeminal neuralgia.
Guided imagery can be used to address bad habits like smoking but will not be able to
relieve the pain from trigeminal neuralgia.
Anticonvulsants are acceptable if the pain is not persistent, but for persistent pain,
surgery would be considered the best option.
PTS: 1
CON: Perioperative
9. ANS: 2
Chapter: Chapter 6, Pain
Page: 110
Objective: N/A
Difficulty: Difficult
Heading: Selected Clinical Pain Syndromes
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Basic Comfort and Care
Cognitive Level: Analysis [Analyzing]
Concept: Comfort
1
2
3
Feedback
Since the cause of fibromyalgia is not known, there are no curative prescription drugs
available. Therefore, side effects can only be minimized.
The client is provided with coping strategies. Also, pain-relieving therapies such as
physical therapy or muscle relaxants are provided for the client.
Since the cause of fibromyalgia is unknown, there are no preventive vaccines.
PRIMEXAM.COM
4
Surgery is not an option as the pain is not localized but is a spreading type of pain.
PTS: 1
CON: Comfort
10. ANS: 3
Chapter: Chapter 6, Pain
Page: 111
Objective: N/A
Difficulty: Moderate
Heading: Selected Clinical Pain Syndromes
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Basic Comfort and Care
Cognitive Level: Application [Applying]
Concept: Sensory Perception
1
2
3
4
Feedback
Tension headache is not associated with rhinorrhea or tearing eyes.
Migraines are not associated with rhinorrhea.
The hallmark of cluster headaches is tearing of the eye and rhinorrhea. Cluster
headaches also occur during sleep or the morning hours.
Cephalgia is just a general term for headaches.
PTS: 1
CON: Sensory Perception
11. ANS: 1
Chapter: Chapter 6, Pain
Page: 99
Objective: N/A
Difficulty: Easy
Heading: Selected Clinical Pain Syndromes
Integrated Process: Nursing process
Client Need: Physiological Integrity: Basic Comfort and Care
Cognitive Level: Knowledge [Remembering]
Concept: Perioperative
1
2
3
4
Feedback
Injury and surgery have been known to trigger complex regional pain syndrome.
Complex regional pain syndrome is not triggered by viral infections.
Complex regional pain syndrome is not triggered by a brain tumor.
Radiculitis is spinal nerve impingement and causes sciatica or cervical radiculopathy.
PTS: 1
CON: Perioperative
12. ANS: 2
Chapter: Chapter 6, Pain
Page: 111
Objective: N/A
Difficulty: Difficult
Heading: Selected Clinical Pain Syndromes
Integrated Process: Nursing Process
PRIMEXAM.COM
Client Need: Physiological Integrity: Basic Comfort and Care
Cognitive Level: Analysis [Analyzing]
Concept: Comfort
1
2
Feedback
Sharp, stabbing radiating pain is characteristic of cluster headaches.
Tension headaches present as a bandlike sensation in the head.
3
Throbbing headaches with associated symptoms of nausea are characteristic of
migraines.
4
Flashing lights in the visual field precede a migraine headache.
PTS: 1
CON: Comfort
13. ANS: 3
Chapter: Chapter 6, Pain
Page: 111
Objective: N/A
Difficulty: Moderate
Heading: Selected Clinical Pain Syndromes
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Medication
1
2
3
Feedback
Tricyclic antidepressants are used to prevent migraines, not treat migraines.
Beta blockers are used to prevent migraines, not treat migraines.
Sumatriptan is a selective serotonin receptor agonist that is used to treat migraines.
4
Anticonvulsants are used to treat trigeminal neuralgia.
PTS: 1
CON: Medication
14. ANS: 4
Chapter: Chapter 6, Pain
Page: 109
Objective: N/A
Difficulty: Moderate
Heading: Selected Clinical Pain Syndromes
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Basic Comfort and Care
Cognitive Level: Application [Applying}
Concept: Comfort
1
Feedback
If the client has not had a prior history of vesicular rash, there would be no need to
check for postherpetic neuralgia.
PRIMEXAM.COM
2
3
4
If the client has no tender points and does not have a greater than 3-month history of
pain and aches, there would be no cause to check for fibromyalgia.
If there is no history of severe pain, edema, or discoloration of the skin, there would be
no cause to check for complex regional pain syndrome.
Cervical radiculopathy is entrapment of spinal nerves in the cervical region that causes
pain in the neck that radiates to the arm associated with the numbness.
PTS: 1
CON: Comfort
MULTIPLE RESPONSE
15. ANS: 3, 5
Chapter: Chapter 6, Pain
Page: 93
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts Related to Pain
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Sensory Perception
1.
2.
3.
4.
5.
Feedback
This is incorrect. Efferent neurons are motor nerves.
This is incorrect. Efferent neurons extend to the muscles of the body.
This is correct. Afferent neurons enter the dorsal horn.
This is incorrect. Efferent neurons exit the spinal cord through the ventral horn.
This is correct. Afferent neurons are sensory nerves that carry pain, temperature, touch,
and pressure sensations into the spinal cord.
PTS: 1
CON: Sensory Perception
16. ANS: 1, 3
Chapter: Chapter 6, Pain
Page: 94
Objective: N/A
Difficulty: Easy
Heading: The Central Nervous System and Pain
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Neurologic Regulation
1.
2.
3.
4.
Feedback
This is correct. A-delta fibers are myelinated.
This is incorrect. A-delta fibers cause the first, short-lived acute experience of pain.
This is correct. A-delta fibers are small in diameter.
This is incorrect. C-delta fibers cause persistent dull pain.
PRIMEXAM.COM
5.
This is incorrect. A-delta fibers conduct impulses rapidly.
PTS: 1
CON: Neurologic Regulation
17. ANS: 4, 5
Chapter: Chapter 6, Pain
Page: 94
Objective: N/A
Difficulty: Difficult
Heading: Basic Concepts Related to Pain
Integrated Processes: Nursing Process
Client Need: Physiological Integrity
Cognitive Level: Evaluation [Evaluating]
Concept: Neurological Regulation
1.
2.
3.
4.
5.
Feedback
This is incorrect. Motor neurons cross over at the medulla to control the opposite side of
the body.
This is incorrect. Motor neurons exit through the ventral horn of the spinal cord.
This is incorrect. Motor neurons descend downward in the spinal cord.
This is correct. The spinothalamic tract directs sensory neuronal impulses from the spinal
cord to the hypothalamus.
This is correct. The spinothalamic tract directs sensory neuronal impulses from the spinal
cord up through the brainstem to the upper region of the brain cortex.
PTS: 1
CON: Comfort
18. ANS: 2, 3, 5
Chapter: Chapter 6, Pain
Page: 99
Objective: N/A
Difficulty: Moderate
Heading: Types of Pain
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiologic Adaptation
Cognitive Level: Application [Applying]
Concept: Sensory Perception
1.
2.
3.
4.
5.
Feedback
This is incorrect. Sustained noxious stimuli such as persistent inflammation can cause
chronic pain.
This is correct. Neuropathic pain is a kind of pain that cannot be described as either acute
or chronic.
This is correct. Neuropathic pain usually causes a burning, tingling, and shooting
sensation.
This is incorrect. Neuropathic pain occurs in the legs, back, feet, and thighs.
This is correct. Neuropathic pain is caused by disorders such as postherpetic neuralgias,
spinal nerve radiculopathy, and diabetic polyneuropathy.
PRIMEXAM.COM
PTS: 1
CON: Sensory Perception
19. ANS: 1, 3, 4
Chapter: Chapter 6, Pain
Page: 101
Objective: N/A
Difficulty: Moderate
Heading: Pain Assessment
Integrated Processes: Nursing Process
Client Need: Physiological Integrity
Cognitive Level: Application [Applying]
Concept: Assessment
1.
2.
3.
4.
5.
Feedback
This is correct. The clinician should ask the client if the pain is throbbing, aching, stabbing,
crushing, or piercing.
This is incorrect. A clinician can use a 0 to 10 scale to know the severity of pain.
This is correct. The client should be asked for a number that describes the severity of the
pain.
This is correct. The clinician should ask about associated symptoms, such as depression,
anxiety, anorexia, and nausea.
This is incorrect. The clinician should obtain the history of the client to assess the pain and
accompanying symptoms.
PTS: 1
CON: Assessment
20. ANS: 2, 3, 4
Chapter: Chapter 6, Pain
Page: 101
Objective: N/A
Difficulty: Moderate
Heading: Pain Assessment
Integrated Processes: Nursing Process
Client Need: Physiological Integrity
Cognitive Level: Application [Applying]
Concept: Comfort
1.
2.
3.
4.
5.
Feedback
This is incorrect. The area of pain should be examined by the clinician at the end.
This is correct. The history of the client should be examined thoroughly.
This is correct. The client’s complaint of pain should be listened to by the clinician.
This is correct. Pain (referred to as the fifth vital sign) should be assessed.
This is incorrect. The client should be allowed to point to the area of pain before the
physical exam.
PTS: 1
CON: Comfort
21. ANS: 1, 2, 3
Chapter: Chapter 6, Pain
Page: 101
PRIMEXAM.COM
Objective: N/A
Difficulty: Difficult
Heading: Pain Assessment
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Inflammation
1.
2.
3.
4.
5.
Feedback
This is correct. Spasmodic pain such as hyperperistalsis within hollow organs can cause
colicky pain.
This is correct. If the hollow organ is the intestine, its muscular walls can cause colicky
pain.
This is correct. The muscular walls of the gallbladder can spasm around a gallstone causing
colicky pain.
This is incorrect. Myocardial pain can present like epigastric pain of the esophagus.
This is incorrect. When there is a rupture of an organ beneath the diaphragm, free air can
escape from the organ and causes abdominal pain.
PTS: 1
CON: Inflammation
22. ANS: 1, 2, 5
Chapter: Chapter 6, Pain
Page: 103
Objective: N/A
Difficulty: Difficult
Heading: Basic Pathophysiological Concepts Related to Pain
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Mood
1.
2.
3.
4.
5.
Feedback
This is correct. A client with depression may have increased or decreased appetite.
This is correct. It is common for a depressed individual’s activities to become restricted.
This is incorrect. Sleep loss and poor-quality sleep are more common in clients with
depression than excessive sleepiness.
This is incorrect. A client with depression may have decreased concentration.
This is correct. Chronic fatigue is a condition characterized by persistent fatigue. This
condition can be seen in a client with depression.
PTS: 1
CON: Mood
23. ANS: 3, 4, 5
Chapter: Chapter 6, Pain
Page: 108
Objective: N/A
Difficulty: Difficult
Heading: Treatment
PRIMEXAM.COM
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Basic Care and Comfort
Cognitive Level: Analysis [Analyzing]
Concept: Comfort
1.
2.
3.
4.
5.
Feedback
This is incorrect. Counseling is not an option for clients with complex regional pain
syndrome as their pain is not imagined.
This is incorrect. Alternative medicine is not an option for complex regional pain
syndrome.
This is correct. Acupuncture relieves pain by inserting thin needles along invisible energy
channels called meridians along the length of the body.
This is correct. TENS uses a low-voltage electrical current to help relieve pain.
This is correct. Guided imagery promotes relaxation by allowing the body to respond to an
imagined scenario as real.
PTS: 1
CON: Comfort
24. ANS: 2, 4
Chapter: Chapter 6, Pain
Page: 108
Objective: N/A
Difficulty: Easy
Heading: Treatment
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Basic Comfort and Care
Cognitive Level: Knowledge [Remembering]
Concept: Comfort
1.
2.
3.
4.
5.
Feedback
This is incorrect. Thoughts and suggestions are used in guided imagery.
This is correct. IDET is a thermal therapy that uses heat.
This is incorrect. Electric current is used as therapy in transcutaneous electrical neural
stimulation (TENS).
This is correct. Heat is delivered to the spinal disc via an electrothermal catheter.
This is incorrect. Thin solid metallic needles are used in acupuncture.
PTS: 1
CON: Comfort
25. ANS: 1, 4, 5
Chapter: Chapter 6, Pain
Page: 109
Objective: N/A
Difficulty: Moderate
Heading: Selected Clinical Pain Syndromes
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Cellular Regulation
PRIMEXAM.COM
1.
2.
3.
4.
5.
Feedback
This is correct. Metastatic cancer cells in the bone weaken the bone matrix causing pain
and compromising skeletal strength.
This is incorrect. Spinal nerve impingement by a herniated disk is not a reason for cancerrelated bone pain.
This is incorrect. Cancer does not lead to hyperglycemia of nerve cells.
This is correct. A tumor within the bone can involve endosteal and haversian nerves, which
can cause pain.
This is correct. Tumors secrete enzyme and inflammatory mediators that produce dull bone
pain.
PTS: 1
CON: Cellular Regulation
PRIMEXAM.COM
Chapter 7: Fluid and Electrolyte Imbalances
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. What is oncotic pressure?
1. The pushing force exerted by water in the bloodstream.
2. The pressure exerted by electrolytes in the bloodstream.
3. The force exerted by albumin in the bloodstream.
4. None of the above.
2. Which IV fluids should be avoided for a client with cerebral edema?
1. Isotonic solution
2. Hypertonic solution
3. Hypotonic solution
4. None of the above
3. A client’s lab results show overproduction of aldosterone. What is the best nursing intervention to maintain
serum electrolytes levels in the client?
1. Administration of spironolactone
2. Recommendation of sodium-rich foods
3. Administer sodium chloride injection
4. Give magnesium sulfate injection
4. A registered nurse is teaching a student nurse about the reason for the development of natriuresis. Which
statement made by the student nurse indicates effective teaching?
1. “Natriuresis develops as a result of the excretion of large amounts of sodium.”
2. “Natriuresis develops as a result of the excretion of large amounts of potassium.”
3. “Natriuresis develops as a result of increased concentration of potassium and water in the
blood.”
4. “Natriuresis develops as a result of the reabsorption of sodium into the bloodstream.”
5. A client has +3 pitting edema on the feet and also has ascites. What is the most important clinical feature to be
monitored given this condition?
1. Hemoglobin level
2. Serum albumin level
3. Red blood cells count
4. White blood cells count
6. During evaluation of a client who has undergone a bariatric surgery, the nurse finds that the client has an
abnormally rapid heartbeat and hypotension. Which condition has the client developed?
1. Dehydration
2. Hypervolemia
3. Hypernatremia
4. None of the above
7. A nurse is caring for a client who has undergone cardiac surgery. What is the best method to assess the client’s
fluid loss or gain?
1. Measuring body weight and vital signs every day
2. Recording blood pressure and calorie intake every day
PRIMEXAM.COM
3. Recording 24-hour fluid intake and output and calorie intake
4. Taking waist measurement and placing a Foley catheter
8. Which substance can reduce the body’s response to cardiac drugs?
1. Calcium
2. Sodium
3. Potassium
4. Magnesium
9. A 55-year-old hypervolemic client has headache, muscle cramp, vomiting, and looks confused. Which
condition has the client developed?
1. Hyponatremia
2. Hypernatremia
3. Hypokalemia
4. Hypocalcemia
10. What is the best intervention to correct hypervolemic hyponatremia in a client diagnosed with a serum sodium
level of 120 mEq/L?
1. Administration of tolvaptan
2. Administration of sevelamer
3. Administration of alendronate
4. None of the above
11. What is the daily potassium requirement of humans for optimal cell functioning?
1. 20 mEq
2. 60 mEq
3. 3.5 mEq
4. 8.5 mEq
12. A client is on digitalis and the lab results show that the client is hypokalemic. What effect could hypokalemia
have on the drug administered?
1. It might cause pericarditis.
2. It can cause digitalis toxicity.
3. It can increase the effectiveness of digitalis.
4. It might not have any effect on digitalis.
13. A physician orders IV potassium infusion for a hypokalemic client. Which intervention should be avoided by
the nurse while administering IV potassium?
1. Administration of hypertonic potassium chloride IV bolus
2. Administration of diluted IV potassium
3. Administration of 20 mEq of potassium chloride
4. Slow administration of potassium supplements
14. Which condition causes pseudohypocalcemia?
1. Hyperkalemia
2. Hyponatremia
3. Hypophosphatemia
4. Hypoalbuminemia
15. A client has increased serum phosphorus levels. Which condition related to hyperphosphatemia would the
nurse expect to find in the client?
1. Hypocalcemia
PRIMEXAM.COM
2. Hypernatremia
3. Hypomagnesaemia
4. Hyperkalemia
16. Which substance is transported to the cells by facilitated transport?
1. Glucose
2. Sodium
3. Potassium
4. Albumin
17. A client’s serum phosphorus level is 5.5 mg/dL. Which clinical manifestations would the client exhibit?
1. Tetany and hypotension
2. Tetany and muscle weakness
3. Ataxia and hypertension
4. Muscle weakness and tremor
18. A client has hypertension and elevated serum calcium concentration. Which condition is likely to occur in the
client?
1. Osteopenia
2. Platelet dysfunction
3. Osteomalacia
4. Ventricular fibrillation
19. Which condition is called hypocalcemia?
1. Serum calcium less than 8.5 mg/dL
2. Serum calcium less than 2.5 mg/dL
3. Serum calcium less than 1.5 mg/dL
4. None of the above.
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
20. A client is running a high temperature and is found to have fluid volume deficit. Which signs and symptoms
are likely to appear in the client because of fluid volume deficit? Select all that apply.
1. Orthostatic hypotension
2. Crackles in lungs
3. Dyspnea
4. Poor skin turgor
5. Dark urine with low specific gravity
21. A client’s serum magnesium level is 1 mg/dL. What are the possible causes for this finding? Select all that
apply.
1. Prolonged diarrhea
2. Laxative abuse
3. Liver failure
4. Hyperparathyroidism
5. Lack of vitamin D
22. What nutritional advice should the nurse give to a hypokalemic client? Select all that apply.
1. “Consume more orange juice.”
PRIMEXAM.COM
2.
3.
4.
5.
“Add dried fruits to your diet.”
“Consume more bananas and meat.”
“Consume a low protein diet.”
“Add more salt to your diet.”
23. A registered nurse is teaching a student nurse about the effects of aldosterone. Which statements made by the
student nurse are correct? Select all that apply.
1. “It increases blood volume.”
2. “It increases blood pressure.”
3. “It stimulates the excretion of sodium.”
4. “It stimulates the reabsorption of potassium.”
5. “It decreases renal perfusion.”
24. A registered nurse is teaching a student how to analyze the electrocardiogram of a hypokalemic client. Which
statements made by the student nurse indicate effective teaching? Select all that apply.
1. “A prolonged PR interval will be observed.”
2. “A flattened T wave will be observed.”
3. “A prominent U wave will be observed.”
4. “Widened P waves will be observed.”
5. “A reduced PR interval will be observed.”
Completion
Complete each statement.
PRIMEXAM.COM
25. A client’s serum sodium level is 140 mEq/L and serum glucose level is 90 mg/dL. The client’s blood urea
nitrogen is 12 mg/dL. Calculate the serum osmolality of the client.
Chapter 7: Fluid and Electrolyte Imbalances
Answer Section
MULTIPLE CHOICE
1. ANS: 3
Chapter: Chapter 7, Fluid and Electrolyte Imbalances
Page: 119, 120
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts of Fluid and Electrolyte Balance
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Fluid and Electrolyte Balance
Feedback
1
2
3
4
The pushing force exerted by water in the bloodstream is called hydrostatic pressure.
The force that pulls water into the bloodstream from the interstitial fluid (ISF) and
intracellular fluid (ICF) is known as osmotic pressure. Osmotic pressure is exerted by
the electrolytes and plasma proteins.
The force exerted by albumin in the bloodstream is known as oncotic pressure. Albumin
attracts water and helps retain water inside the blood vessels.
The force exerted by albumin in the bloodstream is known as oncotic pressure, so the
option “none of the above” is incorrect.
PTS: 1
CON: Fluid and Electrolyte Balance
2. ANS: 3
Chapter: Chapter 7, Fluid and Electrolyte Imbalances
Page: 121
Objective: N/A
Difficulty: Difficult
Heading: Basic Concepts of Fluid and Electrolyte Balance
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Evaluation [Evaluating]
Concept: Fluid and Electrolyte Balance
Feedback
1
2
Isotonic solution has the same tonicity as blood and does not cause fluid shifts. Besides,
it does not modify the size of the cells in the body.
A hypertonic solution causes the cells to shrink by adding solutes to the bloodstream
when infused into it. Hence, a hypertonic solution is generally used to reduce cell
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swelling in the cerebral edema.
A hypotonic solution adds water to the bloodstream when infused into it. Hence, it is
used in the treatment of dehydration. A hypotonic solution should not be used to treat
clients with cerebral edema because it will worsen the condition.
Hypotonic solutions cause the body cells to swell, thus worsening cerebral edema.
Therefore, the option “none of the above” is incorrect.
PTS: 1
CON: Fluid and Electrolyte Balance
3. ANS: 1
Chapter: Chapter 7, Fluid and Electrolyte Imbalances
Page: 123
Objective: N/A
Difficulty: Difficult
Heading: Basic Concepts of Fluid and Electrolyte Balance
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Evaluation [Evaluating]
Concept: Fluid and Electrolyte Balance
Feedback
1
2
3
4
Spironolactone is an aldosterone antagonist that causes potassium retention in the
bloodstream. It interferes with sodium reabsorption in the distal tubules and stimulates
the excretion of sodium. Hence, the appropriate nursing intervention in the situation
given is the administration of spironolactone.
Aldosterone causes increased reabsorption of sodium into the bloodstream and
stimulates the excretion of potassium. Therefore, the nurse should not recommend
sodium-rich foods to the client.
Sodium chloride injection should not be given to the client because overproduction of
aldosterone causes increased serum sodium and reduced serum potassium
concentration.
The client should not be given magnesium sulfate injection because it is administered to
clients with low serum magnesium concentration.
PTS: 1
CON: Fluid and Electrolyte Balance
4. ANS: 1
Chapter: Chapter 7, Fluid and Electrolyte Imbalances
Page: 123
Objective: N/A
Difficulty: Difficult
Heading: Basic Concepts of Fluid and Electrolyte Balance
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Evaluation [Evaluating]
Concept: Fluid and Electrolyte Balance
Feedback
PRIMEXAM.COM
1
2
3
4
Natriuresis is a natural dieresis initiated by the body. It is the excretion of large amounts
of sodium and water by the kidneys.
Natriuresis does not develop as a result of excretion of large amounts of potassium by
the kidneys.
Natriuresis is not associated with increased concentration of potassium and water in the
blood.
Natriuresis is not associated with the reabsorption of sodium in the bloodstream.
PTS: 1
CON: Fluid and Electrolyte Balance
5. ANS: 2
Chapter: Chapter 7, Fluid and Electrolyte Imbalances
Page: 124
Objective: N/A
Difficulty: Difficult
Heading: Basic Pathophysiological Concepts of Fluid and Electrolyte Imbalance
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Evaluation [Evaluating]
Concept: Fluid and Electrolyte Balance
Feedback
1
2
3
4
The client’s hemoglobin might have to be checked. However, it is not the primary
nursing intervention in the given situation. A very low hemoglobin level can cause
swelling in the arms and legs.
The physician should first monitor the serum albumin level because reduced oncotic
pressure due to hypoalbuminemia can result in edema throughout the body at every
capillary–cell interface. The edema is most often visible in the peritoneal cavity as a
swollen abdomen. The condition can cause pitting edema in the lower extremities too,
and depending on the severity of the condition, the client might have +1, +2, or +3
pitting edema.
Ordering a red blood cell count is not the primary intervention in the given condition.
Red blood cells contain hemoglobin. When the hemoglobin level is abnormally low, it
might cause swelling in the arms and legs.
Ordering a white blood cell count is not the primary intervention in the given situation.
Leukemia is an abnormal rise in the number of white blood cells. When leukemia cells
get collected in the liver or spleen, it causes them to enlarge. This might be noticed as
swelling of the belly.
PTS: 1
CON: Fluid and Electrolyte Balance
6. ANS: 1
Chapter: Chapter 7, Fluid and Electrolyte Imbalances
Page: 124
Objective: N/A
Difficulty: Moderate
Heading: Assessment of Fluid Volume Status
Integrated Processes: Nursing Process
PRIMEXAM.COM
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Fluid and Electrolyte Balance
1
2
3
4
Feedback
Tachycardia and hypotension are the symptoms of dehydration. In this case, the client
might have been dehydrated, so the client must take more fluids to avoid dehydration.
An abnormal increase in the blood volume or plasma volume is called hypervolemia.
Edema, increased body weight, and hypertension are some of the symptoms of
hypervolemia.
Reduced blood pressure is not a symptom of increased serum sodium levels.
An abnormally rapid heartbeat and hypotension are the symptoms of dehydration, so
the option “none of the above” is incorrect because the client might have been
dehydrated.
PTS: 1
CON: Fluid and Electrolyte Balance
7. ANS: 1
Chapter: Chapter 7, Fluid and Electrolyte Imbalances
Page: 125
Objective: N/A
Difficulty: Difficult
Heading: Assessment of Fluid Volume Status
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Evaluation [Evaluating]
Concept: Fluid and Electrolyte Balance
1
2
3
4
Feedback
Fluid gain or loss can be assessed by measuring the client’s body weight every day. A
weight change of 2 pounds in a day is likely to occur because of loss or gain of water in
the body.
Fluid loss or gain cannot be assessed by recording the blood pressure and calorie intake.
Fluid loss or gain is assessed by recording 24-hour fluid intake and output by the client.
However, calorie intake cannot be used to assess fluid gain or loss.
A Foley catheter is placed to drain out the urine from the bladder, and is not used for
measuring the urine output. Weight measurement cannot be used for assessing fluid
gain or loss in the body.
PTS: 1
CON: Fluid and Electrolyte Balance
8. ANS: 1
Chapter: Chapter 7, Fluid and Electrolyte Imbalances
Page: 128
Objective: N/A
Difficulty: Easy
Heading: Assessment of Fluid Volume Status
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
PRIMEXAM.COM
Cognitive Level: Knowledge [Remembering]
Concept: Fluid and Electrolyte Balance
1
2
3
4
Feedback
Changes in the serum calcium levels can diminish the body’s responsiveness to cardiac
drugs.
Changes in the serum sodium levels do not interfere with the body’s responsiveness to
cardiac drugs.
Changes in the serum potassium levels do not hamper with the body’s responsiveness to
cardiac drugs.
Changes in the serum magnesium levels do not slow down the body’s responsiveness to
cardiac drugs.
PTS: 1
CON: Fluid and Electrolyte Balance
9. ANS: 1
Chapter: Chapter 7, Fluid and Electrolyte Imbalances
Page: 128, 129
Objective: N/A
Difficulty: Moderate
Heading: Assessment of Fluid Volume Status
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analyze [Analyzing]
Concept: Fluid and Electrolyte Balance
1
2
3
4
Feedback
Headache, confusion, vomiting, muscle cramps, and lethargy are some of the symptoms
of delusional hyponatremia in the presence of hypervolemia.
Dry mouth, irritability, hypertension, weight gain, oliguria, and dry skin are the
symptoms of increased serum sodium levels.
Anorexia, postural hypotension, nausea, vomiting, and muscle weakness are the
symptoms of hypokalemia.
Hypotension, arrhythmias, seizures, and muscles spasms are some of the symptoms of
hypocalcemia.
PTS: 1
CON: Fluid and Electrolyte Balance
10. ANS: 1
Chapter: Chapter 7, Fluid and Electrolyte Imbalances
Page: 129
Objective: N/A
Difficulty: Difficult
Heading: Assessment of Fluid Volume Status
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Evaluation [Evaluating]
Concept: Fluid and Electrolyte Balance
PRIMEXAM.COM
1
2
3
4
Feedback
Tolvaptan is used to treat hypervolemic hyponatremia, which is indicated by a serum
sodium of 125 mEq/L or even less. Tolvaptan is used to treat low levels of salt in the
blood.
Sevelamer is used to treat hyperphosphatemia, so it cannot be administered to treat
hypervolemic hyponatremia.
Alendronate is used to inhibit the bone reabsorption by osteoclasts and hypercalcemia
condition, so it cannot be administered to treat hypervolemic hyponatremia.
Tolvaptan is used to treat hypervolemic hyponatremia, so the option “none of the
above” is incorrect.
PTS: 1
CON: Fluid and Electrolyte Balance
11. ANS: 1
Chapter: Chapter 7, Fluid and Electrolyte Imbalances
Page: 131
Objective: N/A
Difficulty: Easy
Heading: Assessment of Fluid Volume Status
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Knowledge [Remembering]
Concept: Fluid and Electrolyte Balance
1
2
3
4
Feedback
A daily potassium intake of a minimum of 10 to 30 mEq is essential for optimal
functioning of human cells.
While treating hypokalemia, the total potassium chloride infused intravenously should
not exceed 60 mEq/day.
A serum potassium concentration below 3.5 mEq/L is known as hypokalemia.
A serum calcium level less than 8.5 mEq/dL is associated with hypocalcemia.
PTS: 1
CON: Fluid and Electrolyte Balance
12. ANS: 2
Chapter: Chapter 7, Fluid and Electrolyte Imbalances
Page: 131
Objective: N/A
Difficulty: Difficult
Heading: Assessment of Fluid Volume Status
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Evaluation [Evaluating]
Concept: Fluid and Electrolyte Balance
1
2
Feedback
Administration of digitalis to a hypokalemic client will not cause pericarditis.
Digitalis binds to the open binding sites of potassium and causes digitalis toxicity when
the drug is administered to hypokalemic clients.
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When digitalis is administered to a hypokalemic client, the effectiveness of the drug
does not increase.
When digitalis is administered to a hypokalemic client, it results in digitalis toxicity.
PTS: 1
CON: Fluid and Electrolyte Balance
13. ANS: 1
Chapter: Chapter 7, Fluid and Electrolyte Imbalances
Page: 130, 131
Objective: N/A
Difficulty: Difficult
Heading: Assessment of Fluid Volume Status
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Evaluation [Evaluating]
Concept: Fluid and Electrolyte Balance
1
2
3
4
Feedback
Hypertonic IV potassium chloride should not be administered as an IV bolus. Though
IV potassium is never administered IV push, it is often administered in a diluted,
controlled rate bolus referred to as a K-run.
While administering IV potassium, the solution should always be diluted.
Generally, 20 mEq of potassium chloride per liter of intravenous solution is
administered to clients who are placed on nothing by mouth orders.
Rapid administration of IV potassium can lead to cardiac arrest, so IV potassium needs
to be administered slowly.
PTS: 1
CON: Fluid and Electrolyte Balance
14. ANS: 4
Chapter: Chapter 7, Fluid and Electrolyte Imbalances
Page: 132
Objective: N/A
Difficulty: Easy
Heading: Assessment of Fluid Volume Status
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Fluid and Electrolyte Balance
1
2
3
4
Feedback
Increased serum potassium levels or hyperkalemia do not cause pseudohypocalcemia.
Elevated serum sodium levels or hyponatremia do not cause pseudohypocalcemia.
Decreased serum phosphorus levels or hypophosphatemia are not associated with
pseudohypocalcemia.
Decreased serum albumin levels or hypoalbuminemia can cause the appearance of low
serum calcium levels called pseudohypocalcemia.
PTS: 1
CON: Fluid and Electrolyte Balance
PRIMEXAM.COM
15. ANS: 1
Chapter: Chapter 7, Fluid and Electrolyte Imbalances
Page: 133, 134
Objective: N/A
Difficulty: Easy
Heading: Assessment of Fluid Volume Status
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Fluid and Electrolyte Balance
1
2
3
4
Feedback
Hyperphosphatemia is generally accompanied by low serum calcium levels, which is
also known as hypocalcemia.
Increased serum sodium levels or hypernatremia are not associated with increased
serum phosphorus levels.
Low serum magnesium levels or hypomagnesaemia are not associated with increased
serum phosphorus levels.
Increased serum potassium levels or hyperkalemia are not accompanied by increased
serum phosphorus levels.
PTS: 1
CON: Fluid and Electrolyte Balance
16. ANS: 1
Chapter: Chapter 7, Fluid and Electrolyte Imbalances
Page: 118
Objective: N/A
Difficulty: Easy
Heading: Transport Mechanisms
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Fluid and Electrolyte Balance
1
2
3
4
Feedback
Glucose is transported into the cells by the carrier protein insulin through a process
known as facilitated transport. It involves the passing of certain molecules through the
plasma membrane with assistance from carrier proteins.
Sodium transport occurs in the cells with the help of energy. This process is known as
active transport.
Potassium is transported to the cells by active transport.
Albumin is not transported by facilitated transport.
PTS: 1
CON: Fluid and Electrolyte Balance
17. ANS: 1
Chapter: Chapter 7, Fluid and Electrolyte Imbalances
Page: 138
Objective: N/A
PRIMEXAM.COM
Difficulty: Moderate
Heading: Making the Connections
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Fluid and Electrolyte Balance
1
2
3
4
Feedback
Tetany and reduced blood pressure indicate hyperphosphatemia.
Tetany indicates hyperphosphatemia, but muscle weakness indicates
hypophosphatemia.
Ataxia and hypertension indicate hypercalcemia.
Muscle weakness and tremor indicate hypophosphatemia.
PTS: 1
CON: Fluid and Electrolyte Balance
18. ANS: 1
Chapter: Chapter 7, Fluid and Electrolyte Imbalances
Page: 137
Objective: N/A
Difficulty: Moderate
Heading: Making the Connections
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Fluid and Electrolyte Balance
1
2
3
4
Feedback
The client might develop osteopenia. Osteopenia indicates low bone density and shows
the presence of an elevated serum calcium concentration.
Platelet dysfunction is an indication of hypophosphatemia.
Osteomalacia indicates the presence of hypophosphatemia.
Ventricular fibrillation is an indication of the presence of hypocalcemia.
PTS: 1
CON: Fluid and Electrolyte Balance
19. ANS: 1
Chapter: Chapter 7, Fluid and Electrolyte Imbalances
Page: 132
Objective: N/A
Difficulty: Easy
Heading: Making the Connections
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Fluid and Electrolyte Balance
1
Feedback
When the serum calcium level is less than 8.5 mg/dL, the condition is known as
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3
4
hypocalcemia.
When the serum phosphorus level is less than 2.5mg/dL, the condition is called
hypophosphatemia.
When the serum magnesium level is less than 1.5 mg/dL, the condition is called
hypomagnesaemia.
A serum calcium level less than 8.5 mg/dL is called hypocalcemia, so the option “none
of the above” is incorrect.
PTS: 1
CON: Fluid and Electrolyte Balance
MULTIPLE RESPONSE
20. ANS: 1, 4
Chapter: Chapter 7, Fluid and Electrolyte Imbalances
Page: 125, 127
Objective: N/A
Difficulty: Moderate
Heading: Fluid Volume Deficit
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Fluid and Electrolyte Balance
1.
2.
3.
4.
5.
Feedback
This is correct. Orthostatic hypotension is a symptom of fluid volume deficit.
This is incorrect. Crackles in the lungs are a symptom of fluid volume excess.
This is incorrect. Dyspnea might occur due to pulmonary fluid accumulation in case of
fluid volume excess.
This is correct. Fluid volume deficit results in poor skin turgor.
This is incorrect. Dark urine with high specific gravity is a symptom of fluid volume
deficit.
PTS: 1
CON: Fluid and Electrolyte Balance
21. ANS: 1, 2, 3
Chapter: Chapter 7, Fluid and Electrolyte Imbalances
Page: 134
Objective: N/A
Difficulty: Moderate
Heading: Causes of Hypomagnesemia and Hypermagnesemia
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Fluid and Electrolyte Balance
1.
2.
Feedback
This is correct. Prolonged diarrhea can lower the serum magnesium concentration.
This is correct. Laxative abuse is caused by reduced serum magnesium concentration.
PRIMEXAM.COM
3.
4.
5.
This is correct. Liver failure can lower the serum magnesium levels.
This is incorrect. Hyperparathyroidism is caused by elevated serum magnesium
concentration.
This is incorrect. Lack of vitamin D results in increased serum magnesium levels.
PTS: 1
CON: Fluid and Electrolyte Balance
22. ANS: 1, 2, 3
Chapter: Chapter 7, Fluid and Electrolyte Imbalances
Page: 131
Objective: N/A
Difficulty: Difficult
Heading: Assessment of Fluid Volume Status
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Evaluation [Evaluating]
Concept: Fluid and Electrolyte Balance
1.
2.
3.
4.
5.
Feedback
This is correct. Foods such as orange juice are good sources of potassium, so they should
be included in the hypokalemic client’s diet.
This is correct. Dried fruits are a good source of potassium, and they can help reverse
hypokalemia.
This is correct. Bananas and meat are abundant sources of potassium. Having a banana,
meat, and big glass of orange juice every day is sufficient to replace the potassium lost
after 1 hour of hard exercise.
This is incorrect. A protein-rich diet is recommended by dieticians to hypokalemic clients.
This is incorrect. Hypokalemic clients should consume low salt or low sodium foods in
their diet.
PTS: 1
CON: Fluid and Electrolyte Balance
23. ANS: 1, 2
Chapter: Chapter 7, Fluid and Electrolyte Imbalances
Page: 122
Objective: N/A
Difficulty: Moderate
Heading: Basic Concepts of Fluid and Electrolyte Balance
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Fluid and Electrolyte Balance
1.
2.
3.
Feedback
This is correct. Aldosterone increases the absorption of water and increases the blood
volume.
This is correct. Aldosterone increases blood pressure.
This is incorrect. Aldosterone stimulates the excretion of potassium into the nephrons
tubules.
PRIMEXAM.COM
4.
5.
This is incorrect. Aldosterone stimulates the reabsorption of sodium from the distal tubules
into the bloodstream when the blood volume decreases.
This is incorrect. Renin is an enzyme secreted by the kidneys to increase renal perfusion.
PTS: 1
CON: Fluid and Electrolyte Balance
24. ANS: 1, 2, 3
Chapter: Chapter 7, Fluid and Electrolyte Imbalances
Page:131
Objective: N/A
Difficulty: Difficult
Heading: Assessment of Fluid Volume Status
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Evaluation [Evaluating]
Concept: Fluid and Electrolyte Balance
1.
2.
3.
4.
5.
Feedback
This is correct. A prolonged PR interval is observed in clients who are hypokalemic.
This is correct. Hypokalemia results in a flattened T wave.
This is correct. A prominent U wave is observed on ECG when the client is hypokalemic.
This is incorrect. Widened P waves can be observed in clients who are hyperkalemic.
This is incorrect. A reduced PR interval is observed in hypocalcemic clients.
PTS: 1
CON: Fluid and Electrolyte Balance
COMPLETION
25. ANS:
290 milliosmoles of solute/kg of water
Chapter: Chapter 7, Fluid and Electrolyte Imbalances
Page: 120
Objective: N/A
Difficulty: Moderate
Heading: Basic Concepts of Fluid and Electrolyte Balance
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Fluid and Electrolyte Balance
Feedback: Serum osmolality can be calculated using the formula,
Serum osmolality (milliosmoles of solute/kg of water ) = 2x serum sodium + serum glucose/18 + BUN/2.4
= 2 × 140 + 90/18 + 12/2.4
= 280 + 5 + 5
= 290
The client’s osmolality is within the normal range. Normal plasma osmolality is 282 – 295 milliosmoles per
kilogram of water.
PRIMEXAM.COM
PTS: 1
CON: Fluid and Electrolyte Balance
PRIMEXAM.COM
Chapter 8: Acid-Base Imbalances
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. A nurse is analyzing an arterial blood gas report of a client with chronic obstructive pulmonary disease and
respiratory acidosis. Which compensation mechanism is likely to occur?
A. The kidneys will retain bicarbonate.
B. The kidneys will excrete bicarbonate.
C. The lungs will retain carbon dioxide.
D. The lungs will excrete carbon dioxide.
2. A nurse is caring for a client who has been diagnosed with renal failure. Which mechanism of compensation
for the acid-base disturbance does the nurse recognize in the client?
A. The client retains carbon dioxide in excess.
B. The client’s oxygen saturation level improves.
C. The client’s blood pH decreases from the present value.
D. The client breathes rapidly to eliminate carbon dioxide.
3. A nurse is caring for a client who is anxious and dizzy following a traumatic experience. The arterial blood
gas findings include a pH level of 7.48, partial pressure of oxygen at 110, partial pressure of carbon dioxide at
25, and bicarbonate at 2D. Which initial intervention does the nurse implement?
A. Administer antidepressants.
B. Administer oxygen through a mask.
C. Encourage the client to breathe into a paper bag.
D. Administer sodium bicarbonate intravenously.
4. An unconscious client is brought to the hospital. The client’s arterial blood gases show a pH greater than 7.45
and a bicarbonate level of 36 mEq/L. Which acid-base imbalance has the client developed?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
5. An elderly client is demonstrating lethargy, confusion, and a respiratory rate of 8 breaths per minute. The
nurse sees that the last dose of medication administered through a client-controlled analgesic pump was
within the last 30 minutes. Which acid-base disorder might the client have developed?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
6. Hyperventilation of the lungs increases
A. Blood pH.
B. Acid in the blood.
C. Carbon dioxide in the blood.
D. None of the above.
7. Which is a normal blood pH?
A. 7.00
PRIMEXAM.COM
B. 7.20
C. 7.35
D. None of the above
8. What is hypocapnea?
A. Low partial pressure of oxygen
B. Elevated partial pressure of carbon dioxide
C. Diminished partial pressure of carbon dioxide
D. None of the above
9. Which is an acidic pH of blood?
A. 6.00
B. 7.40
C. 8.00
D. 8.35
10. Which condition is developed due to metabolic acidosis with an elevated anion gap?
A. Ketoacidosis
B. Hypoaldosteronism
C. Hyperalimentation
D. None of the above
11. A client who is taking his board exams is nervous and breathing heavily in the examination hall. Which acidbase imbalance has the client developed?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
12. Which arterial blood gas value is necessary to identify if a condition is compensated or uncompensated?
A. Blood pH
B. Blood bicarbonate
C. Oxygen saturation
D. Partial pressure of oxygen
13. Which condition is caused by an increase in the amount of potassium in the blood?
A. Hypocapnea
B. Hypotension
C. Hyperkalemia
D. Hypercalcemia
14. A comatose client’s blood pH is 7.1, partial pressure of carbon dioxide is 16 mm Hg, and bicarbonate
concentration is 5 mEq/L. Which acid-base imbalance has the client developed?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. None of the above
15. Which is a physical assessment finding of respiratory acidosis?
A. Cyanosis
B. Tachycardia
C. Hypotension
PRIMEXAM.COM
D. Hypertension
16. What is the normal range of bicarbonate concentration in the blood?
A. 35–45 mEq/L
B. 90–100 mEq/L
C. 22–26 mEq/L
D. 7.35–7.45 mEq/L
17. What change occurs as a result of hypoventilation?
A. Partial pressure of carbon dioxide increases.
B. Lungs expel carbon dioxide.
C. Respiratory alkalosis occurs.
D. None of the above
18. Which is the compound that donates hydrogen ions in a solution?
A. Acid
B. Base
C. Buffer
D. None of the above
19. Which condition is associated with diminished levels of partial pressure of carbon dioxide?
A. Hypoxia
B. Hypoxemia
C. Hypocapnea
D. Hypercapnea
20. What information can be interpreted from arterial blood gas values?
A. Acidosis and alkalosis
B. Respiratory and metabolic conditions
C. Disorder of the lungs
D. All of the above
NARRBEGIN: Exhibit
Exhibit
NARREND
21. A client has nausea and vomiting for 3 days due to a viral infection. Arterial blood gas values of the client are
documented.
Blood pH
Partial pressure of carbon
dioxide
Partial pressure of oxygen
Bicarbonate concentration
Oxygen saturation
7.61
49 mm Hg
99 mm Hg
18 mEq/L
99%
Which statement is correct according to the interpretation of the arterial blood gas values?
A. The blood is basic.
B. The lungs are not responsible for the alkalosis.
C. The condition is uncompensated alkalosis.
PRIMEXAM.COM
D. All of the above
22. A client is hospitalized for diarrhea. Arterial blood gas values of the client are documented.
Blood pH
Partial pressure of carbon
dioxide
Partial pressure of oxygen
Bicarbonate concentration
Oxygen saturation
7.50
27 mm Hg
92 mm Hg
17 mEq/L
91%
Which statement is correct according to the interpretation of the arterial blood gas?
A. The client has developed alkalosis.
B. The client has a lung problem.
C. The client has developed an uncompensated condition.
D. All of the above
23. A client who is unconscious due to drug toxicity is brought to the emergency room. The client’s vital signs
include a body temperature of 97.8ºF, pulse rate of 90 beats/minute, respiratory rate of 12 breaths/minute, and
blood pressure of 100/70 mm Hg. The arterial blood gas values of the client are also documented.
Blood pH
Partial pressure of carbon
dioxide
Partial pressure of oxygen
Bicarbonate concentration
Oxygen saturation
7.29
32 mm Hg
95 mm Hg
17 mEq/L
98%
Which condition has the client developed?
A. Compensated respiratory acidosis
B. Compensated respiratory alkalosis
C. Uncompensated metabolic acidosis
D. Uncompensated respiratory acidosis
24. Arterial blood gas values of a client are documented by the nurse.
Blood pH
Partial pressure of carbon
dioxide
Partial pressure of oxygen
Bicarbonate concentration
Oxygen saturation
7.37
47 mm Hg
85 mm Hg
26 mEq/L
87%
Which condition has the client developed?
A. Compensated metabolic acidosis
B. Compensated respiratory acidosis
C. Uncompensated respiratory acidosis
D. Uncompensated metabolic alkalosis
PRIMEXAM.COM
25. A client suffering from an asthma attack is brought to the emergency department. The client’s body
temperature is 98.4ºF, pulse rate is 110 beats/minute, respiratory rate is 24 shallow breaths/minute, and the
blood pressure is 136/86 mm Hg. Arterial blood gas values are also documented.
Blood pH
Partial pressure of carbon
dioxide
Partial pressure of oxygen
Bicarbonate concentration
Oxygen saturation
7.30
58 mm Hg
88 mm Hg
29 mEq/L
88%
Which condition has the client developed?
A. Compensated metabolic acidosis
B. Compensated respiratory acidosis
C. Compensated respiratory alkalosis
D. Uncompensated respiratory acidosis
PRIMEXAM.COM
Chapter 8: Acid-Base Imbalances
Answer Section
MULTIPLE CHOICE
1. ANS: A
Chapter: Chapter 8, Acid-Base Imbalances
Page: 150
Objective: N/A
Difficulty: Difficult
Heading: Pathological Concepts Regarding Acid-Base Imbalances
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Oxygenation: pH Regulation: Nursing Roles
Feedback
A
The kidneys will compensate for a respiratory disorder by retaining bicarbonates.
B
Excretion of bicarbonate causes acidosis.
C
Retaining carbon dioxide causes respiratory acidosis.
D
Excreting carbon dioxide causes respiratory alkalosis.
PTS: 1
CON: Oxygenation: pH Regulation: Nursing Roles
2. ANS: D
Chapter: Chapter 8, Acid-Base Imbalances
Page: 150
Objective: N/A
Difficulty: Difficult
Heading: Pathological Concepts Regarding Acid-Base Imbalances
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Oxygenation: pH Regulation: Nursing Roles
Feedback
A
Healthy kidneys compensate by reabsorbing bicarbonate into the bloodstream and
excreting potential hydrogen. This mechanism does not occur as the client has kidney
failure.
B
Oxygenation disturbance is not associated with the acid-base status of a client with
renal failure.
C
Metabolic acidosis lowers the blood pH of the client. This is a manifestation of
metabolic acidosis and is not a compensation mechanism.
D
In metabolic acidosis, rapid breathing acts as compensation by eliminating carbon
dioxide. This type of breathing is called as Kussmaul’s breathing.
PTS: 1
CON: Oxygenation: pH Regulation: Nursing Roles
3. ANS: C
Chapter: Chapter 8, Acid-Base Imbalances
PRIMEXAM.COM
Page: 148
Objective: N/A
Difficulty: Difficult
Heading: Pathological Concepts Regarding Acid-Base Imbalances
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Basic Care and Comfort
Cognitive Level: Analysis [Analyzing]
Concept: Oxygenation: pH Regulation: Nursing Roles
Feedback
A
Antidepressants are administered if the client has not responded to conservative
treatments. This is not an initial intervention that the nurse would implement.
B
Oxygen levels are high, so the nurse should not administer oxygen. Administering
oxygen would exacerbate the condition.
C
The initial intervention that the nurse should provide is to make the client breath into a
paper bag. This mechanism can replace lost carbon dioxide.
D
The nurse should not administer sodium bicarbonate as the blood pH of the client is
elevated.
PTS: 1
CON: Oxygenation: pH Regulation: Nursing Roles
4. ANS: B
Chapter: Chapter 8, Acid-Base Imbalances
Page: 150
Objective: N/A
Difficulty: Difficult
Heading: Pathological Concepts Regarding Acid-Base Imbalances
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Oxygenation: pH Regulation
Feedback
A
In metabolic acidosis, the pH will be less than 7.
B
The client has developed metabolic alkalosis. In metabolic alkalosis, the pH will be
greater than 7.45, and the bicarbonate concentration will be greater than 35 mEq/L.
C
In respiratory acidosis, the level of pH in bloodstream decreases below 7.35.
D
In respiratory alkalosis, the bicarbonate concentration in bloodstream decreases.
PTS: 1
CON: Oxygenation: pH Regulation
5. ANS: C
Chapter: Chapter 8, Acid-Base Imbalances
Page: 152
Objective: N/A
Difficulty: Difficult
Heading: Pathological Concepts Regarding Acid-Base Imbalances
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Oxygenation: pH Regulation
PRIMEXAM.COM
A
B
C
D
Feedback
Headache, vomiting, nausea, and anorexia are the symptoms present in clients with
metabolic acidosis.
Dizziness, agitation, weakness, vomiting, and diarrhea are the symptoms present in
clients with metabolic alkalosis.
Acute respiratory acidosis is caused due to sudden failure of ventilation. Overdose of
sedative drugs can lead to this condition. Anxiety, restlessness, shortness of breath,
confusion, and rapid breathing are symptoms of respiratory acidosis.
Tingling of extremities, muscle cramps, tetany, and coma are the symptoms of
respiratory alkalosis.
PTS: 1
CON: Oxygenation: pH Regulation
6. ANS: A
Chapter: Chapter 8, Acid-Base Imbalances
Page: 152
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts of Acid-Base Balance
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: pH Regulation
Feedback
A
Hyperventilation of the lungs increases pH of the blood.
B
Hyperventilation of the lungs decreases the acid in the blood.
C
Hyperventilation of the lungs decreases the carbon dioxide in the blood.
D
Hyperventilation of the lungs increases pH of the blood.
PTS: 1
CON: pH Regulation
7. ANS: C
Chapter: Chapter 8, Acid-Base Imbalances
Page: 143
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts of Acid-Base Balance
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: pH Regulation
Feedback
A
The pH of blood is said to be acidic when the pH falls below 7.35. Therefore, 7.00 is an
acidic pH.
B
The pH of blood is said to be acidic when the pH falls below 7.35. Therefore, 7.20 is an
acidic pH.
C
The normal value of blood pH is 7.35–7.45. Therefore, 7.35 is a normal pH value of
blood.
D
The normal value of blood pH is 7.35–7.45.
PRIMEXAM.COM
PTS: 1
CON: pH Regulation
8. ANS: C
Chapter: Chapter 8, Acid-Base Imbalances
Page: 148
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts of Acid-Base Balance
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Oxygenation
Feedback
A
Low partial pressure of oxygen in blood is called hypoxia or hypoxemia.
B
Elevated partial pressure of carbon dioxide is called hypercapnea.
C
Diminished partial pressure of carbon dioxide is called hypocapnea.
D
Diminished partial pressure of carbon dioxide is called hypocapnea.
PTS: 1
CON: Oxygenation
9. ANS: A
Chapter: Chapter 8, Acid-Base Imbalances
Page: 141
Objective: N/A
Difficulty: Moderate
Heading: Basic Concepts of Acid-Base Balance
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: pH Regulation
Feedback
A
A blood pH value less than 7.35 is considered acidic. Therefore, 6.0 is an acidic pH.
B
A blood pH value between 7.35–7.45 is considered normal. Therefore, 7.40 is a normal
pH.
C
A blood pH value greater than 7.45 is considered basic. Therefore, 8.00 is a basic pH.
D
A blood pH value greater than 7.45 is considered basic. Therefore, 8.35 is a basic pH.
PTS: 1
CON: pH Regulation
10. ANS: A
Chapter: Chapter 8, Acid-Base Imbalances
Page: 146
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts of Acid-Base Balance
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Hematologic Regulation
PRIMEXAM.COM
A
B
C
D
Feedback
Ketoacidosis is a condition where an elevated anion gap is observed.
Hyperalimentation is a condition where normal anion gap is observed.
Hypoaldosteronism is a condition where normal anion gap is observed.
Ketoacidosis is a condition where an elevated anion gap is observed.
PTS: 1
CON: Hematologic Regulation
11. ANS: C
Chapter: Chapter 8, Acid-Base Imbalances
Page: 147
Objective: N/A
Difficulty: Moderate
Heading: Pathological Concepts Regarding Acid-Base Imbalances
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Oxygenation
Feedback
A
Clients with metabolic acidosis exhibit various symptoms such as headache,
drowsiness, confusion, vomiting, hypotension, and nausea.
B
Clients with metabolic alkalosis exhibit symptoms such as confusion, dizziness,
agitation, weakness, vomiting, and diarrhea.
C
Clients with respiratory acidosis exhibit symptoms such as anxiety, restlessness,
lethargy, rapid breathing, and cough. Therefore, the client in the given situation has
developed respiratory acidosis.
D
Clients with respiratory alkalosis exhibit symptoms such as muscle cramps, tetany,
confusion, anxiety, and seizures.
PTS: 1
CON: Oxygenation
12. ANS: A
Chapter: Chapter 8, Acid-Base Imbalances
Page: 147
Objective: N/A
Difficulty: Moderate
Heading: Pathological Concepts Regarding Acid-Base Imbalances
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Hematologic Regulation: pH Regulation
Feedback
A
The blood pH value helps in differentiating between a compensated and uncompensated
condition. Normal blood pH is considered compensated and abnormal pH is considered
uncompensated.
B
Analysis of the bicarbonate concentration of blood will reveal the method of
compensation of the body.
C
The oxygen saturation level indicates the presence or absence of a lung problem.
D
The partial pressure of oxygen indicates the presence or absence of a lung problem.
PRIMEXAM.COM
PTS: 1
CON: Hematologic Regulation: pH Regulation
13. ANS: C
Chapter: Chapter 8, Acid-Base Imbalances
Page: 149
Objective: N/A
Difficulty: Moderate
Heading: Pathological Concepts Regarding Acid-Base Imbalances
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Oxygenation
Feedback
A
A decrease in the partial pressure of carbon dioxide in blood leads to hypocapnea.
B
A decrease in blood pressure leads to hypotension.
C
A potassium ion increase in the blood leads to hyperkalemia.
D
A decrease in the serum calcium levels in the blood leads to hypocalcemia.
PTS: 1
CON: Oxygenation
14. ANS: A
Chapter: Chapter 8, Acid-Base Imbalances
Page: 149
Objective: N/A
Difficulty: Moderate
Heading: Pathological Concepts Regarding Acid-Base Imbalances
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Hematologic Regulation, pH Regulation
Feedback
A
The client has developed metabolic acidosis as indicated by low blood pH and low
bicarbonate levels.
B
In metabolic alkalosis, the blood pH will be greater than 7.45.
C
In respiratory acidosis, the bicarbonate level will be greater than 45 mm Hg.
D
The client has developed metabolic acidosis.
PTS: 1
CON: Hematologic Regulation, pH Regulation
15. ANS: A
Chapter: Chapter 8, Acid-Base Imbalances
Page: 152
Objective: N/A
Difficulty: Easy
Heading: Pathological Concepts Regarding Acid-Base Imbalances
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Hematologic Regulation: Oxygenation
PRIMEXAM.COM
A
B
C
D
Feedback
Cyanosis is a symptom of respiratory acidosis.
Tachycardia is a symptom of respiratory alkalosis.
Hypotension is a symptom of metabolic acidosis.
Hypertension is a symptom of metabolic alkalosis.
PTS: 1
CON: Hematologic Regulation: Oxygenation
16. ANS: C
Chapter: Chapter 8, Acid-Base Imbalances
Page: 150
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts of Acid-Base Balance
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Hematologic Regulation
Feedback
A
The normal range of partial pressure of carbon dioxide in the blood is 35–45 mm Hg.
B
The normal range of partial pressure of oxygen in the blood is 90–100 mm Hg.
C
The normal range of bicarbonate in the blood is 22–26 mEq/L
D
The normal range of pH in the blood is 7.35–7.45 mEq/L.
PTS: 1
CON: Hematologic Regulation
17. ANS: A
Chapter: Chapter 8, Acid-Base Imbalances
Page: 142
Objective: N/A
Difficulty: Moderate
Heading: Pathological Concepts Regarding Acid-Base Imbalances
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Hematologic Regulation: pH Regulation
Feedback
A
Hypoventilation increases the partial pressure of carbon dioxide as the lungs retain
carbon dioxide.
B
Hypoventilation retains carbon dioxide in the body.
C
Hypoventilation leads to acidosis as it increases the partial pressure of carbon dioxide
greater than 45 mm Hg.
D
Hypoventilation increases the partial pressure of carbon dioxide as the lungs retain
carbon dioxide.
PTS: 1
CON: Hematologic Regulation: pH Regulation
18. ANS: A
Chapter: Chapter 8, Acid-Base Imbalances
Page: 141
PRIMEXAM.COM
Objective: N/A
Difficulty: Moderate
Heading: Basic Concepts of Acid-Base Balance
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Hematologic Regulation: pH Regulation
Feedback
A
An acid is the compound that donates hydrogen ions in a solution. When the hydrogen
ions are excess in a solution, the solution is acidic.
B
A base is the compound that accepts hydrogen ions. When basic ions are excess in a
solution, the solution is alkaline.
C
A buffer is a neutralizer, which balances the pH of the bloodstream.
D
An acid is the compound that donates hydrogen ions in a solution.
PTS: 1
CON: Hematologic Regulation, pH Regulation
19. ANS: C
Chapter: Chapter 8, Acid-Base Imbalances
Page: 143
Objective: N/A
Difficulty: Moderate
Heading: Basic Concepts of Acid-Base Balance
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Hematologic Regulation: Oxygenation
Feedback
A
Low partial pressure of oxygen in the blood is called hypoxia.
B
The other name for hypoxia is hypoxemia. Low partial pressure of oxygen in blood is
called hypoxia.
C
Diminished partial pressure of carbon dioxide in the blood is called hypocapnea.
D
An elevated level of partial pressure of carbon dioxide in blood is called hypercapnea.
PTS: 1
CON: Hematologic Regulation: Oxygenation
20. ANS: D
Chapter: Chapter 8, Acid-Base Imbalances
Page: 142, 143
Objective: N/A
Difficulty: Moderate
Heading: Basic Concepts of Acid-Base Balance
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Hematologic Regulation: Oxygenation
Feedback
A
Acidosis and alkalosis of the bloodstream can be determined using arterial blood gas
value. If the pH is lower than 7.35, the bloodstream is acidic. If the pH is greater than
PRIMEXAM.COM
B
C
D
7.45, the bloodstream is basic.
Respiratory and metabolic condition can be determined by the arterial blood value and
partial pressure of oxygen. High partial pressure of oxygen is caused by respiratory
conditions and low level of oxygen partial pressure is caused by metabolic conditions.
Abnormal values of partial pressure of oxygen or an abnormal level of oxygen
saturation is an indication of a lung disorder.
Arterial blood gas value is used to interpret acidosis or alkalosis, respiratory or
metabolic condition of the blood, and disorders of the lungs.
PTS: 1
CON: Hematologic Regulation: Oxygenation
21. ANS: D
Chapter: Chapter 8, Acid-Base Imbalances
Page: 142, 143
Objective: N/A
Difficulty: Difficult
Heading: Pathological Concepts Regarding Acid-Base Imbalances
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Hematologic Regulation: pH Regulation
A
B
C
D
Feedback
The blood pH of the client is greater than 7.45. Therefore, the blood is basic or alkaline.
The partial pressure of oxygen and saturation of oxygen are normal, which indicates
normal lung function. Therefore, the lungs are not responsible for the alkalosis
condition.
The condition is uncompensated alkalosis because the pH value of the blood is greater
than the normal value.
The blood is basic, the lungs are not responsible for the alkalosis, and the condition is
uncompensated alkalosis.
PTS: 1
CON: Hematologic Regulation: pH Regulation
22. ANS: D
Chapter: Chapter 8, Acid-Base Imbalances
Page: 144
Objective: N/A
Difficulty: Difficult
Heading: Pathological Concepts Regarding Acid-Base Imbalances
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Hematologic Regulation: pH Regulation
A
B
Feedback
The blood pH is greater than 7.45. Therefore, the client has developed alkalosis.
The low partial pressure of carbon dioxide indicates that the client has a pulmonary
problem. The partial pressure and saturation of oxygen are low, which confirms that the
PRIMEXAM.COM
C
D
client has a lung problem.
The blood pH of the client is not in the normal range. Therefore, the client has
developed an uncompensated condition.
The client has developed alkalosis, a ung problem, and an uncompensated condition.
PTS: 1
CON: Hematologic Regulation: pH Regulation
23. ANS: C
Chapter: Chapter 8, Acid-Base Imbalances
Page: 144
Objective: N/A
Difficulty: Difficult
Heading: Pathological Concepts Regarding Acid-Base Imbalances
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Oxygenation: pH Regulation
A
B
C
D
Feedback
In compensated respiratory acidosis, the blood pH will be in the normal range. The
normal range of blood pH is 7.35–7.45.
In compensated respiratory alkalosis, the blood pH will be in the normal range. The
normal range of blood pH is 7.35–7.45.
The client has developed uncompensated metabolic acidosis. The low pH, normal
partial pressure of oxygen, low partial pressure of carbon dioxide, and normal
saturation of oxygen indicate uncompensated metabolic acidosis.
In uncompensated respiratory acidosis, the bicarbonate concentration will be greater
than 45 mm Hg and blood pH will drop below 7.35.
PTS: 1
CON: Oxygenation: pH Regulation
24. ANS: B
Chapter: Chapter 8, Acid-Base Imbalances
Page: 145
Objective: N/A
Difficulty: Difficult
Heading: Pathological Concepts Regarding Acid-Base Imbalances
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Hematologic Regulation: pH Regulation
A
B
C
Feedback
In compensated metabolic acidosis, the bicarbonate concentration in the blood will be
less than 22 mEq/L.
The client has developed compensated respiratory acidosis. The normal pH level, high
oxygen partial pressure, and normal bicarbonate levels indicate compensated
respiratory acidosis.
In an uncompensated condition, the blood pH of the client will be abnormal. Here, the
PRIMEXAM.COM
D
client has a normal pH.
In an uncompensated condition, the blood pH of the client will be abnormal. Here, the
client has a normal pH.
PTS: 1
CON: Hematologic Regulation: pH Regulation
25. ANS: D
Chapter: Chapter 8, Acid-Base Imbalances
Page: 144
Objective: N/A
Difficulty: Difficult
Heading: Pathological Concepts Regarding Acid-Base Imbalances
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Oxygenation: pH Regulation
A
B
C
D
Feedback
In compensated metabolic acidosis, the pH of blood will be in the normal range. The
normal range of blood pH is 7.35–7.45.
In compensated respiratory acidosis, the pH of blood will be in the normal range. The
normal range of blood pH is 7.35–7.45.
In compensated respiratory alkalosis, the pH of blood will be in the normal range. The
normal range of blood pH is 7.35–7.45.
The client has developed uncompensated respiratory acidosis. The abnormal and low
pH, low partial pressure of oxygen, high partial pressure of carbon dioxide, and low
saturation of oxygen indicate uncompensated respiratory acidosis.
PTS: 1
CON: Oxygenation: pH Regulation
PRIMEXAM.COM
Chapter 9: Infection and Inflammation
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. A client reports persistent cough. The nurse suspects the client may have developed tuberculosis. Which
diagnostic test does the nurse expect the primary health-care provider to prescribe to confirm this condition?
1. Histological examination
2. X-ray of the lungs
3. Both A and B
4. Electrocardiogram
2. The nurse is reviewing the complete blood count of a client who presents with fever. The white blood cell
count of the client is 15,000 cells/mL. Which condition has the client developed?
1. Leukocytosis
2. Leukopenia
3. Neutrophilia
4. None of the above
3. A client reports fever and shortness of breath. The complete blood count with differential shows a white blood
count of 16,000 cells/mL with90% neutrophils,2% eosinophils, and 1% basophils. Which condition has the
client developed?
1. Viral pneumonia
2. Bacterial pneumonia
3. Both A and B
4. Systemic lupus erythematosus
4. While assessing the vital signs of a 35-year-old client, the nurse records a blood pressure of 130/85 and body
temperature as 1030 F. The client’s complete blood count value indicates the presence of an acute infection.
What is the best nursing intervention for this client?
1. Administer aspirin to reduce fever.
2. Avoid administering ibuprofen to reduce fever.
3. Avoid administering acetaminophen to reduce fever.
4. All of the above
5. A 2-year-old client was brought to the hospital with fever. Reports revealed that the client has developed an
acute infection. What nursing intervention should the nurse implement for the client?
1. Administer aspirin.
2. Administer a salicylate-based nonsteroidal anti-inflammatory drug (NSAID).
3. Administer ibuprofen.
4. None of the above
6. A client has developed an infection after a dental implant surgery. Which condition is the client likely to
develop if the infection is left untreated?
1. Septicemia
2. Anthracosis
3. Tuberculosis
4. None of the above
7. A client has been working in a coal mine for a long time. Which condition is the client likely to develop?
PRIMEXAM.COM
1.
2.
3.
4.
Celiac disease
Anthracosis
Chronic hepatitis
Rheumatoid arthritis
8. How is acute inflammation different from chronic inflammation?
1. Acute inflammation is characterized by the predominance of neutrophils.
2. Acute inflammation is characterized by the predominance of monocytes.
3. Acute inflammation is characterized by the predominance of lymphocytes.
4. Acute inflammation is characterized by the predominance of macrophages.
9. A registered nurse is teaching a group of student nurses about the cell cycle and tissue healing. Which
statement made by a student nurse needs correction?
1. “Hepatocytes remain in the resting stage until stimulated.”
2. “Bone marrow cells are examples of labile cells.”
3. “Cardiac myocytes proliferate during the cell cycle and heal tissue damage.”
4. “Brain cells affected by stroke cannot regenerate.”
10. A registered nurse is teaching a student nurse about the effects of nutrition on wound healing. Which
statement made by the student nurse indicates the need for further teaching?
1. “A negative nitrogen balance improves the wound healing process.”
2. “Fats are essential for wound healing.”
3. “A protein-rich diet should be given to clients after surgery.”
4. “Vitamins are essential for wound healing.”
11. A client with arthritis asks the nurse the reason for delayed healing of the ulcers the client has developed on
the knees. Which is the best answer?
1. “Prednisone, a corticosteroid, delays the healing process.”
2. “Amitriptyline, an antidepressant, delays the healing process.”
3. “Naproxen, a nonsteroidal anti-inflammatory drug, delays the healing process.”
4. “Celebrex, a nonsteroidal anti-inflammatory drug, delays the healing process.”
12. While caring for an obese client who has undergone an abdominal surgery, the nurse finds that the client
vomits occasionally. What is the complication of healing that the client might have developed?
1. Dehiscence
2. Pressure ulcers
3. Adhesion D
4. None of the above
13. A client who recently underwent an abdominal surgery is scheduled for an immediate surgery due to a wound
healing complication. What is the complication of healing that the client might have developed?
1. Dehiscence
2. Evisceration
3. Keloid
4. All of the above
14. A nurse is teaching a client with a decubitus ulcer about the nutrients required for wound healing. Which
statement made by the client indicates effective learning?
1. “Consuming orange juice will improve wound healing.”
2. “Consuming dairy products will encourage rapid wound healing.”
3. “Adding zinc to the diet will help with wound healing.”
PRIMEXAM.COM
4. “Taking vitamin K will reduce the risk of decubitus ulcers.”
15. Which bacteria proliferates quickly due to ischemia?
1. Clostridium perfringens
2. Treponema pallidum
3. Mycobacteria tuberculi
4. All of the above
16. Which component of the blood is involved during an inflammatory response due to a respiratory burst from
the mitochondria?
1. Eosinophils
2. Basophils
3. Neutrophils
4. Lymphocytes
17. Which component of the blood surrounds and consumes foreign material in phagocytosis?
1. White blood cells
2. Blood plasma
3. Red blood cells
4. Blood platelets
18. A client was brought to the hospital with wounds sustained from a bicycling accident. Which clinical
interventions should the nurse carry out to facilitate optimal wound healing?
1. Vigorous irrigation
2. Cleansing while changing dressing
3. Removal of foreign matter
4. All of the above
19. An ultrasound performed on a client shows an abnormal connection between the trachea and esophagus. What
term best describes the complication that the client has developed?
1. Evisceration
2. Fistula
3. Stricture
4. None of the above
20. Which component enables the blood vessels to dilate and become more permeable during the vascular phase
of inflammation?
1. White blood corpuscles
2. Blood platelets
3. Inflammatory mediators
4. C-reactive proteins
NARRBEGIN: Exhibit
Exhibit
NARREND
21. A nurse is caring for four clients in a hospital. Which wound takes extensive time and requires more support
to heal?
Client 1
Appendectomy site
Client 2
Pressure ulcers
Client 3
First-degree burn on
PRIMEXAM.COM
Client 4
Tonsillectomy site
the arms
1.
2.
3.
4.
Client 1
Client 2
Client 3
Client 4
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
22. Which components of the blood attract platelets to the site of the injury in the form of a chemical signal?
Select all that apply.
1. Histamine
2. Interleukins
3. Microbial agents
4. Endothelial cells
5. White blood corpuscles
23. What are the inflammatory mediators that are released from white blood cells (WBCs)? Select all that apply.
1. TNF-alpha
2. Interleukins
3. Fibrinogen
4. Leukotrienes
5. Granuloma
24. A registered nurse is teaching a student nurse about C-reactive proteins. Which statement made by the student
nurse indicates effective teaching? Select all that apply.
1. “It identifies the presence of foreign material in the immune system.”
2. “It stimulates other inflammatory cytokines.”
3. “It prevents WBC adhesion to endothelium.”
4. “It stimulates gastric mucous production.”
5. “It identifies the presence of tubercles.”
25. Which clients would benefit from hyperbaric oxygen therapy? Select all that apply.
1. A client with a skin graft
2. A client with diabetic foot ulcers
3. A client with anthracosis
4. A client with osteoarthritis
5. A client with gangrene in the toes
PRIMEXAM.COM
Chapter 9: Infection and Inflammation
Answer Section
MULTIPLE CHOICE
1. ANS: 3
Chapter: Chapter 9, Infection and Inflammation
Page: 162, 163
Objective: N/A
Difficulty: Moderate
Heading: Inflammation and the Inflammatory Response
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Inflammation
1
2
3
4
Feedback
A tubercle is a chronic inflammatory granuloma where the region of infection is
infiltrated with macrophages. It can be identified through histological examination.
A tubercle is a chronic inflammatory granuloma where the region of infection is
infiltrated with macrophages. It often occurs in the lungs. X-ray of the lungs is useful to
identify a tubercle.
A histological examination and x-ray of the chest are used to identify the presence of a
tubercle.
An electrocardiogram is a test used to identify cardiac diseases.
PTS: 1
CON: Inflammation
2. ANS: 1
Chapter: Chapter 9, Infection and Inflammation
Page: 159
Objective: N/A
Difficulty: Moderate
Heading: Types of Inflammation
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Hematologic Regulation
1
2
3
4
Feedback
Leukocytosis occurs when the number of white blood cells is greater than11,000 cells/
microliter. Therefore, the client has developed leukocytosis.
Leukopenia refers to the number of white blood cells falling below 4,000 cells/mL.
Neutrophilia occurs when the number of neutrophils rises and is known as a “left shift.”
The client has developed leukocytosis since the number of white blood cells is
above11,000 cells/mL.
PRIMEXAM.COM
PTS: 1
CON: Hematologic Regulation
3. ANS: 2
Chapter: Chapter 9, Infection and Inflammation
Page: 160
Objective: N/A
Difficulty: Difficult
Heading: Inflammation and the Inflammatory Response
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Hematologic Regulation
A
B
C
D
Feedback
Viral pneumonia is a condition where the count of lymphocytesis90% and the white blood cell
count is elevated to at least 16,000cells/mL.
The elevated white blood cell count of 16,000 with 90% neutrophils is an indication of
bacterial pneumonia. Therefore, the client has developed bacterial pneumonia.
The client has developed bacterial pneumonia. In viral pneumonia, the count of lymphocytes
will be high whereas in bacterial pneumonia the count of neutrophils will be high. The client
has a high percentage of neutrophils; therefore the client has developed bacterial pneumonia.
Systemic lupus erythematosus is a chronic inflammatory disease.
PTS: 1
CON: Hematologic Regulation
4. ANS: 1
Chapter: Chapter 9, Infection and Inflammation
Page: 160
Objective: N/A
Difficulty: Difficult
Heading: Inflammation and the Inflammatory Response Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Hematologic Regulation
1
2
3
4
Feedback
The nurse should administer aspirin when the client is experiencing a fever greater than
102°F. Aspirin inhibits prostaglandin formation and reduces fever.
The nurse should administer ibuprofen because it reduces fever by inhibiting the
formation of prostaglandins.
The nurse should administer acetaminophen because it reduces fever by inhibiting the
formation of prostaglandins.
The nurse should administer aspirin.
PTS: 1
CON: Hematologic Regulation
5. ANS: 4
Chapter: Chapter 9, Infection and Inflammation
Page: 162, 163
Objective: N/A
PRIMEXAM.COM
Difficulty: Moderate
Heading: Inflammation and the Inflammatory Response
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Hematologic Regulation
1
2
3
4
Feedback
The nurse should not administer aspirin because, due to age, the client is at risk of
developing Reye’s syndrome. Reye’s syndrome is a life-threatening disease which
damages mitochondria and leads to liver failure.
The nurse should not administer a salicylate-based NSAID because the client is at risk
of developing Reye’s syndrome. Reye’s syndrome is a life-threatening disease, which
damages mitochondria and leads to liver failure.
The nurse should not administer ibuprofen because the client is at risk of developing
Reye’s syndrome. Reye’s syndrome is a life-threatening disease which damages
mitochondria and leads to liver failure.
The nurse should not administer aspirin, ibuprofen, or any salicylate based NSAID
because the client is at risk of developing Reye’s syndrome.
PTS: 1
CON: Hematologic Regulation
6. ANS: 1
Chapter: Chapter 9, Infection and Inflammation
Page: 165
Objective: N/A
Difficulty: Moderate
Heading: Factors That Affect Wound Healing
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Hematologic Regulation
1
2
3
4
Feedback
The client is at risk of developing septicemia, which is bacteria in blood that often
occurs with severe infection. Surgical inserted devices can predispose the client to
infection.
Anthracosis refers to black lung disease caused by inhalation of coal dust.
Tuberculosis is a chronic inflammation caused by mycobacteria tuberculi.
The client is at risk of developing septicemia.
PTS: 1
CON: Hematologic Regulation
7. ANS: 2
Chapter: Chapter 9, Infection and Inflammation
Page: 162
Objective: N/A
Difficulty: Moderate
Heading: Types of Inflammation
PRIMEXAM.COM
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Inflammation
1
2
3
4
Feedback
Celiac disease is an autoimmune disease that affects the small intestine. The disease is
caused by adverse reactions of the gut to gluten. Celiac disease does not occur due to
inhaling dust in coal mines.
Anthracosis is a condition characterized by the accumulation of carbon in the lungs due
to inhaling coal dust. Therefore, the client is likely to develop anthracosis.
Chronic hepatitis is a long lasting inflammation of the liver and is characterized by the
presence of inflammatory cells in the tissue. It is caused by hepatitis C virus.
Rheumatoid arthritis is a condition characterized by joint inflammation and pain in the
joints. It is an autoimmune disease.
PTS: 1
CON: Inflammation
8. ANS: 1
Chapter: Chapter 9, Infection and Inflammation
Page: 162
Objective: N/A
Difficulty: Difficult
Heading: Types of Inflammation
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Inflammation; Infection; Immunity
1
2
3
4
Feedback
Acute inflammation is characterized by an increase in the level of neutrophils. Acute
inflammation is manifested by increased vascular permeability, increased blood flow,
edema, and neutrophil proliferation.
Chronic inflammation is characterized by the predominance of monocytes. An
increased level of monocytes in the blood is an indication of chronic inflammation.
Chronic inflammation is characterized by the predominance of lymphocytes. CD4 Tlymphocytes are particularly elevated in chronic inflammation.
Chronic inflammation is characterized by the predominance of macrophages.
Macrophages release inflammatory paracrines, growth factors, and protein.
PTS: 1
CON: Inflammation; Infection; Immunity
9. ANS: 3
Chapter: Chapter 9, Infection and Inflammation
Page: 164
Objective: N/A
Difficulty: Difficult
Heading: The Cell Cycle
Integrated Processes: Teaching/Learning
PRIMEXAM.COM
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Cellular Regulation
1
2
3
4
Feedback
Hepatocytes are found in the liver. These cells are stable cells and require major stimuli
to undergo mitosis and regenerate in a cell cycle. These cells remain in a resting stage
unless stimulated when they enter the cell cycle.
Bone marrow cells are examples of labile cells. Borrow marrow cells continually divide
and replicate throughout life. Due to the active synthesis of blood cells, bone marrow
cells divide and replace cells that are constantly eliminated throughout life.
Cardiac myocytes do not proliferate and do not take part in the cell cycle. Cardiac
myocytes are permanent cells that have lost their ability to proliferate. These cells
involved in infarction are considered dead because they are unable to function.
Brain cells involved in stroke are permanent cells that have lost their ability to undergo
mitosis. Hence, they do not proliferate. These cells are considered to be dead cells.
PTS: 1
CON: Cellular Regulation
10. ANS: 1
Chapter: Chapter 9, Infection and Inflammation
Page: 164
Objective: N/A
Difficulty: Difficult
Heading: Factors That Affect Wound Healing
Integrated Processes: Teaching/Learning
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Skin Integrity; Assessment
1
2
3
4
Feedback
A positive nitrogen balance is required for wound healing. When a client’s nitrogen
intake exceeds nitrogen excretion, it results in a positive nitrogen balance and improves
the wound healing process.
Fats are important components of the cell membrane. Therefore, they are essential
during the wound healing process.
Proteins are necessary for cellular regeneration and synthesis of connective tissues.
Therefore, clients are placed on a protein-rich diet after surgery for rapid healing.
Vitamins are essential in the wound healing process. For example, vitamins A and C are
essential for building proteins and increasing collagen strength.
PTS: 1
CON: Skin Integrity; Assessment
11. ANS: 1
Chapter: Chapter 9, Infection and Inflammation
Page: 165
Objective: N/A
Difficulty: Moderate
Heading: Factors That Affect Wound Healing
PRIMEXAM.COM
Integrated Processes: Teaching/Learning
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Medication
1
2
3
4
Feedback
Prednisone is a corticosteroid used for treating arthritis. Corticosteroids might delay
wound healing by inhibiting collagen synthesis. Therefore, the client receiving
prednisone may have delayed wound healing.
Amitriptyline is an antidepressant given to arthritic clients to manage pain. The drug
does not affect the wound healing process.
Naproxen is a nonsteroidal anti-inflammatory drug used for pain management in
arthritis. The drug does not interfere with wound healing.
Celebrex is a nonsteroidal anti-inflammatory drug used for reducing pain in clients with
arthritis. The drug does not affect the wound healing process.
PTS: 1
CON: Medication
12. ANS: 1
Chapter: Chapter 9, Infection and Inflammation
Page: 167
Objective: N/A
Difficulty: Moderate
Heading: Dysfunctional Wound Healing
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Perioperative; Skin Integrity
1
2
3
4
Feedback
Obese clients are at higher risk of experiencing dehiscence because the fatty tissues do
not readily heal. In addition, vomiting increases intraabdominal pressure, thus creating
a higher risk of dehiscence.
Pressure ulcers are a kind of chronic wounds caused by unrelieved pressure.
Adhesions are abnormal bands of internal scar tissue that can form after a surgical
procedure.
The client might develop dehiscence, so the option “none of the above” is incorrect.
PTS: 1
CON: Perioperative; Skin Integrity
13. ANS: 2
Chapter: Chapter 9, Infection and Inflammation
Page: 167
Objective: N/A
Difficulty: Moderate
Heading: Dysfunctional Wound Healing
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
PRIMEXAM.COM
Concept: Perioperative; Skin Integrity
1
2
3
4
Feedback
Nursing interventions to treat dehiscence include maintaining bed rest and applying
binders to prevent further complications. Dehiscence does not require surgery.
Evisceration is a wound healing complication that is a surgical emergency. The client
should be prepared for a surgical procedure immediately to avoid further complications.
A keloid is the excessive accumulation of epithelium and collagen during wound
healing. Keloids can be reduced by cosmetic surgery, but it is not required immediately.
Evisceration requires surgical procedures. Therefore, the answer option “all of the
above” is incorrect.
PTS: 1
CON: Perioperative; Skin Integrity
14. ANS: 1
Chapter: Chapter 9, Infection and Inflammation
Page: 165
Objective: N/A
Difficulty: Difficult
Heading: Factors That Affect Wound Healing
Integrated Processes: Teaching/Learning
Client Need: Physiological Integrity: Basic Care and Comfort
Cognitive Level: Evaluation [Evaluating]
Concept: Nutrition; Skin Integrity
1
2
3
4
Feedback
Orange juice is a rich source of vitamin C. Vitamin C increases collagen strength and
helps in building proteins in the body. It also strengthens the epithelial membrane.
Therefore, consuming orange juice will improve wound healing.
Dairy products are rich in calcium. Calcium supports bone growth, but it is not
associated with wound healing.
Zinc is necessary for cellular metabolism, but it does not improve wound healing.
Vitamin K enables the synthesis of coagulation factors, but it does not help reduce the
development of decubitus ulcers.
PTS: 1
CON: Nutrition; Skin Integrity
15. ANS: 1
Chapter: Chapter 9, Infection and Inflammation
Page: 165
Objective: N/A
Difficulty: Easy
Heading: Factors That Affect Wound Healing
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Inflammation
Feedback
PRIMEXAM.COM
1
2
3
4
Ischemia fosters the growth of anaerobic bacteria such as clostridium perfringens, the
microorganism that causes gangrene.
Ischemia does not foster the growth of treponema pallidum. Treponema pallidum
causes diseases such as syphilis. Viruses, parasites, fungi, and bacteria can also cause
chronic inflammatory disorders, as can prolonged exposure to toxic agents.
Ischemia does not foster the growth of mycobacteria tuberculi. Mycobacteria tuberculi
are the etiological agents of tuberculosis.
Clostridium perfringens are the bacteria that are encouraged to grow due to ischemia.
Therefore, choice A is correct and all other answers are incorrect.
PTS: 1
CON: Inflammation
16. ANS: 3
Chapter: Chapter 9, Infection and Inflammation
Page: 166
Objective: N/A
Difficulty: Easy
Heading: Inflammation and the Inflammatory Response
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Inflammation
1
2
3
4
Feedback
Eosinophils are a type of white blood cell that contain granules, which turn into
macrophages.
Basophils are referred to as granulocytes because they contain important enzymes and
inflammatory mediators to support the inflammatory process and fight infection.
Neutrophils are involved in phagocytosis of microbial organisms and cellular debris.
Therefore, there is a respiratory burst from the mitochondria.
Lymphocytes are one of the types of white blood cells. During an inflammatory
process, lymph nodes enlarge and become tender because of the active proliferation of
lymphocytes.
PTS: 1
CON: Inflammation
17. ANS: 1
Chapter: Chapter 9, Infection and Inflammation
Page: 166
Objective: N/A
Difficulty: Easy
Heading: Inflammation and the Inflammatory Response
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Knowledge [Remembering]
Concept: Inflammation
Feedback
PRIMEXAM.COM
1
2
3
4
Phagocytosis is a process wherein the white blood cells surround and consume the
foreign material.
Blood plasma is the liquid component of the blood, which holds the white blood cells
and red blood cells.
Red blood cells carry oxygen to various tissues. They contain hemoglobin.
Platelets are blood cells that function with the coagulation factors to stop bleeding.
PTS: 1
CON: Inflammation
18. ANS: 4
Chapter: Chapter 9, Infection and Inflammation
Page: 167
Objective: N/A
Difficulty: Moderate
Heading: Factors That Affect Wound Healing
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Inflammation
1
2
3
4
Feedback
Vigorous irrigation of the wound site will help in the removal of foreign bodies, which
increase the risk of infection.
Cleansing of the wound site every time the dressing is changed will help in the removal
of foreign bodies, which increase the risk of infection.
Removal of foreign matter from the wound site is important because they increase the
risk of infection.
Vigorous irrigation, cleansing, and removal of foreign bodies are the clinical
interventions the nurse should carry out to facilitate optimal wound healing.
PTS: 1
CON: Inflammation
19. ANS: 2
Chapter: Chapter 9, Infection and Inflammation
Page: 167
Objective: N/A
Difficulty: Easy
Heading: Cellular Regeneration, Tissue Repair, and Healing
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Inflammation
1
2
3
Feedback
The extrusion of internal tissues and organs from an open wound is called wound
evisceration.
An abnormal connection between two different organs or tissues is known as fistula.
The client has developed a tracheoesophageal fistula.
A wound healing complication that causes closure of an open area of the body or
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4
narrowing of an open area of the body is called a stricture.
The client has developed a tracheoesophageal fistula. Therefore, the answer option
“none of the above” is incorrect.
PTS: 1
CON: Inflammation
20. ANS: 3
Chapter: Chapter 9, Infection and Inflammation
Page: 158
Objective: N/A
Difficulty: Easy
Heading: Inflammation and the Inflammatory Response
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Knowledge [Remembering]
Concept: Inflammation
Feedback
1
2
3
4
White blood cells are brought to the damaged area during the inflammatory response.
White blood cells secrete substances that protect tissues from the initial injury.
Platelets travel to the site of injury or infection in order to promote blood clotting.
Inflammatory mediator histamine enables the blood vessel to dilate and become more
permeable at the site of inflammation during vascular phase III.
C-reactive proteins are substances released by the liver. They influence the
inflammatory process by stimulating, modulating, and deactivating the reaction.
PTS: 1
CON: Inflammation
21. ANS: 2
Chapter: Chapter 9, Inflammation and Dysfunctional Wound Healing
Page: 165
Objective: N/A
Difficulty: Moderate
Heading: Normal Wound Healing
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Skin Integrity; Assessment
1
2
Feedback
Appendectomy is the surgical removal of the appendix to cure appendicitis. The
surgical wound is an example of primary intention healing. Primary intention healing
involves no or minimal tissue loss and the edges are well approximated. The wound
undergoes a rapid healing process. It does not take extensive time and support to heal.
Pressure ulcers are caused when the area of the skin is placed under pressure. Pressure
ulcers are examples of secondary intention healing. These wounds have large areas of
missing skin and deeper tissue damage. Abundant granulation and fibrous tissues are
required to heal the wound and restore the original tissue structure. Hence, these
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wounds require extensive time and more support for healing.
First-degree burns on the arms are superficial wounds. These types of wounds cause
minimal skin damage. Hence, these wounds do not require much time to heal.
Tonsillectomy is the surgical removal of tonsils. The tonsillectomy site heals by
primary intention healing. It does not require extensive time and support to heal.
PTS: 1
CON: Skin Integrity; Assessment
MULTIPLE RESPONSE
22. ANS: 3, 4, 5
Chapter: Chapter 9, Infection and Inflammation
Page: 158
Objective: N/A
Difficulty: Easy
Heading: Inflammation and the Inflammatory Response
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Inflammation
1.
2.
3.
4.
5.
Feedback
This is incorrect. Histamine is a compound which is released by cells in response to injury
and in allergic and inflammatory reactions. It causes arteriolar vasodilation, large artery
vasoconstriction, and increased permeability of venules.
This is incorrect. Interleukins are a class of glycoproteins produced by leucocytes to
regulate immune responses.
This is correct. A chemical signal from microbial agents attracts platelets and other white
blood cells to the site of injury during the cellular phase of inflammation. This is called
chemotaxis. This kills microorganisms or inhibits their growth.
This is correct. The foundation of scar tissue is formed by endothelial cells, which are
called granulation tissue.
This is correct. The white blood cells arrive at the site of inflammation and line up along
the endothelium in the area of inflammation.
PTS: 1
CON: Inflammation
23. ANS: 1, 2, 4
Chapter: Chapter 9, Infection and Inflammation
Pages: 158, 159
Objective: N/A
Difficulty: Easy
Heading: Inflammation and the Inflammatory Response
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Knowledge [Remembering]
Concept: Inflammation
PRIMEXAM.COM
1.
2.
3.
4.
5.
Feedback
This is correct. TNF-alpha is a tumor necrosis factor that can improve the release of WBCs
into the bloodstream. It also facilitates the release of pituitary corticotropin in the body.
This is correct. Interleukins are tumor necrosis factors. Some of the inflammatory
mediators released by WBCs are referred to as cytokines.
This is incorrect. Fibrinogen influences the inflammatory process by stimulating,
modulating, and deactivating the reaction.
This is correct. Prostaglandins (PGs), leukotrienes, TNF-alpha, and ILs are inflammatory
mediators released from WBCs. Leukotrienes provoke bronchiole inflammation in asthma.
This is incorrect. A granuloma is an area where macrophages have aggregated and are
transformed into epithelial-like or epithelioid cells.
PTS: 1
CON: Inflammation
24. ANS: 1, 2, 3
Chapter: Chapter 9, Infection and Inflammation
Page: 159
Objective: N/A
Difficulty: Difficult
Heading: Inflammation and the Inflammatory Response
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Inflammation
1.
2.
3.
4.
5.
Feedback
This is correct. C-reactive proteins are acute-phase proteins released by the liver. They are
essential to identify foreign material for the immune system.
This is correct. C-reactive proteins are both pro-inflammatory and anti-inflammatory in
action and can stimulate other inflammatory cytokines.
This is correct. C-reactive proteins prevent white blood cell adhesion to the endothelium.
The WBCs arrive at the site of inflammation. They organize along the endothelium in the
area of inflammation. They then release many different inflammatory mediators such as Creactive proteins.
This is incorrect. The prostaglandins formed from the cyclooxygenase-1 (cox-1) pathway
stimulate gastric mucous production and form clots.
This is incorrect. A tubercle is a chronic inflammatory granuloma where the region of
infection is infiltrated with macrophages.
PTS: 1
CON: Inflammation
25. ANS: 1, 2, 5
Chapter: Chapter 9, Infection and Inflammation
Page: 165
Objective: N/A
Difficulty: Moderate
Heading: Factors That Affect Wound Healing
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
PRIMEXAM.COM
Cognitive Level: Application [Applying]
Concept: Skin Integrity; Oxygenation
1.
2.
3.
4.
5.
Feedback
This is correct. A skin graft requires an oxygenated wound bed to heal. Hyperbaric oxygen
therapy is used to heal skin graft wounds. The therapy enhances blood circulation and
oxygenation of cells two times as compared to normal oxygenation of cells.
This is correct. Diabetic foot ulcers are open wounds that occur on the foot in diabetic
clients. Hyperbaric oxygen therapy is effective in treating diabetic foot ulcers because
increased blood flow and oxygen supply to wounds improve wound healing.
This is incorrect. Anthracosis is a chronic lung disease that occurs due to the accumulation
of carbon in the lungs. Hyperbaric oxygen therapy is not used to treat anthracosis.
This is incorrect. Osteoarthritis is characterized by pain and inflammation and reduces
motion of the lungs. Hyperbaric oxygen therapy is not used to treat osteoarthritis.
This is correct. Gangrene refers to dead tissues due to lack of blood flow to the tissues and
bacterial infection. Hyperbaric oxygen therapy is used to treat gangrene. Blood-rich
oxygen slows the growth of bacteria and helps the infected tissue heal easily.
PTS: 1
CON: Skin Integrity; Oxygenation
PRIMEXAM.COM
Chapter 10: Infectious Diseases
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. Which disease is spread from human to human via droplet infections through coughing or sneezing?
1. Mumps
2. Poliomyelitis
3. Herpes simplex
4. West Nile virus infection
2. Which is a protozoan infection?
1. Enterobiasis
2. Creutzfeldt-Jakob disease
3. Giardiasis
4. Coccidiomycosis
3. Which is an antibiotic-resistant bacterium?
1. Staphylococcus saprophyticus
2. Staphylococcus aureus
3. Streptococcus pyogenes
4. Streptococcus viridians
4. Which is the key symptom of meningitis?
1. Abdominal pain
2. Nuchal rigidity
3. Sensitivity to sound
4. Dysuria
5. What is a preventive measure for the vector-transmitted disease leishmaniasis?
1. Using insect repellant
2. Using vaccines
3. Avoiding vector-infested areas
4. Isolating the client
6. What approach is used to diagnose typhoid?
1. Tissue sampling
2. Urine culture
3. Serological antibodies
4. Sputum test
7. Which among these secretes a natural antiviral defense?
1. Ciliated respiratory tract cells
2. Alveolar macrophages
3. Respiratory epithelial cells
4. Cervical lymph nodes
8. A nurse demonstrates understanding of predisposing factors to Pseudomonas aeruginosa by selecting which
one of the following?
1. Urinary tract catheterization
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2. Hospital food
3. Nebulizer
4. Hospital linens
9. Which is the diagnostic test required to detect Legionnaire’s disease?
1. Neurological tests
2. Tissue sampling
3. Antibody titers
4. Arterial blood gases
10. Which is the distinctive rash of Erythema infectiosum (Fifth disease)?
1. Pinpoint red macules and petechiae
2. Dewdrops on a rose petal
3. Slapped-cheek appearance
4. Purpura and ecchymotic rash
11. Based on what would you justify that rubella causes teratogenic side effects?
1. Microcephaly in the fetus
2. Retinitis in the fetus
3. Vision impairment in the fetus
4. Spontaneous abortion of the fetus
12. What would be the diagnostic tests for malaria considering that the pathogen multiplies in the RBCs?
1. Test for anemia
2. Elevated level of bilirubin
3. Serological testing for specific antibodies
4. Urine test
13. Which virus caused the Spanish flu epidemic of 1918 that took many lives?
1. Epstein Barr virus
2. Cytomegalovirus
3. Influenza virus
4. Morbillivirus
14. Which is the reservoir for Neisseria meningitidis?
1. African fruit bat
2. White-tailed deer
3. Contaminated drinking water
4. Human nasopharynx
15. What are prions?
1. They are bacterial spores.
2. They are abnormal proteins.
3. They are fungal agents.
4. They are helminths.
16. Which fact would you select to justify why both the Ebola and Marburg viruses are classified as Category A
bioterrorism agents?
1. They cause hemorrhagic fevers.
2. They are virulent, stable, and infective as small-particle aerosols.
3. They are transmitted by direct contact through blood and body fluids.
4. There is no standard treatment.
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17. Which symptom is diagnostic for variant Creutzfeldt-Jakob disease?
1. Mental confusion
2. Personality changes
3. Problems with hearing, seeing, and smelling
4. Jerky muscle movements
18. Which diagnostic test confirms tapeworm infection?
1. Blood test
2. Stool test
3. Urine test
4. Antibody titers
19. Coccidiomycosis is an airborne disease.What conclusion can you draw about its mode of transmission?
1. Transmitted by fungal spores
2. Transmitted by vector bites
3. Transmitted by prions
4. Transmitted by contaminated food
20. How would you show your understanding of the fact that vaginal candidiasis a side effect of long-term
antibiotic use?
1. By the fact that it is an opportunistic infection.
2. By the fact that it eradicates lactobacillus in the vagina.
3. By the fact that it is caused by an antibiotic-resistant bacteria in the vagina.
4. By the fact that it is caused by decreased vaginal pH due to antibiotic use.
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
21. When would you recommend medical therapy in the treatment of infection?Select all that apply.
1. When there is prolonged manifestation of an infection
2. When there are no vaccines to prevent the infection
3. When there is undue risk to the people in contact with the client
4. When there is undue risk to the client
5. When the first line of defense fails to contain the infection
22. What aspects of culture analysis make the study so useful?Select all that apply.
1. Identification of microbes
2. Understanding the extent of infection
3. Studying the existence of antibodies
4. Studying the microbe’s susceptibility to antibiotics
5. Differentiating the gram-negative from the gram-positive bacteria
23. Which data is used to distinguish serological testing from other laboratory studies? Select all that apply.
1. Quantifying based on antibody titers
2. Analyzing for cell changes
3. Quantifying levels of immunoglobulin
4. Identifying antigen
5. Detection of microorganism’s genetic material
24. How would you justify that an emerging infectious disease is not always a new disease?Select all that apply.
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1.
2.
3.
4.
5.
Due to the disease being undetected
Due to reappearance of the disease
Due to antibiotic-resistant bacteria
Due to breakdown in public health measures
Due to realization about the mechanism of the disease process
Other
25. An infectious process has several different stages before it progresses to a full-blown disease. (Enter the letter
of each step in the proper sequence, do not use commas or spaces.)
A. Prodromal stage
B. Resolution phase
C. Convalescent stage
D. Incubation period
PRIMEXAM.COM
E. Acute stage
Chapter 10: Infectious Diseases
Answer Section
MULTIPLE CHOICE
1. ANS: 1
Chapter: Chapter 10, Infectious Diseases
Page: 174
Objective: N/A
Difficulty: Easy
Heading: Selected Viral Infections
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Safety and Infection Control
Cognitive Level: Comprehension [Understanding]
Concept: Infection
Feedback
1
2
3
4
Mumps is transmitted by droplet infection from a cough or a sneeze.
Polio enters the body through a fecal-oral route from contaminated food.
Herpes simplex is transmitted through close skin contact.
West Nile virus is spread through mosquito bites.
PTS: 1
CON: Infection
2. ANS: 3
Chapter: Chapter 10, Infectious Diseases
Page: 196, 197
Objective: N/A
Difficulty: Easy
Heading: Selected Parasitic Infections
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Safety and Infection Control
Cognitive Level: Knowledge [Remembering]
Concept: Infection
Feedback
1
2
3
4
Enterobiasis is a helminth infection caused by pinworms.
Creutzfeldt-Jakob disease is caused by a prion.
Giardiasis is caused by a protozoan called Giardia lamblia.
Coccidiomycosis is a fungal infection.
PTS: 1
CON: Infection
3. ANS: 2
Chapter: Chapter 10, Infectious Diseases
Page: 179
Objective: N/A
Difficulty: Easy
PRIMEXAM.COM
Heading: Selected Bacterial Infections
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Safety and Infection Control
Cognitive Level: Knowledge [Remembering]
Concept: Infection
Feedback
1
2
3
4
Staphylococcus saprophyticus normally colonize the skin, and are not antibiotic
resistant.
With widespread use of antibiotics, Staphylococcus aureus strains are found to be
methicillin resistant and vancomycin resistant.
Streptococcus pyogenes is not antibiotic resistant.
Streptococcus viridans is not antibiotic resistant.
PTS: 1
CON: Infection
4. ANS: 2
Chapter: Chapter 10, Infectious Diseases
Page: 179
Objective: N/A
Difficulty: Easy
Heading: Selected Bacterial Infections
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Safety and Infection Control
Cognitive Level: Comprehension [Understanding]
Concept: Inflammation
Feedback
1
2
3
4
Abdominal pain is not a sign of meningitis as it does not affect the gastrointestinal
organs.
Nuchal rigidity or stiffness in the neck is a symptom of meningitis and can be confirmed
as Kernig’s and Brudzinski signs.
Sensitivity to sound is not a key sign of meningitis.
Dysuria is a sign of urinary tract infection, not meningitis.
PTS: 1
CON: Inflammation
5. ANS: 1
Chapter: 10, Infectious Diseases
Page: 193
Objective: N/A
Difficulty: Moderate
Heading: Selected Parasitic Infections
Integrated Process: Nursing Process
Client Need: Safety and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Safety
Feedback
1
Leishmaniasis is spread through sandflies. Therefore, using insect repellant to repel
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2
3
4
sandflies is one of the preventive measures.
There are no vaccines against leishmaniasis.
Avoiding vector-infested areas will not help those who mandatorily have to live in the
area, such as soldiers in the Persian Gulf in whom the disease is common. Besides,
sandflies and rodents are ubiquitous.
There is no need to isolate the client as leishmaniasis is transmitted by sandfly.
PTS: 1
CON: Safety
6. ANS: 3
Chapter: 10, Infectious Diseases
Page: 170
Objective: N/A
Difficulty:Moderate
Heading: Selected Bacterial Infections
Integrated Process: Nursing Process
Client Need: Safety and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Infection
Feedback
1
2
3
4
Tissue sampling is used to confirm leishmaniasis, not typhoid.
A urine culture is used to confirm a urinary tract infection, not typhoid.
Serological antibodies can help diagnose typhoid.
A sputum test is used to detect Streptococcus pneumoniae, not typhoid.
PTS: 1
CON: Infection
7. ANS: 3
Chapter: 10, Infectious Diseases
Page: 174, 175
Objective: N/A
Difficulty: Difficult
Heading: Basic Concepts of Infection
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Immunity
Feedback
1
2
3
4
Ciliated respiratory tract cells do the physical act of sweeping away.
Alveolar macrophages are only present to phagocytose small organisms.
Respiratory epithelial cells secrete interferon, which is the body’s natural antiviral
cytokine.
Cervical lymph nodes store WBCs to defend against microorganisms.
PTS: 1
CON: Immunity
8. ANS: 1
Chapter: 10, Infectious Diseases
PRIMEXAM.COM
Page: 172
Objective: N/A
Difficulty:Moderate
Heading: Selected Bacterial Infections
Integrated Process: Nursing Process
Client Need: Safety and Effective Care Environment: Safety and Infection Control
Cognitive Level: Application [Applying]
Concept: Perioperative
Feedback
1
2
3
4
Pseudomonas aeruginosa can cause urinary tract infections in a hospital setting, and
urinary tract catheterization predisposes one to it.
Hospital food is not a source of pseudomonas infections, and it is not commonly
transmitted through oral routes.
Nebulizers cannot predispose clients to Pseudomonas aeruginosa.
Hospital linens are not a common cause of pseudomonas infection as skin contact is not
the method of transmission.
PTS: 1
CON: Perioperative
9. ANS: 4
Chapter: 10, Infectious Diseases
Page: 172
Objective: N/A
Difficulty: Difficult
Heading: Selected Bacterial Infections
Integrated Process: Nursing Process
Client Need: Safety and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Infection
Feedback
1
2
3
4
There are no specific neurological tests to diagnose Legionnaire’s disease.
Tissue sampling is not used to diagnose Legionnaire’s disease.
Antibody titers have no role to play in diagnosing Legionnaire’s disease.
Arterial blood gases are used to diagnose Legionnaire’s disease.
PTS: 1
CON: Infection
10. ANS: 3
Chapter: 10, Infectious Diseases
Page: 173
Objective: N/A
Difficulty: Moderate
Heading: Selected Viral Infections
Integrated Process: Nursing Process
Client Need: Safety and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Assessment
PRIMEXAM.COM
Feedback
1
2
3
4
Pinpoint red macules and petechiae called Forchheimer spots are seen over the soft
palate and uvula in German measles.
Dewdrops on a rose petal is the classic pattern of rash of chickenpox.
A slapped-cheek appearance that looks like sunburn on the facial skin is the first stage
rash of Fifth disease.
Purpura and ecchymotic rash are seen in Neisseria meningitidis.
PTS: 1
CON: Assessment
11. ANS: 4
Chapter: 10, Infectious Diseases
Page: 190
Objective: N/A
Difficulty: Difficult
Heading: Selected Viral Infections
Integrated Process: Nursing Process
Client Need: Safety and Effective Care Environment: Management of Care
Cognitive Level: Evaluation [Evaluating]
Concept: Pregnancy
Feedback
1
2
3
4
Microcephaly is caused by cytomegalovirus.
Retinitis is caused by cytomegalovirus.
Toxoplasmagondii causes vision impairment in the fetus.
Since rubella affects the embryo by causing spontaneous abortion, it is said to have
teratogenic effects.
PTS: 1
CON: Pregnancy
12. ANS: 3
Chapter: 10, Infectious Diseases
Page: 193
Objective: N/A
Difficulty: Moderate
Heading: Selected Parasitic Infections
Integrated Process: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Hematologic Regulation
Feedback
1
2
3
4
Anemia is common to several medical conditions and not specific to malaria.
Bilirubin, which is a byproduct of hemoglobin breakdown, is common to other medical
conditions and therefore elevated bilirubin is not considered diagnostic for malaria.
Serological testing to diagnose specific antibodies against plasmodium is also diagnostic
for malaria.
A urine test will not help to diagnose malaria as it infects the blood and not the urinary
system.
PRIMEXAM.COM
PTS: 1
CON: Hematologic Regulation
13. ANS: 3
Chapter: Chapter 10, Infectious Diseases
Page: 188
Objective: N/A
Difficulty: Easy
Heading: Selected Viral Infections
Integrated Process: Nursing Process
Client Need: Safety and Effective Care Environment: Safety and Infection Control
Cognitive Level: Knowledge [Remembering]
Concept: Infection
Feedback
1
2
3
4
The Epstein Barr virus causes infectious mononucleosis.
Cytomegalovirus causes mononucleosis-type symptoms in adults or can be
asymptomatic and can cause a wide range of disorders.
The Spanish flu was an epidemic caused by the influenza virus that took many lives in
1918.
Morbillivirus causes measles, which is different from flu.
PTS: 1
CON: Infection
14. ANS: 4
Chapter: Chapter 10, Infectious Diseases
Page: 172
Objective: N/A
Difficulty: Easy
Heading: Selected Bacterial Infections
Integrated Process: Nursing Process
Client Need: Safety and Effective Care Environment: Safety and Infection Control
Cognitive Level: Knowledge [Remembering]
Concept: Infection
Feedback
1
2
3
4
The African fruit bat is the reservoir for Marburg virus.
The white-tailed deer is the reservoir for Lyme disease.
Contaminated drinking water is a general reservoir for several infections but not
Neisseria meningitidis.
The human nasopharynx is the reservoir for Neisseria meningitidis.
PTS: 1
CON: Infection
15. ANS: 2
Chapter: Chapter 10, Infectious Diseases
Page: 173, 174
Objective: N/A
Difficulty: Easy
Heading: Prion Infectious Disease
Integrated Process: Nursing Process
PRIMEXAM.COM
Client Need: Safety and Effective Care Environment: Management of Care
Cognitive Level: Knowledge [Remembering]
Concept: Infection
Feedback
1
2
3
4
Prions are not bacterial spores.
Prions are abnormal proteins that are infectious.
Prions are not fungal in nature.
Helminths are worms, while prions are abnormal proteins.
PTS: 1
CON: Infection
16. ANS: 2
Chapter: 10, Infectious Diseases
Page: 193, 194
Objective: N/A
Difficulty: Difficult
Heading: Selected Viral Infections
Integrated Process: Nursing Process
Client Need: Safety and Effective Care Environment: Safety and Infection Control
Cognitive Level: Analysis [Analyzing]
Concept: Infection
1
2
3
4
Feedback
There are other pathogens that cause hemorrhagic fevers, and all of them are not
reportable or classified as Category A bioterrorism agents.
The potent killer combination and high infectivity make them Category A bioterrorism
agents.
There are several other pathogens that are transmitted through blood and body fluids
that are not classified as Category A bioterrorism agents.
There are several other diseases caused by pathogens that do not have standard
treatment options and they are not classified as Category A bioterrorism agents.
PTS: 1
CON: Infection
17. ANS: 3
Chapter: 10, Infectious Diseases
Page: 198
Objective: N/A
Difficulty: Moderate
Heading: Selected Parasitic Infections
Integrated Process: Nursing Process
Client Need: Safety and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Sensory Perception
1
Feedback
While there is mental confusion in the variant, there is memory loss in CreutzfeldtJakob disease, and therefore it is difficult to distinguish one from the other.
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2
3
4
While there are personality changes in Creutzfeldt-Jakob disease, there are psychiatric
problems in the variant, making it difficult to distinguish one from the other.
There are problems with hearing, seeing, and smelling in variant Creutzfeldt-Jakob
disease and these symptoms are noted for weeks or months.
Involuntary jerky movements found in Creutzfeldt-Jakob disease are similar to poor
muscle coordination and muscle spasms found in variant Creutzfeldt-Jakob disease,
making it difficult to distinguish one from other.
PTS: 1
CON: Sensory Perception
18. ANS: 2
Chapter: 10, Infectious Diseases
Page: 198
Objective: N/A
Difficulty: Difficult
Heading: Selected Parasitic Infections
Integrated Process: Nursing Process
Client Need: Safety and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Nutrition
Feedback
1
2
3
4
A blood test will not confirm a tapeworm infection.
A stool test can confirm the diagnosis of tapeworm by showing the presence of eggs or
segments of the worm.
A urine test cannot confirm a tapeworm infection.
Antibody titers are used for infections caused by microbes and not by tapeworm.
PTS: 1
CON: Nutrition
19. ANS: 1
Chapter: 10, Infectious Diseases
Page: 195, 196
Objective: N/A
Difficulty: Difficult
Heading: Coccidiomycosis
Integrated Process: Nursing Process
Client Need: Safety and Effective Care Environment: Safety and Infection Control
Cognitive Level: Analysis [Analyzing]
Concept: Infection
Feedback
1
2
3
4
Coccidiomycosis is a fungal infection caused by inhalation of fungal spores in the air.
There is no vector involved in the spread of coccidiomycosis. Vector-borne diseases can
be contagious, while coccidiomycosis is not.
While it is true that little is known about how prions (abnormal proteins) are formed or
gain entry into humans, it is not the cause of coccidiomycosis.
The fungal spores are inhaled from air and do not have an oral entry via contaminated
food.
PRIMEXAM.COM
PTS: 1
CON: Infection
20. ANS: 2
Chapter: 10, Infectious Diseases
Page: 175
Objective: N/A
Difficulty: Moderate
Heading: Basic Concepts of Infection
Integrated Process: Nursing Process
Client Need: Safety and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Female Reproduction
Feedback
1
2
3
4
Women who contract vaginal candidiasis are not necessarily immunosuppressed and are
not prey to opportunistic infection.
Antibiotics destroy lactobacillus that actually keeps the vaginal pH low. This factor is a
protective mechanism to ward off infection.
Antibiotic-resistant bacteria do not cause vaginal candidiasis.
Antibiotics do not cause a decrease in vaginal pH, and if anything a decreased vaginal
pH is protective.
PTS: 1
CON: Female Reproduction
MULTIPLE RESPONSE
21. ANS: 1, 3, 4
Chapter: 10, Infectious Diseases
Page: 178
Objective: N/A
Difficulty: Difficult
Heading: Basic Concepts of Infection
Integrated Process: Nursing Process
Client Need: Safety and Effective Care Environment: Management of Care
Cognitive Level: Evaluation [Evaluating]
Concept: Critical Thinking
1.
2.
3.
4.
5.
Feedback
This is correct. A prolonged manifestation could mean an immunocompromised state when
treatment becomes necessary.
This is incorrect. Absence of preventive vaccines is not a criterion for medical therapy.
This is correct. If the infection is a killer disease and easily transmitted, it is treated to
avoid risk to people in contact with the client.
This is correct. If certain stages of infection can cause undue risk to the client, the infection
has to be aborted before the stage is reached.
This is incorrect. When the first line of defense fails to contain an infection, the second line
of defense, called adaptive immune system, can contain the infection.
PRIMEXAM.COM
PTS: 1
CON: Critical Thinking
22. ANS: 1, 2, 4
Chapter: 10, Infectious Diseases
Page: 178, 179
Objective: N/A
Difficulty: Difficult
Heading: Basic Concepts of Infection
Integrated Process: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Evaluation [Evaluating]
Concept: Assessment
1.
2.
3.
4.
5.
Feedback
This is correct. A culture of the infected tissue or body fluid is grown on agar to identify
the microbes.
This is correct. The extent of infection can be inferred by the number of microorganisms
per high-power field or volume of substrate.
This is incorrect. Antibodies to the antigen (microbes) are inferred from serological testing
as the blood and not the substrate will contain the antibodies.
This is correct. The culture medium can be infused with antibiotics to study the growth or
suppression of microbes.
This is incorrect. Differentiating between gram-negative and gram-positive bacteria is done
through staining techniques and not through culture.
PTS: 1
CON: Assessment
23. ANS: 1, 3
Chapter: 10, Infectious Diseases
Page: 187
Objective: N/A
Difficulty: Difficult
Heading: Basic Concepts of Infection
Integrated Process: Nursing Process
Client Need: Safety and Effective Care Environment: Management of Care
Cognitive Level: Analyzing [Analysis]
Concept: Immunity
1.
2.
3.
4.
5.
Feedback
This is correct. Antibodies are found in blood serum and therefore are specific to
serological testing.
This is incorrect. Histology deals with the study of characteristic cell changes.
This is correct. Levels of IgM and IgG in the blood serum can predict the stage of
infection.
This is incorrect. Antigen identification combines culture and microscopic methods.
This is incorrect. Detection of a microorganism’s genetic material is achieved through
polymerase chain reaction (PCR).
PRIMEXAM.COM
PTS: 1
CON: Immunity
24. ANS: 1, 2, 5
Chapter: 10, Infectious Diseases
Page: 178, 179
Objective: N/A
Difficulty: Difficult
Heading: Basic Concepts of Infection
Integrated Process: Nursing Process
Client Need: Safety and Effective Care Environment: Management of Care
Cognitive Level: Analyzing [Analysis]
Concept: Infection
1.
2.
3.
4.
5.
Feedback
This is correct. The infection was present in the population but had not been detected.
This is correct. After a decline in the incidence of an infection, the infection can reoccur.
This is incorrect. Antibiotic-resistant bacteria cause reemergence of an infectious disease
and not emergence of an infectious disease.
This is incorrect. A breakdown in public health measures causes reemergence of infectious
disease.
This is correct. On realizing an established disease has an infectious origin, the disease
becomes an emerging infectious disease.
PTS: 1
CON: Infection
ORDERED RESPONSE
25. ANS:
DAECB
Chapter: 10, Infectious Diseases
Page: 190
Objective: N/A
Difficulty: Moderate
Heading: Basic Concepts of Infection
Integrated Process: Nursing Process
Client Need: Safety and Effective Care Environment: Management of Care
Cognitive Level:Application [Applying]
Concept: Infection
Feedback:The incubation period is the first stage when the pathogen begins to replicate in the host and has not
yet caused identifiable symptoms. The prodromal stage is the second stage when the host has a vague sense of
illness with an initial appearance of symptoms. The host is highly contagious in this stage. The acute stage is
the third stage when the symptoms become specific and the host experiences the full disease. The host’s
defenses are in full force fighting off the infection. The host remains contagious at this stage. The fourth stage
is the convalescent stage when the pathogen is gradually being eliminated and the infection is being contained
with a resolution of the symptoms. The resolution phase is the fifth and final phase with total elimination of
pathogens from the host and no residual signs or symptoms of the infection.
PRIMEXAM.COM
PTS: 1
CON: Infection
PRIMEXAM.COM
Chapter 11: Disorders of the Immune System
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. Which cells are known as granular lymphocytes?
1. Kupffer cells
2. Microglial cells
3. T cells
4. Natural killer cells
2. Where does maturation of T lymphocytes occur?
1. Spleen
2. Bone marrow
3. Thymus gland
4. Lymph nodes
3. Which is the predominant immunoglobulin produced after a host’s re-exposure to an antigen?
1. Immunoglobulin G (IgG)
2. Immunoglobulin A (IgA)
3. Immunoglobulin E (IgE)
4. Immunoglobulin D (IgD)
4. A 27-year-old client is pregnant. The blood group of the client and the fetus are incompatible. Which
antibodies produced by the mother against the fetus’s blood cells do not affect the fetus?
1. IgM
2. IgG
3. IgD
4. None of the above
5. Which immunity is developed by an individual after experiencing an illness?
1. Innate immunity
2. Active acquired adaptive immunity
3. Passive acquired adaptive immunity
4. None of the above
6. Which is an example of passive acquired adaptive immunity?
1. Newborns receiving immunity through breast milk
2. Individuals becoming immune to chicken pox after infection
3. Individuals becoming immune to measles after infection
4. None of the above
7. IgA is found most in
1. tears.
2. plasma.
3. blood.
4. All of the above.
8. A registered nurse is teaching nursing students about passive acquired adaptive immunity. Which statement
made by a student nurse indicates effective learning?
PRIMEXAM.COM
1.
2.
3.
4.
“It provides immediate immunity.”
“It is a short-term immunity.”
“It is not associated with immunologic memory.”
All of the above.
9. A woman who is planning to get pregnant is ordered to obtain an antibody screening test. The test shows
negative IgM. What does the test result indicate about the client?
1. She has been exposed to rubella.
2. She has developed rubella infection.
3. She needs to be given the rubella vaccine.
4. She is immune to rubella.
10. A client develops an erythematosus rash on the hands two days after working in the garden. What type of
hypersensitivity reaction has the client developed?
1. Type I immediate
2. Type II cytotoxic
3. Type III immune complex-mediated
4. Type IV delayed
11. A registered nurse is teaching a student nurse about assessing the results of a Mantoux test done on a 15-yearold client. The results indicate 5 mm tissue induration. Which statement made by the student nurse indicates
effective learning?
1. “The client is has an active case of tuberculosis (TB).”
2. “The client has had an exposure to TB.”
3. “The client has not had an exposure to TB.”
4. “The client should be given TB vaccine immediately.”
12. A nurse is assessing four clients who are suspected to have systemic lupus erythematosus. Which client has
developed the disease?
Signs and
symptoms
1.
2.
3.
4.
Client 1
Client 2
Client 3
Client 4
Fever, butterfly rash
on face, and joint
inflammation
Fever, swollen
joints, and general
malaise
Erythema
nodosum, weight
loss, and fever
Hypothermia,
elevated red blood
cell count, and
weight gain
Client 1
Client 2
Client 3
Client 4
13. A nurse is reviewing the prescriptions of four clients in the hospital. Compare the effects of the medications
prescribed to the clients and identify the client who is most likely being treated for systemic lupus
erythematosus (SLE).
Client 1
Client 2
Client 3
Client 4
Amoxicillin,
vancomycin, Imodium
Hydrocortisone,
hydroxychloroquine,
Cyclophosphamide,
mycophenolate,
Codeine, ibuprofen,
PRIMEXAM.COM
methotrexate
1.
2.
3.
4.
infliximab
naproxen
Client 1
Client 2
Client 3
Client 4
14. A registered nurse is teaching a student nurse about the common side effects of methotrexate therapy, which is
used to treat clients with rheumatoid arthritis. Which statement made by the student nurse indicates effective
learning?
1. “The client’s white blood cell count will be below 4,500 cells per microliter.”
2. “The client’s weight will increase by 2 kg.”
3. “The client’s urine specific gravity will be 1.030.”
4. All of the above.
15. A client with scleroderma complains of painful ulcers on the knees. Which condition has the client?
1. Telangiectasis
2. Calcinosis
3. Sclerodactyly
4. Raynaud’s phenomenon
16. A registered nurse is teaching a nursing student about the diagnostic test done for chronic mucocutaneous
candidiasis. What statement made by the student nurse indicates effective teaching?
1. “Potassium hydroxide wet mount is used to diagnose candida infection.”
2. “An antinuclear antibodies test is used to diagnose candida infection.”
3. “A C-reactive protein test is used to diagnose candida infection.”
4. “Urinalysis is used to diagnose candida infection.”
17. A nurse is reviewing the prescriptions of four clients. Assess the effects of the medication prescribed and
identify the client who is most likely being treated for chronic mucocutaneous candidiasis.
Client 1
Client 2
Client 3
Client 4
Ketoconazole
Codeine
Amoxicillin
Acyclovir
1.
2.
3.
4.
Client 1
Client 2
Client 3
Client 4
18. A nurse is reviewing the prescriptions of four clients who are being treated for chronic mucocutaneous
candidiasis. Compare the effects of the medications and choose the medication that is least effective in
treating chronic mucocutaneous candidiasis (CMC).
Client 1
Client 2
Client 3
Client 4
Itraconazole
Amorolfine
Fluconazole
Amphotericin B
PRIMEXAM.COM
1.
2.
3.
4.
Client 1
Client 2
Client 3
Client 4
19. A client has a positive ELISA test. On examination, the client is found to have fever, weight loss, and candida
infections. The client also complains of night sweats. What would be the CD4 levels?
1. 700 cells per microliter
2. 500 cells per microliter
3. 200 cells per microliter
4. 350 cells per microliter
20. A nurse who is engaged in maternal-child health care has a blood sample drawn for rubella antibody
screening. The test result shows very low titer values. Compare the nursing intervention stated and choose the
best nursing intervention for the given situation.
1. The nurse should consult the physician and receive the rubella vaccine immediately.
2. The nurse should consult the physician and receive the MMR vaccine immediately.
3. The nurse does not require any vaccinations.
4. None of the above
21. Which is an autoimmune disease?
1. Osteoarthritis
2. Rheumatoid arthritis
3. Type II diabetes
4. All of the above
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
22. A registered nurse is teaching nursing students about CD4 cells. Which statements made by a student nurse
indicate effective teaching? Select all that apply.
1. “The CD4 cells directly attack antigens.”
2. “The CD4 cells produce immunoglobulins.”
3. “The CD4 cells mature into plasma cells.”
4. “The human immunodeficiency virus attacks CD4 cells.”
5. “The CD4 cells are T cells that take part in cell-mediated immunity.”
23. A registered nurse is teaching a student nurse about interpreting blood test reports and urinalysis reports of
clients with systemic lupus erythematosus (SLE). Which statements made by the student nurse indicate
effective teaching? Select all that apply.
1. “A high antinuclear antibodies (ANA) level is more specific to clients with SLE.”
2. “Erythrocyte sedimentation rate is high in clients with SLE.”
3. “Leukopenia and thrombocytopenia are often observed in clients with SLE.”
4. “C-reactive proteins are low in clients with acute SLE.”
5. “Urinalysis reports of clients with SLE show bacteriuria and pyuria.”
24. A registered nurse is teaching a student nurse about the diagnosis and treatment of hypogammaglobulinemia.
Assess the statements made by the student nurse and identify the statements that indicate the need for further
teaching. Select all that apply.
1. “The diagnosis should be made when a child is 1 year old.”
PRIMEXAM.COM
2.
3.
4.
5.
“Bronchiectasis is common in clients with hypogammaglobulinemia.”
“Decreased IgG levels are observed in clients with hypogammaglobulinemia.”
“Decreased levels of IgM are observed in clients with hypogammaglobulinemia.”
“Live vaccine should be administered to the client.”
25. A registered nurse is teaching a student nurse about the diagnosis of AIDS. Assess the statements made by the
student nurse and identify the statements that indicate effective learning. Select all that apply.
1. “HIV RNA assay measures the viral load in clients with AIDS.”
2. “A viral load of 5,000 copies indicates the client is at a high risk of developing AIDS.”
3. “A CD4 to CD8 ratio of 2:1 is observed in clients with AIDS.”
4. “A negative ELISA test indicates the client is positive for HIV.”
5. “A Western Blot test is a conformity test for HIV antibody.”
PRIMEXAM.COM
Chapter 11: Disorders of the Immune System
Answer Section
MULTIPLE CHOICE
1. ANS: 4
Chapter: Chapter 11, Disorders of the Immune System
Page: 202
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts of Immunity
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Immunity: Infection
Feedback
1
2
3
4
Kupffer cells found in the liver are examples of macrophages. They are not known as
granular lymphocytes.
Microglial cells in the brain are examples of macrophages. They are not referred to as
granular lymphocytes.
T cells or T lymphocytes play a vital role in cell-mediated immunity. They are not
known as granular lymphocytes.
Natural killer cells act as a first-line of defense in the body and are a part of the innate
immune system. They contain cytoplasmic granules and are referred to as granular
lymphocytes.
PTS: 1
CON: Immunity: Infection
2. ANS: 3
Chapter: Chapter 11, Disorders of the Immune System
Page: 203
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts of Immunity
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Immunity: Infection
Feedback
1
2
3
4
The maturation of B lymphocytes occurs in the spleen.
B lymphocytes mature in the bone marrow.
T lymphocytes mature in the thymus glands.
B cells, which are also known as B lymphocytes, mature in lymph nodes.
PRIMEXAM.COM
PTS: 1
CON: Immunity: Infection
3. ANS: 1
Chapter: Chapter 11, Disorders of the Immune System
Page: 204
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts of Immunity
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Immunity: Infection
Feedback
1
2
3
4
Immunoglobulin G is the predominant immunoglobulin produced after a host’s reexposure to an antigen. IgG comprises 75% to 80% of the total serum
immunoglobulins.
Immunoglobulin A comprises 7% to 15% of the total serum immunoglobulins. IgA is
mainly found in saliva and nasal secretions.
Immunoglobulin E is generally present in a low concentration in the blood, but it
increases during allergic reactions.
Immunoglobulin D comprises only 1% of total serum immunoglobulins.
PTS: 1
CON: Immunity: Infection
4. ANS: 1
Chapter: Chapter 11, Disorders of the Immune System
Page: 204
Objective: N/A
Difficulty: Moderate
Heading: Basic Concepts of Immunity
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Immunity
Feedback
1
2
3
4
During pregnancy, if the mother and fetus have incompatible blood types, IgM
antibodies will be developed by the mother against the fetus’s blood cells. However,
because of the large size of IgM antibodies, they cannot cross the placenta, and the fetus
is protected.
During pregnancy, if the mother and fetus have incompatible blood types, IgM
antibodies will be developed by the mother against the fetus’s blood cells. The mother
will not produce IgG antibodies in the given situation.
During pregnancy, if the mother and fetus have incompatible blood types, IgM
antibodies will be developed by the mother against the fetus’s blood cells. The mother
will not produce IgD antibodies in the given situation.
The option “none of the above” is incorrect because IgM antibodies are developed by
PRIMEXAM.COM
the mother against the fetus’s blood cells in the given condition.
PTS: 1
CON: Immunity
5. ANS: 2
Chapter: Chapter 11, Disorders of the Immune System
Page: 204
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts of Immunity
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Immunity: Infection
Feedback
1
2
3
4
Innate immunity is the natural mechanism of the body that wards off foreign bodies as a
first line of defense. Mucous producing cells are part of the body’s innate immunity
mechanism.
Active acquired adaptive immunity is obtained through exposure to an antigen. It is
developed after an individual experiences an illness.
Passive acquired adaptive immunity is obtained by an individual after he or she is given
pre-made, fully formed antibodies, such as vaccines, against an antigen.
The option ‘none of the above” is incorrect because the immunity developed by an
individual after he or she experiences an illness is active acquired adaptive immunity.
PTS: 1
CON: Immunity: Infection
6. ANS: 1
Chapter: Chapter 11, Disorders of the Immune System
Page: 205
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts of Immunity
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Immunity
Feedback
1
2
3
4
When a breastfed infant receives fully formed, maternally produced antibodies through
breast milk, the infant acquires passive acquired adaptive immunity.
When an individual contracts chicken pox infection, the individual develops active
acquired adaptive immunity.
After an individual contracts measles infection, the individual develops active acquired
adaptive immunity.
The option “none of the above’ is incorrect because a newborn acquiring immunity
through breast milk is an example of passive acquired adaptive immunity.
PRIMEXAM.COM
PTS: 1
CON: Immunity
7. ANS: 1
Chapter: Chapter 11, Disorders of the Immune System
Page: 204
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts of Immunity
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Immunity
Feedback
1
2
3
4
IgA is mainly found in tears, saliva, nasal secretions, respiratory secretions, and
gastrointestinal fluids.
IgA comprises only 7% to 15% of the total serum immunoglobulins. It is found more in
saliva, nasal secretions, breast milk, and so on.
IgG comprises approximately 75% to 85% of the immunoglobulins present in the
blood.
The answer option “all of the above’ is incorrect because IgA is mainly found in
secretions such as tears.
PTS: 1
CON: Immunity
8. ANS: 4
Chapter: Chapter 11, Disorders of the Immune System
Page: 204
Objective: N/A
Difficulty: Difficult
Heading: Basic Concepts of Immunity
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Evaluation [Evaluating]
Concept: Immunity
Feedback
1
2
3
4
Passive acquired adaptive immunity can be acquired immediately after administration
of a vaccine or immunoglobulin.
Passive acquired adaptive immunity is a short-term immunity compared to active
acquired adaptive immunity, which is a long-lasting immunity.
In active acquired adaptive immunity, the body recognizes the antigens and remembers
the antigen, whereas in passive acquired adaptive immunity, the body does not
remember the antigen. It is not associated with immunologic memory.
The answer option “all of the above” is correct because all the answer options are
characteristics of passive acquired adaptive immunity.
PRIMEXAM.COM
PTS: 1
CON: Immunity
9. ANS: 3
Chapter: Chapter 11, Disorders of the Immune System
Page: 206
Objective: N/A
Difficulty: Moderate
Heading: Vaccines
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Immunity: Infection
Feedback
1
2
3
4
The test result does not indicate that the client has been exposed to rubella. A positive
IgM indicates that the client has been exposed to rubella recently.
The test result does not indicate the client has developed rubella infection. A positive
IgG indicates that the client has been exposed to rubella in the past and is immune to
rubella.
The test result indicates that the client needs to be given the rubella vaccine because the
client has never developed immunity to rubella.
The test result does not indicate the client is immune to rubella.
PTS: 1
CON: Immunity: Infection
10. ANS: 4
Chapter: Chapter 11, Disorders of the Immune System
Page: 208
Objective: N/A
Difficulty: Moderate
Heading: Hypersensitivity
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Infection: Skin Integrity: Immunity
Feedback
1
2
3
4
Type I immediate hypersensitivity is an allergic reaction that develops on re-exposure
to an antigen. The development of allergic rhinitis when an individual is exposed to
mold I is an example of type I immediate hypersensitivity.
In type II cytotoxic hypersensitivity, the immunoglobulins target the cells coated with
antigens. Phagocytosis and antibody-mediated cell destruction occur in type II
hypersensitivity reactions.
Type III immune complex-mediated hypersensitivity occurs when antigen combines
with the immunoglobulins in the bloodstream and is deposited in the tissues, resulting
in organ dysfunction.
Type IV delayed hypersensitivity is a cell-mediated immune response that takes at least
two days to develop after an exposure to an antigen. A delayed hypersensitivity reaction
PRIMEXAM.COM
occurs with exposure to poison ivy. The client has developed delayed hypersensitivity.
PTS: 1
CON: Infection: Skin Integrity: Immunity
11. ANS: 2
Chapter: Chapter 11, Disorders of the Immune System
Page: 209
Objective: N/A
Difficulty: Difficult
Heading: Hypersensitivity
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Evaluation [Evaluating]
Concept: Infection: Immunity: Safety
Feedback
1
2
3
4
If the Mantoux test result indicates an induration reaction of 10 mm or greater, the client
might have active TB.
If the Mantoux test result exhibits an induration reaction of 5 mm or fewer, then the
client has probably had an exposure to TB in the past.
If the Mantoux test result does not exhibit any swelling or induration reaction, the client
has not had TB infection or exposure.
If the Mantoux test result exhibits an induration reaction of 5 mm or fewer, then the
client has probably had an exposure to TB in the past. So there is no need for
administering TB vaccine to the client.
PTS: 1
CON: Infection: Immunity: Safety
12. ANS: 1
Chapter: Chapter 11, Disorders of the Immune System
Page: 211
Objective: N/A
Difficulty: Moderate
Heading: Pathophysiology of Selected Autoimmune Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Immunity: Infection
Feedback
1
2
3
Client 1 has developed systemic lupus erythematosus because fever, a butterfly rash on
the face, and joint inflammation are signs and symptoms of the disease.
Client 2 has not developed systemic lupus erythematosus. Though fever and swollen
joints are symptoms of systemic lupus erythematosus, the presence of a skin rash on the
face is also a typical symptom of the disease. The client is at a higher risk of developing
osteoporosis, as the symptoms exhibited are typical to that condition.
Client 3 has not developed systemic lupus erythematosus because erythema nodosum is
a typical symptom of sarcoidosis. The symptoms of sarcoidosis include fever, weight
PRIMEXAM.COM
4
loss and anorexia, malaise, and fatigue.
Client 4 has not developed systemic lupus erythematosus because a typical symptom of
systemic lupus erythematosus is fever. Hypothermia is not a symptom of systemic lupus
erythematosus. Anemia and weight loss are symptoms of systemic lupus erythematosus.
PTS: 1
CON: Immunity: Infection
13. ANS: 2
Chapter: Chapter 11, Disorders of the Immune System
Page: 212
Objective: N/A
Difficulty: Difficult
Heading: Pathophysiology of Selected Autoimmune Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Evaluation [Evaluating]
Concept: Immunity: Medication
Feedback
1
2
3
4
Client 1 does not have SLE. Amoxicillin and vancomycin are antibiotics. Imodium is an
antidiarrheal drug. Antibiotics and antidiarrheal drugs are not used in the treatment of
SLE.
Client 2 is being treated for SLE. Hydrocortisone is a corticosteroid used in the
treatment of SLE. Hydroxychloroquine is an antimalarial drug used in the treatment of
SLE. Methotrexate is an immunosuppressant used to treat autoimmune diseases such as
SLE.
Client 3 does not have SLE. Cyclophosphamide is an immunosuppressant.
Mycophenolate is a disease-modifying antirheumatic drug used in the treatment of
rheumatoid arthritis. Infliximab blocks the action of THF-alpha, which is a destructive
cytokine.
Client 4 does not have SLE. Codeine is an opioid pain medication used for treating mild
to moderate pain. Ibuprofen is a nonsteroidal anti-inflammatory drug used for relieving
pain. Naproxen is a nonsteroidal anti-inflammatory drug used for treating inflammation
and pain in arthritis.
PTS: 1
CON: Immunity: Medication
14. ANS: 1
Chapter: Chapter 11, Disorders of the Immune System
Page: 212
Objective: N/A
Difficulty: Difficult
Heading: Pathophysiology of Selected Autoimmune Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Immunity: Medication
PRIMEXAM.COM
Feedback
1
2
3
4
Methotrexate therapy is an immunosuppressive therapy used in the treatment of
rheumatoid arthritis, which is an autoimmune disorder. A white blood cell count below
4,500 cells per microliter indicates immunosuppression. This is a common side effect of
the therapy.
Methotrexate therapy is an immunosuppressive therapy. Weight gain might be
associated with the therapy. However, weight gain is not a common side effect of the
therapy.
A urine specific gravity of 1.030 indicates the normal range. Methotrexate therapy does
not alter the urine specific gravity; so any change in urine specific gravity is not a side
effect of the therapy.
Methotrexate therapy is an immunosuppressive therapy used to treat autoimmune
diseases. Therefore, a low white blood cell count is a side effect of the therapy. Hence,
the answer option “all of the above” is incorrect.
PTS: 1
CON: Immunity: Medication
15. ANS: 2
Chapter: Chapter 11, Disorders of the Immune System
Page: 216
Objective: N/A
Difficulty: Moderate
Heading: Pathophysiology of Selected Autoimmune Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Immunity: Skin Integrity
Feedback
1
2
3
4
Telangiectasia is a condition characterized by the dilatation of the capillaries. It causes
the capillaries to appear as small red clusters, often spidery in appearance on the skin.
Calcinosis is a condition in which an abnormal amount of calcium is found in the soft
tissues. Calcinosis develops in the skin and in bony areas. This might cause skin
breakdown.
Sclerodactyly is localized thickening and tightening of the skin of the fingers or toes.
Raynaud’s phenomenon is reduced blood flow to the fingers and toes, which results in
their discoloration.
PTS: 1
CON: Immunity: Skin Integrity
16. ANS: 1
Chapter: Chapter 11, Disorders of the Immune System
Page: 218
Objective: N/A
Difficulty: Difficult
Heading: Pathophysiology of Selected Immunodeficiency Disorders
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
PRIMEXAM.COM
Cognitive Level: Evaluation [Evaluating]
Concept: Assessment: Infection
Feedback
1
2
3
4
Potassium hydroxide preparation is used to diagnose candida infection. Scrapings from
the infected site are suspended in potassium hydroxide and examined microscopically
to confirm the diagnosis.
An antinuclear antibodies test is not a diagnostic test for candida infection. An
antinuclear antibodies test is used to diagnose autoimmune disorders such as systemic
lupus erythematosus.
A C-reactive protein test is not done for confirming candida infection diagnosis. The
test is used to detect inflammation in the body.
Urinalysis is not ordered to diagnose candida infection. The test is used to detect a wide
range of disorders, such as renal disorders and many other conditions.
PTS: 1
CON: Assessment: Infection
17. ANS: 1
Chapter: Chapter 11, Disorders of the Immune System
Page: 218
Objective: N/A
Difficulty: Moderate
Heading: Pathophysiology of Selected Immunodeficiency Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Assessment: Medication
Feedback
1
2
3
4
Ketoconazole is an anti-fungal medication used in the treatment of chronic
mucocutaneous candidiasis.
Codeine is an opioid analgesic used to relieve mild to moderate pain. It is not used to
treat chronic mucocutaneous candidiasis.
Amoxicillin in an antibiotic. It is not used to treat fungal infections.
Acyclovir is an anti-viral medication. It is not used to treat fungal infections.
PTS: 1
CON: Assessment, Medication
18. ANS: 2
Chapter: Chapter 11, Disorders of the Immune System
Page: 218
Objective: N/A
Difficulty: Difficult
Heading: Pathophysiology of Selected Immunodeficiency Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Evaluation [Evaluating]
Concept: Immunity: Medication
PRIMEXAM.COM
Feedback
1
2
3
4
Client 1 is receiving systemic anti-fungal treatment. Systemic antifungal therapy is the
mainstay of CMC therapy. Itraconazole is prescribed for systemic fungal infections.
Client 2 is prescribed a topical anti-fungal agent. The use of topical anti-fungal agents
alone is generally ineffective in treating chronic mucocutaneous candidiasis.
Client 3 is receiving systemic antifungal therapy. Systemic antifungal therapy is the
mainstay of CMC therapy. Fluconazole is preferred when systemic antifungal treatment
is required.
Client 4 is prescribed systemic antifungal therapy. Systemic antifungal therapy is
effective in treating chronic mucocutaneous candidiasis. Amphotericin B is used for
systemic antifungal infections.
PTS: 1
CON: Immunity, Medication
19. ANS: 3
Chapter: Chapter 11, Disorders of the Immune System
Page: 221
Objective: N/A
Difficulty: Moderate
Heading: Human Immunodeficiency Virus Infection
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Immunity: Infection
Feedback
1
2
3
4
A CD4 count of 700 cells per microliter is normal because the normal CD4 count is
700–1200 cells per microliter.
A CD4 count of 500 cells per microliter indicates that there is a significant immune
impairment.
When the CD4 count falls to 200 cells per microliter, the presence of opportunistic
infections and HIV antibodies support the diagnosis of AIDS. The common symptoms
that the client would experience include persistent fever, weight loss, and night sweats.
When the CD4 count of a client falls to 350 cells per microliter, the client should have a
CD4 count performed every 3 months due to the risk of developing AIDS.
PTS: 1
CON: Immunity, Infection
20. ANS: 1
Chapter: Chapter 11, Disorders of the Immune System
Page: 205
Objective: N/A
Difficulty: Difficult
Heading: Vaccines
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Evaluation [Evaluating]
PRIMEXAM.COM
Concept: Immunity: Infection
Feedback
1
2
3
4
A low titer value indicates that the nurse is not immune to rubella. The nurse should
consult the physician and receive a rubella vaccine immediately.
An MMR vaccine is an immunization vaccine against measles, mumps, and rubella. An
MMR vaccine is usually given to children, not adults. Hence, the nurse need not receive
an MMR vaccine.
The test result indicates that the nurse is not immune to rubella. Hence, the nurse need
not consult the physician and receive a rubella vaccination.
The nurse should take a rubella vaccination, as he or she is not immune to rubella. The
nurse might pass on rubella infection to clients in case the nurse has a rubella infection.
PTS: 1
CON: Immunity: Infection
21. ANS: 2
Chapter: Chapter 11, Disorders of the Immune System
Page: 214
Objective: N/A
Difficulty: Easy
Heading: Rheumatoid Arthritis versus Osteoarthritis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Immunity
Feedback
1
2
3
4
Osteoarthritis is not an autoimmune disease. It occurs because of wear and tear or
overuse of joints.
Rheumatoid arthritis is an autoimmune disease. It might occur because of genetic
factors, hormonal imbalance, and immunological factors.
Type II diabetes is not an autoimmune disease; type I diabetes is an autoimmune
disease.
Osteoarthritis and type II diabetes are not autoimmune diseases. Hence, the answer
option “all of the above” is incorrect.
PTS: 1
CON: Immunity
MULTIPLE RESPONSE
22. ANS: 4, 5
Chapter: Chapter 11, Disorders of the Immune System
Page: 203
Objective: N/A
Difficulty: Moderate
Heading: Basic Concepts of Immunity
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
PRIMEXAM.COM
Cognitive Level: Application [Applying]
Concept: Immunity: Infection
1.
2.
3.
4.
5.
Feedback
This is incorrect. CD8 cells directly attack antigens.
This is incorrect. Immunoglobulins are products of plasma cells.
This is incorrect. B lymphocytes mature into plasma cells after they are exposed to an
antigen.
This is correct. The human immune deficiency virus attacks the CD4 cells, one of the
strongest defense mechanisms of the body.
This is correct. The CD4 cells are the most common T cells that take part in cell-mediated
immunity.
PTS: 1
CON: Immunity: Infection
23. ANS: 2, 3
Chapter: Chapter 11, Disorders of the Immune System
Page: 211
Objective: N/A
Difficulty: Difficult
Heading: Pathophysiology of Selected Autoimmune Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Evaluation [Evaluating]
Concept: Immunity: Infection
1.
2.
3.
4.
5.
Feedback
This is incorrect. A high antinuclear antibodies (ANA) test is ordered by the primary
healthcare provider if she or he suspects the client has an autoimmune disease such as SLE.
However, an elevated ANA level is not specific only to SLE. Autoimmune diseases, such
as cancers and inflammatory disorders, also cause an elevated ANA level.
This is correct. Erythrocyte sedimentation rate is used to detect inflammation associated
with autoimmune diseases such as SLE. Erythrocyte sedimentation rate is usually high in
clients with SLE.
This is correct. A decrease in the number of white blood cells, which is also known as
leukopenia, is a common finding in clients with SLE. Thrombocytopenia is the deficiency
of platelets in the blood, which is a common clinical manifestation in SLE.
This is incorrect. C-reactive proteins are produced by the liver, and high levels of C
reactive proteins are associated with inflammation caused in SLE.
This is incorrect. The urinalysis reports of clients with SLE generally show the presence of
proteinuria, pyuria, and hematuria.
PTS: 1
CON: Immunity: Infection
24. ANS: 1, 5
Chapter: Chapter 11, Disorders of the Immune System
Page: 218
Objective: N/A
Difficulty: Difficult
PRIMEXAM.COM
Heading: Pathophysiology of Selected Immunodeficiency Disorders
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Evaluation [Evaluating]
Concept: Immunity
1.
2.
3.
4.
5.
Feedback
This is correct. This indicates the need for further teaching. The diagnosis of
hypogammaglobulinemia should be made after a child is 2 years old. Low
immunoglobulin levels can be caused by normal delay of B cell maturation in children
younger than 2 years of age.
This is incorrect.This indicates effective teaching. Bronchiectasis is a condition
characterized by enlargement of parts of the airways of the lungs. Bronchiectasis caused by
respiratory infections is common in hypogammaglobulinemia.
This is incorrect.This indicates effective teaching. Decreased IgG levels are generally
observed in clients with hypogammaglobulinemia. The IgG levels are steadily below the 5th
percentile for age.
This is incorrect.This indicates effective teaching. Decreased IgM levels may be observed
in clients with hypogammaglobulinemia. However, it is less frequently observed in clients
with hypogammaglobulinemia.
This is correct.This indicates the need for further teaching. Live vaccines should not be
administered to clients with hypogammaglobulinemia because these clients have a
decreased number of immunoglobulin.
PTS: 1
CON: Immunity
25. ANS: 1, 5
Chapter: Chapter 11, Disorders of the Immune System
Page: 221
Objective: N/A
Difficulty: Difficult
Heading: Human Immunodeficiency Virus Infection
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Evaluation [Evaluating]
Concept: Immunity: Infection: Assessment
1.
2.
3.
4.
5.
Feedback
This is correct. HIV RNA assay is used to measure the amount of virus present in the
bloodstream, which is also called viral load. It is the most sensitive and earliest test for
diagnosing HIV infection.
This is incorrect. A viral load greater than 10,000 copies/mL indicates that the client is at a
higher risk of developing AIDS.
This is incorrect. The CD4 to CD8 ratio becomes 1:2 with HIV infection. The ratio is
generally 2:1 in normal clients.
This is incorrect. A negative ELISA test indicates the client is negative for HIV.
This is correct. A Western Blot test is done to confirm the presence of HIV antibodies if the
ELISA test shows the client is positive for HIV.
PRIMEXAM.COM
PTS: 1
CON: Immunity: Infection: Assessment
PRIMEXAM.COM
Chapter 12: White Blood Cell Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. Which part of the body produces white blood cells?
1. Tonsils
2. Adenoids
3. Thymus gland
4. Bone marrow
2. The complete blood count report of a client, the enlarged lymph nodes, and epistaxis indicate that the client
has developed acute lymphocytis leukemia. What could be the reason for the occurrence of epistaxis in the
client?
1. Crowding of platelets by blast cells
2. Invasion of blast cells into the central nervous system
3. Proliferation of blast cells in the center of the bones
4. None of the above
3. Which white blood cells are the first responders in defense against antigens?
1. Basophils
2. Macrophages
3. B lymphocytes
4. T lymphocytes
4. On reviewing the blood reports of a client who presents with a fever, the nurse finds that the white blood cell
count is 13,000/microliter. What term should the nurse use when documenting this finding?
1. Leukocytosis
2. Leukopenia
3. Neutrophilia
4. None of the above
5. A nurse is reviewing the complete blood count of a client who presents with an infection. It shows that the
white blood cell count is 9,000/microliter, neutrophil count is 8,500, leukocyte count is 4,000, eosinophil
count is 600/microliter, and basophil is 1%. What should the nurse use when documenting this finding?
1. Eosinophilia
2. Neutrophilia
3. Leukocytosis
4. None of the above
6. A client with an infection was brought to the hospital. The complete blood count with differential report
shows a white blood cell count of 3,000/uL. Which condition has the client developed?
1. Leukopenia
2. Leukocytosis
3. Thrombocytopenia
4. None of the above
7. A 65-year-old client undergoes chemotherapy for treating cancer. A complete blood count report after
chemotherapy shows red blood cells -3.02 million cells/microliter, white blood cells -3,200 cells/microliter,
and platelets -100,000/microliter. What disorder does the nurse suspect in the client?
PRIMEXAM.COM
1.
2.
3.
4.
Myelodysplastic syndrome
Lymphocytosis
Monocytic leukocytosis
None of the above
8. An 8-year-old child presents to the hospital with a lymphocytopenia. Based on this diagnosis, what would the
nurse expect to find?
1. A lymphocyte count greater than 9,000/ microliter in infants
2. A lymphocyte count less than 3,000/ microliter in children
3. A lymphocyte count greater than 7,000/ microliter in children
4. All of the above
9. The registered nurse is teaching the student nurse about hematological cancer. Which statement made by the
student nurse indicates effective learning?
1. “Exposure to intense radiation causes cancer.”
2. “Contact with benzene causes cancer.”
3. “Damaged deoxyribonucleic acid causes cancer.”
4. All of the above.
10. Which blood component is developed from megakaryocytes?
1. Platelets
2. Red blood cells
3. White blood cells
4. None of the above
11. A client comes to the hospital with petechiae. The complete blood count report shows a decrease in the
platelet count. What should the nurse include in the plan of care based on the information?
1. Avoid invasive procedures.
2. Discourage the use of stool softeners.
3. Assess the temperature every 6 hours.
4. Encourage the use of a hard bristle toothbrush.
12. A nurse is formulating a nursing diagnosis for a client with chronic lymphoid leukemia. Which nursing
measure should be included in the process?
1. Placing the client in protective isolation
2. Limiting visitors with cold and infections
3. Ensuring that all visitors wash their hands before coming in contact with the client
4. All of the above
13. A nurse is analyzing the report of a 5-year-old client with leukemia, who is receiving chemotherapy. The
platelet count is 20,000/microliter. What would be the best intervention for the nurse to include in the client’s
plan of care?
1. Monitor the client’s vital signs.
2. Check the temperature every six hours.
3. Initiate protective isolation precautions.
4. Use a soft toothbrush for oral care.
14. A client with leukemia received chemotherapy 2 days ago and has subsequently developed acute renal failure.
Which laboratory result should the nurse assess?
1. The release of high amounts of calcium
2. The release of high amounts of uric acid
PRIMEXAM.COM
3. The release of high amounts of potassium
4. The release of high amounts of phosphate
15. A client comes to the hospital with reports of chest pain due to lymphoma. Reports show that the lymphoma
cells have a rapid growth, but are curable. How would this lymphoma be classified?
1. Low-grade lymphoma
2. Intermittent-grade lymphoma
3. High-grade lymphoma
4. None of the above
16. A client comes to the hospital with symptoms of an allergic reaction from an antibiotic. Which blood cells
would show an increase in the complete blood count report?
1. Neutrophils
2. Eosinophils
3. Basophils
4. None of the above
17. The nurse is reviewing the complete blood count of a client who presents with a fever. It shows that the white
blood cell count is 3,000/microliter. What should the nurse use when documenting this finding?
1. Leukocytosis
2. Leukopenia
3. Neutrophilia
4. None of the above
18. An 85-year-old client comes to the hospital and reports severe back pain. The client’s blood report shows IgA
concentration of 2 grams/deciliter and plasma cells of 8% in the bone marrow. The client does not show
symptoms of anemia or hypercalcemia. Based on these findings, what should the nurse suspect?
1. Multiple myeloma
2. Monoclonalgammopathy of undetermined significance
3. Both A and B
4. None of the above
19. Which clinical sign signifies leukocytosis?
1. A white blood count of 3,000/microliter
2. A white blood count of 52,000/microliter
3. A decrease in signs and symptoms of infection
4. Wounds that show no evidence of healing
20. What causes lymphomas?
1. They develop in the precursor cells of the bone marrow.
2. They appear like blast cells.
3. They do not differentiate into mature cells.
4. They arise from abnormal proliferation of T lymphocytes.
21. What is the other name for white blood cells?
1. Leukocytes
2. Erythrocytes
3. Thrombocytes
4. None of the above
PRIMEXAM.COM
22. A 2-year-old client has been brought to the hospital with a fever. The complete blood count report shows a
lymphocyte count of 10,000/microliter, eosinophil count of 1%, and neutrophil count of 2%. What condition
has the client developed?
1. Lymphocytosis
2. Eosinophilia
3. Neutropenia
4. None of the above
NARRBEGIN: Exhibit
Exhibit
NARREND
23. The complete blood count report of a 45-year-old client, who reports an unintended weight loss, is
documented.
Hemoglobin
White blood cells
Albumin
Lymphocytes
9.5 grams/dL
15,000 grams/dL
3.0 grams/dL
500/mL
Which condition has the client developed?
1. Hodgkin’s lymphoma
2. Non-Hodgkin’s lymphoma
3. Neutropenia
4. None of the above
24. A 50-year-old client worked in the radiation department of a hospital for 6 years. He reports weakness and
fatigue. The complete blood report of the client is documented.
White blood cells
Red blood cells
Hemoglobin
Platelet
White blood cell count
Blasts
Lymphocytes
Segs
25,600 cells/µL
3.11million cells/µL
8.9 grams/dL
130,000/µL
150,000 /µL
75%
20%
2%
Based on these findings, what condition should the nurse suspect?
1. Acute lymphocytic leukemia
2. Chronic lymphocytic leukemia
3. Acute myelogenous leukemia
4. Chronic myelogenous leukemia
25. The complete blood count report of a client with a high fever as a result of infection is documented.
Red blood cells
White blood cells
Neutrophils
4.50 million cells/µL
10,000 cells/ µL
2,500 cells/µL
PRIMEXAM.COM
Basophils
Eosinophils
Platelets
50 cells/µL
150 cells/µL
350,000/ µL
Based on these findings, what condition should the nurse suspect?
1. Neutrophilia
2. Neutropenia
3. Leukocytosis
4. Eosinophilia
PRIMEXAM.COM
Chapter 12: White Blood Cell Disorders
Answer Section
MULTIPLE CHOICE
1. ANS: 4
Chapter: Chapter 12, White Blood Cell Disorders
Page: 231
Objective: N/A
Difficulty: Easy
Heading: Synthesis and Maturation of WBCs
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Hematologic Regulation
1
2
3
4
Feedback
White blood cells mature in the tonsils.
White blood cells mature in the adenoids.
White blood cells mature in the thymus gland.
White blood cells are produced in the bone marrow.
PTS: 1
CON: Hematologic Regulation
2. ANS: 1
Chapter: Chapter 12, White Blood Cell Disorders
Page: 240
Objective: N/A
Difficulty: Moderate
Heading: Pathophysiology of Selected WBC Disorders
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Hematologic Regulation
1
2
3
4
Feedback
The reason for the occurrence of epistaxis is the crowding of platelets by blast cells.
This leads to bleeding disorders in the client.
Invasion of blast cells into the central nervous system causes headache.
Proliferation of blast cells in the center of the bones causes bone pain mainly in the
sternum, tibia, and femur bones.
The reason for the occurrence of epistaxis is the crowding of platelets by blast cells.
PTS: 1
CON: Hematologic Regulation
3. ANS: 2
Chapter: Chapter 12, White Blood Cell Disorders
Page: 231
PRIMEXAM.COM
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts of WBC Function
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Hematologic Regulation
1
2
3
4
Feedback
Basophils are a type of granulocyte cells which contribute less than 1% of circulating
white blood cells.
The first responders in defense against antigens are the macrophages. They function
within the innate immune system.
B lymphocytes are a type of lymphoid cells. They are produced in the bone marrow.
T lymphocytes are a type of lymphoid cells. They are produced in the bone marrow.
PTS: 1
CON: Hematologic Regulation
4. ANS: 1
Chapter: Chapter 12, White Blood Cell Disorders
Page: 234
Objective: N/A
Difficulty: Moderate
Heading: Basic Concepts of WBC Pathophysiology
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Hematologic Regulation
1
2
3
4
Feedback
Leukocytosis occurs when the number of white blood cells is greater than 11,000/
microliter. Therefore, the client has developed leukocytosis.
Leukopenia occurs when the number of white blood cells decreases below 4,000/
microliter.
Neutrophilia occurs when the number of neutrophils increases above 7,700/microliter
and the number of white blood cells is lesser than 11,000/microliter.
The client has developed leukocytosis as the number of white blood cells is above
11,000/ microliter.
PTS: 1
CON: Hematologic Regulation
5. ANS: 2
Chapter: Chapter 12, White Blood Cell Disorders
Page: 234
Objective: N/A
Difficulty: Moderate
Heading: Basic Concepts of WBC Pathophysiology
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
PRIMEXAM.COM
Cognitive Level: Application [Applying]
Concept: Hematologic Regulation
1
2
3
4
Feedback
Eosinophilia is a condition where the number of eosinophils is greater than 600/
microliter in blood.
Neutrophilia occurs when the number of neutrophils increases above 7,700/microliter
and the number of white blood cells is fewer than 11,000/microliter. Therefore, the
nurse should document that the client has developed neutrophilia.
Leukocytosis is a condition where the number of leukocytes increases above
4,000/microliter.
The client has developed neutrophilia, as the number of neutrophilia is above
7,700/microliter.
PTS: 1
CON: Hematologic Regulation
6. ANS: 1
Chapter: Chapter 12, White Blood Cell Disorders
Page: 234
Objective: N/A
Difficulty: Difficult
Heading: Basic Concepts of WBC Pathophysiology
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Hematologic Regulation
1
2
3
4
Feedback
The client has developed leukopenia, which is caused by a decrease in the number of
white blood cells below 4,000/uL.
Leukocytosis is a disorder of white blood cells where the number of white blood cells
increases above 11,000/uL.
Thrombocytopenia is a disorder caused by a decrease in the platelet count in the blood.
A decrease in the white blood cells causes leukopenia.
PTS: 1
CON: Hematologic Regulation
7. ANS: 1
Chapter: Chapter 12, White Blood Cell Disorders
Page: 236
Objective: N/A
Difficulty: Difficult
Heading: Basic Concepts of WBC Pathophysiology
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Hematologic Regulation
Feedback
PRIMEXAM.COM
1
2
3
4
The client has developed myelodysplastic syndrome. The client has a decreased number
of all blood components, which is an indication of myelodysplastic syndrome.
Lymphocytosis is a condition where the number of lymphocytes increases within the
bloodstream.
Monocytic leukocytosis is a condition where the white blood cell count is greater than
11,000/microliter, which is mostly caused by a monocyte count above 800/microliter.
The client has developed myelodysplastic syndrome.
PTS: 1
CON: Hematologic Regulation
8. ANS: 2
Chapter: Chapter 12, White Blood Cell Disorders
Page: 235
Objective: N/A
Difficulty: Moderate
Heading: Basic Concepts of WBC Pathophysiology
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Hematologic Regulation
1
2
3
4
Feedback
A lymphocyte count greater than 9,000/ microliter in infants is lymphocytosis.
A lymphocyte count less than 3,000/ microliter in children is lymphocytopenia.
A lymphocyte count greater than 7,000/ microliter in children is lymphocytosis.
A lymphocyte count less than 3,000/ microliter in children is lymphocytopenia.
PTS: 1
CON: Hematologic Regulation
9. ANS: 4
Chapter: Chapter 12, White Blood Cell Disorders
Page: 236
Objective: N/A
Difficulty: Difficult
Heading: Basic Concepts of WBC Pathophysiology
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Hematologic Regulation
1
2
3
4
Feedback
Exposure to intense radiation causes hematological cancers.
Contact with benzene causes hematological cancers.
Damaged deoxyribonucleic acid causes hematological cancers.
Exposure to intense radiation, contact with benzene, and damaged deoxyribonucleic
acid causes hematological cancers.
PTS: 1
10. ANS: 1
CON: Hematologic Regulation
PRIMEXAM.COM
Chapter: Chapter 12, White Blood Cell Disorders
Page: 232
Objective: N/A
Difficulty: Easy
Heading: Epidemiology
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Hematologic Regulation
1
2
3
4
Feedback
Megakaryocytes develop into blood platelets.
Erythroblasts develop into red blood cells.
Myeloblasts and monoblasts develop into different types of white blood cells.
Megakaryocytes develop into blood platelets.
PTS: 1
CON: Hematologic Regulation
11. ANS: 1
Chapter: Chapter 12, White Blood Cell Disorders
Page: 238
Objective: N/A
Difficulty: Difficult
Heading: Basic Concepts of WBC Pathophysiology
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Hematologic Regulation
1
2
3
4
Feedback
Petechiae is the development of small red or purple spots on the skin. Petechiae happen
when there is a decrease in the platelet count. The nurse should avoid invasive
procedures because a low platelet count increases susceptibility to bleeding.
The nurse should encourage the client to use stool softeners to avoid bleeding while
passing stool.
Temperature is not the most important vital sign to monitor in this client.
The nurse should encourage the client to use a soft bristle toothbrush because a low
platelet count would cause gingival bleeding.
PTS: 1
CON: Hematologic Regulation
12. ANS: 4
Chapter: Chapter 12, White Blood Cell Disorders
Page: 238
Objective: N/A
Difficulty: Moderate
Heading: Pathophysiology of Selected WBC Disorders
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
PRIMEXAM.COM
Cognitive Level: Application [Applying]
Concept: Safety: Nursing Roles
1
2
3
4
Feedback
Clients with serious blood conditions such as chronic lymphoid leukemia are prone to
frequent infections. Therefore, the nurse should place the client in protective isolation
to protect him or her from infection.
Clients with serious blood conditions such as chronic lymphoid leukemia are prone to
frequent infections. They readily catch cold and infection when they come in contact
with persons with cold and infection. Therefore, the nurse should limit visitors with
cold and infections.
The nurse should ensure that all visitors meticulously wash their hands before they
come in contact with the client with chronic lymphoid leukemia.
The nurse should place the client in protective isolation, limit visitors with cold and
infections, and ensure that all visitors wash their hands before coming in contact with
the client.
PTS: 1
CON: Safety: Nursing Roles
13. ANS: 4
Chapter: Chapter 12, White Blood Cell Disorders
Page: 234
Objective: N/A
Difficulty: Difficult
Heading: Basic Concepts of WBC Pathophysiology
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Safety: Nursing Roles
1
2
3
4
Feedback
The nurse should monitor the client’s vital signs in order to assess for signs of infection.
However, the client has low platelets and this is not the best intervention.
The nurse should check the temperature every 6 hours in order to prevent infection. The
client’s condition does not indicate any risk of infection.
The nurse should initiate protective isolation precautions in order to prevent infection.
The client’s condition does not indicate any risk of infection.
The nurse should institute bleeding precautions, as the platelet count is low. Bleeding
precautions include using a soft toothbrush for oral care. This will help in preventing
bleeding caused by a decreased platelet count.
PTS: 1
CON: Safety: Nursing Roles
14. ANS: 2
Chapter: Chapter 12, White Blood Cell Disorders
Page: 239
Objective: N/A
Difficulty: Difficult
Heading: Basic Concepts of WBC Pathophysiology
PRIMEXAM.COM
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Hematologic Regulation: Nursing Roles
1
2
3
4
Feedback
Tumor lysis syndrome may occur 48 to 72 hours after initiation of cancer treatment.
This causes a secondary hypocalcemia, which is a decrease in calcium. It is not a cause
for renal failure.
After initiation of cancer treatment for 48 hours to 72 hours, a complication called
tumor lysis syndrome may occur. This releases high amounts of uric acid into the
circulation, which damages glomeruli and nephron tubules. This leads to renal failure in
the client.
Tumor lysis syndrome may occur 48 to 72 hours after initiation of cancer treatment.
This releases high amounts of potassium to the surrounding tissues and circulation;
however, it is not a cause for renal failure.
Tumor lysis syndrome may occur 48 to 72 hours after initiation of cancer treatment.
This releases high amounts of phosphate to the surrounding tissues and circulation;
however, it is not a cause for renal failure.
PTS: 1
CON: Hematologic Regulation: Nursing Roles
15. ANS: 2
Chapter: Chapter 12, White Blood Cell Disorders
Page: 245
Objective: N/A
Difficulty: Moderate
Heading: Pathophysiology of Selected WBC Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Hematologic Regulation
1
2
3
4
Feedback
Slow-growing lymphomas are called low-grade lymphomas. They do not require
immediate treatment until organ function is compromised.
Rapid-growing lymphomas are called intermittent-grade lymphomas. They are usually
curable and require immediate treatment.
Very rapid-growing lymphomas are called high-grade lymphomas. They require
intensive treatment and often are not curable.
Rapid growing lymphomas are called - intermittent-grade lymphomas.
PTS: 1
CON: Hematologic Regulation
16. ANS: 2
Chapter: Chapter 12, White Blood Cell Disorders
Page: 234
Objective: N/A
Difficulty: Moderate
PRIMEXAM.COM
Heading: Basic Concepts of WBC Function
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Hematologic Regulation
1
2
3
4
Feedback
Neutrophils are the first responders to an infection, stressful event, or inflammatory
reactions. Epinephrine and corticosteroids stimulate the generation of neutrophils in the
bloodstream.
Eosinophils are generated by the bone marrow and are released during an allergic
reaction or a parasitic infection. They include granules that contain enzymes such as
histamine, eosinophil peroxidase, ribonuclease, deoxyribonuclease, lipase, and
plasminogen.
Basophils make up less than 1% of the WBCs in the bloodstream, but they rise in
response to infection.
Eosinophils are generated by the bone marrow and are released during allergic
reactions.
PTS: 1
CON: Hematologic Regulation
17. ANS: 2
Chapter: Chapter 12, White Blood Cell Disorders
Page: 234
Objective: N/A
Difficulty: Moderate
Heading: Basic Concepts of WBC Function
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Hematologic Regulation
1
2
3
4
Feedback
Leukocytosis occurs when the number of white blood cells is greater than 50,000/
microliter.
Leukopenia occurs when the number of white blood cells decreases below 4,000/
microliter. Therefore, the client has developed leukopenia.
Neutrophilia occurs when the number of neutrophils increases above 7,700/microliter
and the number of white blood cells is fewer than 11,000/microliter.
The client has developed leucopenia, as the number of white blood cells is below 4,000/
microliter.
PTS: 1
CON: Hematologic Regulation
18. ANS: 2
Chapter: Chapter 12, White Blood Cell Disorders
Page: 246
Objective: N/A
Difficulty: Difficult
PRIMEXAM.COM
Heading: Pathophysiology of Selected WBC Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Hematologic Regulation
1
2
3
4
Feedback
In multiple myeloma, the concentration of monoclonal proteins such as IgA would be
greater than 3 gram/deciliter and the plasma cells would be greater than 10% in the
bone marrow.
The client has developed monoclonalgammopathy of undetermined significance
(MGUS). The monoclonal protein, IgA level less than 3 grams/deciliter and plasma
cells less than 10% in the bone marrow are indications of MGUS. Severe back pain is a
symptom of MGUS.
The symptoms and given values indicate that the client has developed MGUS.
The client has developed MGUS.
PTS: 1
CON: Hematologic Regulation
19. ANS: 2
Chapter: Chapter 12, White Blood Cell Disorders
Page: 234
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts of WBC Function
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Hematologic Regulation
1
2
3
4
Feedback
A decrease in white blood cell count below 4,000/ microliter is leukopenia.
An increase in white blood cell count in excess of 50,000/microliter is leukocytosis.
Leukopenia decreases the signs of infection and increases the risk of infection.
Leukopenia would decrease the client’s healing ability.
PTS: 1
CON: Hematologic Regulation
20. ANS: 4
Chapter: Chapter 12, White Blood Cell Disorders
Page: 236
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts of WBC Pathophysiology
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Hematologic Regulation
PRIMEXAM.COM
1
2
3
4
Feedback
Leukemia develops in the precursor cells of the bone marrow.
Leukemia appears like the immature forms of these cells which are called blast cells.
The blasts cells of leukemia continue to proliferate but do not differentiate into mature
cells.
Lymphoma cells specifically arise from proliferation of B or T lymphocytes. The tumor
mainly begins in the lymph nodes.
PTS: 1
CON: Hematologic Regulation
21. ANS: 1
Chapter: Chapter 12, White Blood Cell Disorders
Page: 231
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts of WBC Function
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Hematologic Regulation
1
2
3
4
Feedback
White blood cells are also known as leukocytes.
Red blood cells are also known as erythrocytes.
Platelets are also known as thrombocytes.
White blood cells are also known as leukocytes.
PTS: 1
CON: Hematologic Regulation
22. ANS: 1
Chapter: Chapter 12, White Blood Cell Disorders
Page: 235
Objective: N/A
Difficulty: Moderate
Heading: Basic Concepts of WBC Function
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Hematologic Regulation
1
2
3
4
Feedback
A value of lymphocytes above 9,000/microliter indicates lymphocytosis. Therefore, the
client has developed lymphocytosis.
Eosinophilia is a condition where the number of eosinophils is greater than 600
microliter in blood.
Neutropenia is a condition where the number of neutrophils decreases below
1,500/microliter.
The client has developed lymphocytosis, as the number of lymphocytes is above 9,000/
microliter.
PRIMEXAM.COM
PTS: 1
CON: Hematologic Regulation
23. ANS: 1
Chapter: Chapter 12, Disorders of White Blood Cells
Page: 245
Objective: N/A
Difficulty: Difficult
Heading: Basic Concepts of WBC Pathophysiology
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Hematologic Regulation
1
2
3
4
Feedback
The client has developed Hodgkin’s lymphoma. Hodgkin’s lymphoma causes
unintended weight loss. The lower hemoglobin count, lower albumin level, elevated
white blood cell count, and low lymphocyte count are indications of Hodgkin’s
lymphoma.
Clients with high lactic dehydrogenase and clients older than 60 years are at risk of
developing non-Hodgkin’s lymphoma.
Clients with neutrophils counts lower than 1,500 neutrophils/µL may develop
neutropenia.
The client has developed Hodgkin’s lymphoma.
PTS: 1
CON: Hematologic Regulation
24. ANS: 4
Chapter: Chapter 12, Disorders of White Blood Cells
Page: 249
Objective: N/A
Difficulty: Difficult
Heading: Pathophysiology of Selected WBC Disorders
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Hematologic Regulation
1
2
3
4
Feedback
In acute lymphocytic leukemia, the stem cell precursors for T or B lymphocytes in the
bone marrow do not function and do not mature beyond the lymphoblast stage.
In chronic lymphocytic leukemia, the B cells have failed to differentiate from precursor
B cells in the bone marrow.
In acute myelogenous leukemia, the number of blood cells produced by the bone
marrow decreases. This leads to anemia, bleeding disorders, and development of
infections.
The client has developed chronic myelogenous leukemia. Weakness and fatigue are
symptoms of this condition. The elevated numbers of white blood cells and blast cells
are indications of chronic myelogenous leukemia.
PRIMEXAM.COM
PTS: 1
CON: Hematologic Regulation
25. ANS: 1
Chapter: Chapter 12, Disorders of White Blood Cells
Page: 234
Objective: N/A
Difficulty: Difficult
Heading: Basic Concepts of WBC Function
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Hematologic Regulation
1
2
3
4
Feedback
The client has developed neutrophilia. The decrease in the number of neutrophils below
7,700/µL and white blood cells less than 11,000/µL is indicative of neutrophilia.
Neutropenia is a condition where the number of neutrophils decreases below 1,500
cells/µL.
Leukocytosis is a condition where there is an increase in the number of blast cells in the
bone marrow.
Eosinophilia is a condition where there is abnormal increase in the number of
eosinophils.
PTS: 1
CON: Hematologic Regulation
PRIMEXAM.COM
Chapter 13: Infection and Inflammation
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. A client’s pulse oximetry reading is 100%; however, the hemoglobin level is 8.5 g/dL. The client’s spouse
asks the nurse what activities the client can safely carry out. Which activity would the nurse recommend?
1. Rock climbing
2. Skiing
3. Trekking
4. Road trip
2. Which is a characteristic of secondary polycythemia?
1. High erythropoietin level
2. Normal erythropoietin level
3. Increased platelet count
4. Elevated white blood cell count
3. People with what blood type are known as universal recipients?
1. A positive
2. B negative
3. AB positive
4. None of the above
4. Which condition would a nurse expect in a client with polycythemia vera?
1. Hyperuricemia
2. Orthopnea
3. Angina
4. Ulcers on lower extremities
5. A child with sickle cell anemia experiences vaso-occlusive episodes. Which is the primary nursing objective
while caring for the child?
1. Managing pain
2. Administering antibiotics
3. Heating the room to comfort the client
4. Restricting fluids
6. A registered nurse is teaching a student nurse about the treatments given for sickle cell anemia. Which
statement made by the student nurse indicates effective teaching?
1. “Hydroxyurea is used to cure sickle cell anemia.”
2. “Acetaminophen is used to manage pain during vaso-occlusive episodes.”
3. “Prednisone is used to treat spleen dysfunction in sickle cell anemia”
4. “Nitric acid is effective in decreasing vaso-occlusive episodes.”
7. A nurse is caring for a child with sickle cell anemia. The parent is asking the nurse about a treatment that
would cure the child. Which is the best answer the nurse can provide the parent?
1. “Improving the nitric acid bioavailability can cure the child.”
2. “Blood transfusion done at frequent intervals can cure the child.”
3. “Splenectomy can cure the child.”
4. “Treatments are aimed at reducing complications, but do not cure the condition.”
PRIMEXAM.COM
8. A 27-year-old male client tells a nurse that his siblings have sickle cell anemia, and he is concerned that his
children might be affected by sickle cell anemia in the future. Which is the most appropriate advice the nurse
should provide the client?
1. “Your partner and you should consult a genetic counselor.”
2. “You will not pass sickle cell anemia to your offspring, so relax.”
3. “You might pass sickle cell anemia to your offspring, so adopt a child.”
4. None of the above.
9. Which diagnostic finding is most likely to be observed in a client with aplastic anemia?
1. Decreased production of T cells
2. Decreased red blood cells, white blood cells, and platelets
3. Decreased level of immunoglobulin A
4. Decreased number of Kupffer cells
10. Which is the most common cause of erythropoietin deficiency?
1. Spleen dysfunction
2. Renal failure
3. Hyperthyroidism
4. Bone marrow damage
11. A 65-year-old client is diagnosed with aplastic anemia. Which condition should the nurse monitor primarily in
the client?
1. Hypertension
2. Dyspnea
3. Hematochezia
4. Bleeding diathesis
12. A 39-year-old client complains that he/she feels tired all the time. The client has tachycardia and is pale. The
complete blood count with differential reports shows the hemoglobin count as 10 g/dL and the mean
corpuscular volume as 75 femoliters. Which condition has the client developed?
1. Microcytic hypochromic anemia
2. Normocytic normochromic anemia
3. Megaloblastic anemia
4. None of the above
13. What factor would contribute to a client having a high hemoglobin count?
1. Being a female
2. Living at high altitudes
3. Being of African-American decent
4. All of the above
14. What does red blood cell distribution width indicate?
1. The average concentration of hemoglobin in each red blood cell
2. The number of new red blood cells in blood
3. The percentage of blood volume that consists of red cells
4. The variation in red blood cell size and width
15. Which value indicates normal number of red blood cells per liter in males?
1. 5 x 106
2. 13 x 106
3. 80 x 106
PRIMEXAM.COM
4. 28 x 106
16. A client has developed microcytic hypochromic anemia. Which dietary intervention should the nurse provide
the client?
1. Foods rich in folic acid
2. Foods rich in iron
3. Foods rich in vitamin D
4. Foods rich in vitamin B
17. Which condition leads to increased reticulocyte count in blood?
1. Excess blood loss from the body
2. Suppression of the bone marrow
3. Poor production of red blood cells
4. All of the above
18. Following an accident, the client arrives to the emergency room bleeding profusely. He had an estimated 15%
to 30% blood loss from the body. What happens to the urine output of the body in this condition?
1. Urine output decreases below 30 mL/hour.
2. Urine output decreases to 5 to 15 mL/hour.
3. There is no effect on urine output.
4. None of the above.
19. A client who complains of weakness is found to have developed anemia. Which physical manifestation should
the nurse look for to confirm that the client has developed iron-deficiency anemia?
1. Cheilitis
2. Koilonychias
3. Glossitis
4. All of the above
20. A client’s pulse oximetry reading is 100%; however, the hemoglobin level is 8.5 g/dL. The client’s spouse
asks the nurse what activities the client can safely carry out. Which activity would the nurse recommend?
1. Rock climbing
2. Skiing
3. Trekking
4. Road trip
NARRBEGIN: Exhibit
Exhibit
NARREND
21. A client presents to the hospital with complaints of chest pain. The complete blood count report of the client
shows the following.
Red blood cells
Hemoglobin
Hematocrit
Mean corpuscular value
Mean corpuscular hemoglobin
3.0 cells x 106
10 g/dL
35%
70
25
Which condition has the client developed?
PRIMEXAM.COM
1.
2.
3.
4.
Folate-deficiency anemia
Vitamin B12 deficiency anemia
Iron-deficiency anemia
None of the above
22. The complete blood count with differential of a client who complains of weakness shows the following.
Red blood cells
Hemoglobin
Hematocrit
Mean corpuscular value
Hemoglobin A
Hemoglobin F
Hemoglobin A2
3.2 cells x 106
9 g/dL
35%
75
0%
80%
10%
Which red blood cell disorder has the client developed?
1. Alpha thalassemia
2. Sickle cell anemia
3. Beta thalassemia
4. None of the above
23. The complete blood count report of a client who complains of headache and weakness shows the following.
Red blood cells
White blood cells
Platelets
Hemoglobin
3.4 cells x 106
7 x 103 g/dL
200,000
10 g/dL
Which condition has the client developed?
1. Anemia
2. Leukopenia
3. Thrombocytopenia
4. None of the above
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
24. A nurse is teaching a client with iron-deficiency anemia about the diet that he or she has to follow. Which
statements made by the client indicate effective learning? Select all that apply.
1. “Consuming orange juice daily will increase iron absorption.”
2. “Drinking a cup of black tea after having meals will increase iron absorption.”
3. “Adding meat to my diet will help improve iron deficiency.”
4. “Consuming grapes every day will increase iron absorption.”
5. “Adding broccoli, beans, and tomato sauce to my diet will help improve iron deficiency.”
25. Which conditions increase the hemoglobin affinity for oxygen? Select all that apply.
1. Hypothermia
2. Hyperthermia
3. Alkalosis
PRIMEXAM.COM
4. Acidosis
5. Hypercapnia
PRIMEXAM.COM
Chapter 13: Infection and Inflammation
Answer Section
MULTIPLE CHOICE
1. ANS: 4
Chapter: Chapter 13, Disorders of Red Blood Cells
Page: 257
Objective: N/A
Difficulty: Moderate
Heading: Oxyhemoglobin Dissociation
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Oxygenation
1
2
3
4
Feedback
When the oxygen saturation of blood is 100% and hemoglobin is low, oxygen delivery
to cells will be inadequate. Inadequate oxygen supply to cells will result in cellular
hypoxia. Oxygen demand will be high while doing activities such as rock climbing.
Hence, the nurse should not recommend rock climbing for the client.
A low hemoglobin level and 100% oxygen saturation of blood will result in inadequate
oxygen supply to cells. Skiing demands more oxygen than the normal oxygen demand
of the body. Hence, the nurse should not recommend skiing for the client.
Oxygen level decreases as an individual climbs up the hill. Since a low hemoglobin
level and 100% oxygen saturation of blood would result in inadequate oxygen supply to
cells, trekking is not recommended for the client.
When the oxygen saturation of blood is 100% and hemoglobin is low, an inadequate
oxygen supply to cells will result. Therefore, the nurse should not recommend that the
client do vigorous exercises or activities that demand an oxygen supply. The nurse can
recommend that the client engage in activities that are less strenuous, such as taking a
road trip on a cross-country vacation.
PTS: 1
CON: Perfusion
2. ANS: 1
Chapter: Chapter 13, Disorders of Red Blood Cells
Page: 259
Objective: N/A
Difficulty: Moderate
Heading: Lack of Bone Marrow Production of RBCs
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Hematologic Regulation
Feedback
PRIMEXAM.COM
1
2
3
4
Secondary polycythemia is characterized by an elevated erythropoietin level.
Erythropoietin is a hormone released by the kidneys to stimulate red blood cell
production. An elevated erythropoietin level is observed in secondary polycythemia.
A normal erythropoietin level is observed in primary polycythemia. A normal
erythropoietin level indicates that polycythemia is occurring without any stimulus from
erythropoietin.
An elevated platelet count is seen in both primary polycythemia and secondary
polycythemia conditions.
An elevated white blood cell count is found in both primary polycythemia and
secondary polycythemia conditions.
PTS: 1
CON: Hematologic Regulation
3. ANS: 3
Chapter: Chapter 13, Disorders of Red Blood Cells
Page: 258
Objective: N/A
Difficulty: Easy
Heading: Blood Types
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Knowledge [Remembering]
Concept: Hematologic Regulation
1
2
3
4
Feedback
People with the A positive blood type are not known as universal recipients because
they have anti-B antibodies in their blood and cannot safely receive B blood types.
People with the B positive blood type are not called universal recipients because they
have anti-A antibodies and cannot safely receive A blood types.
People with the AB positive blood type are known as universal recipients because they
have no antibodies and can accept any type of foreign blood.
People with the AB positive blood type are known as universal recipients, so the option
“none of the above” is incorrect.
PTS: 1
CON: Hematologic Regulation
4. ANS: 1
Chapter: Chapter 13, Disorders of Red Blood Cells
Page: 278
Objective: N/A
Difficulty: Moderate
Heading: Lack of Bone Marrow Production of RBCs
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Urinary Elimination
1
Feedback
A client with polycythemia vera often develops hyperuricemia and gout. A large amount
PRIMEXAM.COM
2
3
4
of cellular breakdown may occur because of the excessive blood cells present in a
polycythemia vera condition. A large amount of DNA breaks down into purines, which
become uric acid.
Orthopnea is a symptom of secondary polycythemia. Shortness of breath, or orthopnea,
is observed in the client, especially while lying down.
Clients with secondary polycythemia experience angina. Angina is not associated with
polycythemia vera.
Ulcers in the lower extremities is not associated with polycythemia vera.
PTS: 1
CON: Urinary Elimination
5. ANS: 1
Chapter: Chapter 13, Disorders of Red Blood Cells
Page: 282
Objective: N/A
Difficulty: Difficult
Heading: Anemias Caused by Decrease in RBC Mass
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Evaluation [Evaluating]
Concept: Hematologic Regulation
Feedback
1
2
3
4
In clients with sickle cell anemia, the misshapen RBCs cannot pass through the
capillaries, and they block the blood flow to tissues and organs. The occlusion in the
blood vessels causes ischemia. The episodes of ischemia are called vaso-occlusive
crises. Vaso-occlusive episodes are extremely painful. Hence, pain management is the
primary objective in such conditions.
Antibiotics are administered to treat infections. Administration of antibiotics does not
reduce pain. Therefore, antibiotics should not be administered to the client experiencing
vaso-occlusive episodes.
Extreme temperature changes, either too hot or too cold, will trigger sickling in clients
with sickle cell anemia. Therefore, the room should not be heated to increase the client’s
comfort.
Dehydration will promote sickling. Therefore, good hydration should be provided to
clients with sickle cell anemia. The client should be encouraged to drink extra fluids.
PTS: 1
CON: Hematologic Regulation
6. ANS: 2
Chapter: Chapter 13, Disorders of Red Blood Cells
Page: 269
Objective: N/A
Difficulty: Difficult
Heading: Anemias Caused by Decrease in RBC Mass
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Hematologic Regulation
PRIMEXAM.COM
1
2
3
4
Feedback
Hydroxyurea is an antitumor drug. It has proven to be effective in reducing vasoocclusive episodes that occur in clients with sickle cell anemia. It is not used for
treating sickle cell anemia.
Acetaminophen is used to relieve mild to moderate pain. The drug is used to reduce
pain that occurs during vaso-occlusive episodes in clients with sickle cell anemia.
Prednisone is a corticosteroid used as an immunosuppressant. It is not used to treat
spleen dysfunction in sickle cell anemia.
Nitric acid helps to keep the blood vessels open and reduces the adhesiveness of red
blood cells. Nitric acid administration might help reduce the formation of sickle cells.
PTS: 1
CON: Hematologic Regulation
7. ANS: 4
Chapter: Chapter 13, Disorders of Red Blood Cells
Page: 277
Objective: N/A
Difficulty: Difficult
Heading: Anemias Caused by Decrease in RBC Mass
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Hematologic Regulation
1
2
3
4
Feedback
Nitric acid is found to be low in clients with sickle cell anemia. Hence, increasing the
bioavailability of nitric acid would reduce the formation of sickle cells, but it will not
cure sickle cell anemia.
Blood transfusions can improve the normal red blood cell count, but they do not cure
sickle cell anemia. However, care should be taken while using blood transfusion
because chronic use of blood transfusion would lead to iron overload.
Splenectomy is done when splenic sequestration crisis is present. It is a life-threatening
condition and needs emergency care. Splenectomy is not a cure for sickle cell anemia.
The treatments given for sickle cell anemia are aimed at reducing pain and
complications of the disease, but they do not provide a cure. Bone marrow transplant
offers the only potential cure for sickle cell anemia; however, due to the risks associated
with the treatment, it is not recommended.
PTS: 1
CON: Hematologic Regulation
8. ANS: 1
Chapter: Chapter 13, Disorders of Red Blood Cells
Page: 266
Objective: N/A
Difficulty: Difficult
Heading: Anemias Caused by Decrease in RBC Mass
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
PRIMEXAM.COM
Cognitive Level: Analysis [Analyzing]
Concept: Hematologic Regulation
1
2
3
4
Feedback
The nurse should advise the client and his partner to meet a genetic counselor. The
client might be a carrier of sickle cell anemia. Therefore, genetic counseling is
important to discuss the chances of passing on the gene to offspring.
The client might be a carrier of sickle cell anemia, since his siblings have the disease. If
both the partners are carriers, the offspring might develop sickle cell anemia. So genetic
counseling is important to learn more about the genetics of the disease.
Not all carriers of sickle cell anemia pass on the gene to the offspring. Therefore, the
nurse should not advise the client to adopt a child.
The nurse should advise the client and his partner to meet a genetic counselor to discuss
the chances of passing on the gene to the offspring. Therefore, the answer option “none
of the above” is incorrect.
PTS: 1
CON: Hematologic Regulation
9. ANS: 2
Chapter: Chapter 13, Disorders of Red Blood Cells
Page: 269
Objective: N/A
Difficulty: Difficult
Heading: Lack of Bone Marrow Production of RBCs
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Hematologic Regulation
1
2
3
4
Feedback
Aplastic anemia does not result in decreased production of T cells. Lymphocytopenia
might result in a decreased production of T cells.
Pancytopenia, a condition characterized by deficiency of red blood cells, white blood
cells, and platelets, is a characteristic symptom of aplastic anemia.
Immunoglobulin A deficiency is not caused by aplastic anemia. Ig A deficiency can be
caused by genetic factors, exposure to benzene, or some medications.
Kupffer cells found in the liver play an important role in the body’s immune
mechanism. Aplastic anemia does not affect or decrease the number of Kupffer cells.
PTS: 1
CON: Hematologic Regulation
10. ANS: 2
Chapter: Chapter 13, Disorders of Red Blood Cells
Page: 277
Objective: N/A
Difficulty: Easy
Heading: Lack of Bone Marrow Production of RBCs
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
PRIMEXAM.COM
Cognitive Level: Knowledge [Remembering]
Concept: Hematologic Regulation
1
2
3
4
Feedback
The spleen is responsible for removing the damaged, old, and malformed red blood
cells. Therefore, dysfunction of the spleen does not affect erythropoietin synthesis.
Erythropoietin is a hormone produced in the kidneys. Therefore, renal failure would
affect the synthesis of the hormone. Renal failure is the most common cause of
erythropoietin deficiency.
Hypothyroidism reduces the production of erythropoietin. Hyperthyroidism does not
affect the synthesis of erythropoietin.
Erythropoietin stimulates the production of red blood cells in the bone marrow.
Erythropoietin is produced in the kidneys, not in the bone marrow. Therefore, bone
marrow damage does not cause erythropoietin deficiency.
PTS: 1
CON: Hematologic Regulation
11. ANS: 4
Chapter: Chapter 13, Disorders of Red Blood Cells
Page: 269
Objective: N/A
Difficulty: Moderate
Heading: Lack of Bone Marrow Production of RBCs
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Hematologic Regulation
1
2
3
4
Feedback
Hypertension is not a clinical manifestation of aplastic anemia. Aplastic anemia results
in deficiency of blood cells, namely red blood cells, white blood cells, and platelets.
Dyspnea is difficulty in breathing. Hematuria Dyspnea is not a clinical manifestation of
aplitic anemia. Tachypnea is a symptom of aplastic anemia.
Hematochezia is the presence of bright red blood in the stool. Hematochezia is not a
clinical manifestation of aplastic anemia.
Bleeding diathesis is the increased susceptibility to bleeding due to low platelet count.
It results in increased blood loss. Aplastic anemia is characterized by the presence of
reduced platelets. Therefore, the nurse should primarily assess the client for bleeding
diathesis.
PTS: 1
CON: Hematologic Regulation
12. ANS: 1
Chapter: Chapter 13, Disorders of Red Blood Cell
Page: 272
Objective: N/A
Difficulty: Difficult
Heading: Basic Concepts of RBC Pathophysiology
Integrated Processes: Nursing Process
PRIMEXAM.COM
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Hematologic Regulation
1
2
3
4
Feedback
The client has developed microcytic hypochromic anemia. The term hypochromic
indicates paler cells. The mean corpuscular volume of the client is less than the normal
value of 80 to100 femoliters, which is an indication of microcytic hypochromic anemia.
Tachycardia and pale color are symptoms of microcytic hypochromic anemia.
In clients with normocytic normochromic anemia, the mean corpuscular value will be
in the normal range. The normal range is 80 to100 femoliters, where the size and color
of red blood cells will be normal.
In clients with megaloblastic anemia, the mean corpuscular value will be greater than
the normal value, which is above 100 femoliters. The size of the red blood cells will be
bigger in megaloblastic anemia.
The symptoms and blood reports of the client indicate that the client has developed
microcytic hypochromic anemia.
PTS: 1
CON: Hematologic Regulation
13. ANS: 2
Chapter: Chapter 13, Disorders of Red Blood Cell
Page: 278
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts of RBC Pathophysiology
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Hematologic Regulation
1
2
3
4
Feedback
Females tend to have lower hemoglobin counts than males.
Clients who live at high altitudes have high hemoglobin counts because of the reduced
oxygen level in the environment. The reduced oxygen level stimulates the bone marrow
to synthesize more red blood cells, which produce hemoglobin.
African-American males tend to have lower hemoglobin counts than white males, so
this factor does not mean having a high hemoglobin count.
Clients who live at high altitudes have higher hemoglobin counts, but being female or
African American does not contribute to having a higher hemoglobin count.
PTS: 1
CON: Hematologic Regulation
14. ANS: 4
Chapter: Chapter 13, Disorders of Red Blood Cell
Page: 259
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts of RBC Pathophysiology
PRIMEXAM.COM
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Hematologic Regulation
1
2
3
4
Feedback
Mean corpuscular hemoglobin indicates the average concentration of hemoglobin in
each red blood cell.
Reticulocyte count indicates the number of new red blood cells in blood.
Hematocrit volume indicates the percentage of blood volume that consists of red cells.
Red blood cell distribution width indicates the variation in red blood cell size and
width. It can be used to find if the client has developed microcytic, macrocytic, or
normocytic anemia.
PTS: 1
CON: Hematologic Regulation
15. ANS: 1
Chapter: Chapter 13, Disorders of Red Blood Cell
Page: 259
Objective: N/A
Difficulty: Easy
Heading: Complete Blood Count Normal Values
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Hematologic Regulation
1
2
3
4
Feedback
The given value is a normal value of red blood cells per liter. The normal range of red
blood cells in males is 4.5 x 106 to 5.5 x 106 and in females, 4.0 to 4.9.
The given value is a normal value of hemoglobin. The normal range of hemoglobin in
males is 13 x 106 to 18 x 106 and in females, 12 x 106 to 16 x 106.
The given value is a normal value of mean corpuscular value. The normal range of
mean corpuscular value is 80 x 106 to 100 x 106.
The given value is the normal value of mean corpuscular hemoglobin. The normal
range of mean corpuscular hemoglobin is 27 x 106 to 32 x 106.
PTS: 1
CON: Hematologic Regulation
16. ANS: 2
Chapter: Chapter 13, Disorders of Red Blood Cell
Page: 271
Objective: N/A
Difficulty: Moderate
Heading: Basic Concepts of RBC Physiology
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Hematologic Regulation
PRIMEXAM.COM
1
2
3
4
Feedback
The nurse should recommend the intake of foods rich in folic acid for clients with
macrocytic or megaloblastic anemia.
Microcytic hypochromic anemia is caused by iron deficiency. Therefore, the nurse
should recommend that the client consume foods rich in iron.
The nurse should recommend the intake of foods rich in vitamin D for clients with
leukemia.
The nurse should recommend the intake of foods rich in vitamin B for clients with
Alzheimer’s disease.
PTS: 1
CON: Hematologic Regulation
17. ANS: 1
Chapter: Chapter 13, Disorders of Red Blood Cell
Page: 265
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts of RBC Physiology
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Hematologic Regulation
1
2
3
4
Feedback
The number of reticulocytes in circulation increases when there is excessive blood loss
from the body.
The number of reticulocytes in circulation decreases when there is suppression of the
bone marrow.
The number of reticulocytes in circulation decreases when there is poor production of
red blood cells.
The number of reticulocytes in circulation increases when there is excessive blood loss
from the body.
PTS: 1
CON: Hematologic Regulation
18. ANS: 1
Chapter: Chapter 13, Disorders of Red Blood Cell
Page: 280
Objective: N/A
Difficulty: Difficult
Heading: Anemias Caused by Decrease in RBC Mass
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Hematologic Regulation
1
Feedback
The urine output will be below 30 mL/hour, since water is conserved by antidiuretic
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4
hormones. The kidney is a highly vascularized organ sensitive to blood volume
alterations.
The urine output will decrease to 5 to 15 mL/hour in clients who suffer 30% to 40% of
blood loss.
Severe blood loss interferes with urine output. It decreases the volume of urine output.
The urine output will be below 30 mL/hour.
PTS: 1
CON: Hematologic Regulation
19. ANS: 4
Chapter: Chapter 13, Disorders of Red Blood Cell
Page: 281
Objective: N/A
Difficulty: Moderate
Heading: Pathophysiology of Selected RBC Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Hematologic Regulation
1
2
3
4
Feedback
The nurse should look for cheilitis, which is an inflammation of the lips. Cheilitis is a
symptom of iron-deficiency anemia.
The nurse should look for koilonychias, which are spoon-shaped nails. Koilonychia is a
symptom of iron-deficiency anemia.
The nurse should look for glossitis, which is a smooth, swollen, red tongue. Glossitis is
a symptom of iron-deficiency anemia.
The nurse should check for cheilitis, koilonychias, and glossitis in the client to confirm
iron-deficiency anemia.
PTS: 1
CON: Hematological Regulation
20. ANS: 4
Chapter: Chapter 13, Disorders of Red Blood Cells
Page: 257
Objective: N/A
Difficulty: Moderate
Heading: Oxyhemoglobin Dissociation
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Oxygenation
1
2
Feedback
When the oxygen saturation of blood is 100% and hemoglobin is low, oxygen delivery
to cells will be inadequate. Inadequate oxygen supply to cells will result in cellular
hypoxia. Oxygen demand will be high while doing activities such as rock climbing.
Hence, the nurse should not recommend rock climbing for the client.
A low hemoglobin level and 100% oxygen saturation of blood will result in inadequate
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4
oxygen supply to cells. Skiing demands more oxygen than the normal oxygen demand
of the body. Hence, the nurse should not recommend skiing for the client.
Oxygen level decreases as an individual climbs up the hill. Since a low hemoglobin
level and 100% oxygen saturation of blood would result in inadequate oxygen supply to
cells, trekking is not recommended for the client.
When the oxygen saturation of blood is 100% and hemoglobin is low, an inadequate
oxygen supply to cells will result. Therefore, the nurse should not recommend that the
client do vigorous exercises or activities that demand an oxygen supply. The nurse can
recommend that the client engage in activities that are less strenuous, such as taking a
road trip on a cross-country vacation.
PTS: 1
CON: Perfusion
21. ANS: 3
Chapter: Chapter 13, Disorders of Red Blood Cell
Page: 259
Objective: N/A
Difficulty: Difficult
Heading: Basic Concepts of RBC Pathophysiology
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Hematologic Regulation
1
2
3
4
Feedback
Folate-deficiency anemia causes macrocytic or megaloblastic anemia. The complete
blood count results show presence of microcytic anemia.
Vitamin B12 deficiency anemia causes macrocytic or megaloblastic anemia. The
complete blood count results show presence of microcytic anemia.
The client has developed iron-deficiency anemia. The low mean corpuscular level and
mean corpuscular hemoglobin are indications of microcytic anemia. Microcytic anemia
occurs due to iron deficiency. Low circulating hemoglobin results in low circulating
oxygen and poor tissue perfusion, which in turn would lead to the development of chest
pain.
“None of the above” is incorrect; the client has developed iron-deficiency anemia.
PTS: 1
CON: Hematologic Regulation
22. ANS: 3
Chapter: Chapter 13, Disorders of Red Blood Cell
Page: 268
Objective: N/A
Difficulty: Difficult
Heading: Basic Concepts of RBC Physiology
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Hematologic Regulation
PRIMEXAM.COM
1
2
3
4
Feedback
Alpha thalassemia is a condition where an alpha polypeptide chain is missing in the
hemoglobin molecule.
Sickle cell anemia is a genetic disorder where the shape of the red blood cells occurs in
a crescent shape.
The client has developed beta thalassemia. The low mean corpuscular level, low mean
corpuscular hemoglobin, and presence of hemoglobin A2 are indicators of beta
thalassemia.
“None of the above” is incorrect; the client has developed beta thalassemia.
PTS: 1
CON: Hematologic Regulation
23. ANS: 1
Chapter: Chapter 13, Disorders of Red Blood Cell
Page: 276
Objective: N/A
Difficulty: Difficult
Heading: Basic Concepts of RBC Pathophysiology
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Hematologic Regulation
1
2
3
4
Feedback
Headache and weakness are the symptoms of anemia. The blood report shows that the
client has low red blood cells and hemoglobin values, which are indications of anemia.
Therefore, the client has developed anemia.
The client has a normal level of white blood cells. Therefore, the client has not
developed leucopenia.
The client has a normal level of platelets. Therefore, the client has not developed
thrombocytopenia.
“None of the above” is incorrect; the client has developed anemia.
PTS: 1
CON: Hematologic Regulation
MULTIPLE RESPONSE
24. ANS: 1, 3, 5
Chapter: Chapter 13, Disorders of Red Blood Cells
Page: 273
Objective: N/A
Difficulty: Difficult
Heading: Iron Metabolism
Integrated Processes: Teaching/Learning
Client Need: Health Promotion and Maintenance
Cognitive Level: Analysis [Analyzing]
Concept: Nutrition
PRIMEXAM.COM
1.
2.
3.
4.
5.
Feedback
This is correct. Consuming orange juice will increase iron absorption in clients with irondeficiency anemia because orange juice is rich in vitamin C. Vitamin C will form
complexes with iron and increase the absorption of iron.
This is incorrect. Drinking a cup of black tea after meals will reduce iron absorption in
clients with iron-deficiency anemia. Black tea contains tannates that decrease the
absorption of iron. Therefore, clients who have iron-deficiency anemia should avoid tea
and coffee.
This is correct. Adding meat to the diet of clients with iron-deficiency anemia will improve
the condition. The iron in animal sources such as meat is most readily absorbed by the
body.
This is incorrect. Drinking grape juice daily will not increase iron absorption in clients with
iron-deficiency anemia because grapes contain tannates. Tannates reduce the absorption of
iron.
This is correct. Adding broccoli, beans, and tomato sauce to the diet of clients with irondeficiency anemia is beneficial. Broccoli, beans, and tomatoes are rich sources of iron, as
well as vitamin C. So adding these foods to the diet will result in generous levels of iron
absorption.
PTS: 1
CON: Nutrition
25. ANS: 1, 3
Chapter: Chapter 13, Disorders of Red Blood Cells
Page: 257
Objective: N/A
Difficulty: Easy
Heading: Oxyhemoglobin Dissociation
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Oxygenation: Perfusion
1.
2.
3.
4.
5.
Feedback
This is correct. Hypothermia, a condition characterized by abnormally low body
temperature, increases the hemoglobin’s affinity for oxygen.
This is incorrect. Hyperthermia is the increase in body temperature compared to normal.
Hyperthermia results in decreased hemoglobin affinity for oxygen.
This is correct. Alkalosis is an excessively alkaline condition of the body fluids. Alkalosis
increases the hemoglobin’s affinity for oxygen.
This is incorrect. Acidosis is an excessively acidic condition of the body fluids. Acidosis
reduces the hemoglobin’s affinity for oxygen.
This is incorrect. Hypercapnia refers to an abnormally high amount of carbon dioxide in
the blood. Hypercapnia results in acidosis and reduces the hemoglobin’s affinity for
oxygen.
PTS: 1
CON: Oxygenation: Perfusion
PRIMEXAM.COM
Chapter 14: Disorders of Platelets, Hemostasis, and Coagulation
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. A nurse is caring for a client who reports with severe bleeding. The primary health-care provider prescribes a
diagnostic test that would measure the time taken for the blood to clot and examine the extrinsic pathway of
coagulation cascade. Which diagnostic test does the nurse expect to be performed?
1. Fibrinogen test
2. Activated partial thromboplastin time test
3. Platelet aggregation test
4. Prothrombin time test
2. A client reports shortness of breath and severe pain in the back, chest, and muscles. Which condition could the
client possibly be diagnosed with?
1. Hemophilia B
2. Hemophilia A
3. Disseminated intravascular coagulation
4. Von Willebrand disease
3. A client with hemolytic-uremic syndrome reports fever, abdominal pain, pale skin, bruising, and bleeding of
the skin. Which medication or treatment will be beneficial for the client?
1. Supportive treatment with dialysis and plasma exchange
2. Aspirin and antiplatelet drugs
3. Desmopressin acetate
4. Immunomodulatory drugs
4. A 30-year-old client who presents with symptoms of redness, heat, and pain in the joints undergoes a
complete blood count test. The blood report shows an increased white blood cell count. Which condition does
this indicate?
1. Inflammation
2. Anemia
3. Increased bleeding tendency
4. Pulmonary embolism
5. A client reports fullness of the stomach, fatigue, nausea, vomiting, and abdominal bloating. The client is
diagnosed with stomach cancer. Which medication does the nurse expect the primary health-care provider to
prescribe?
1. Cisplatin
2. Ticlopidine
3. Cyclosporine
4. Tacrolimus
6. While reviewing a client’s medical history, a nurse understands that the client is at risk of bleeding because
the client’s platelet count is 80,000/uL. Which condition is this?
1. Thrombocytosis
2. Thrombocytopenia
3. Thrombus
4. Thrombosis
PRIMEXAM.COM
7. Which statement is true regarding megakaryocytes?
1. They are invisible in bone marrow.
2. They have a nucleus.
3. They can synthesize proteins.
4. They mature into platelets.
8. Which factor leads to enhanced platelet activity?
1. Disturbances in blood flow
2. Stasis of blood flow
3. Increase in procoagulation factors
4. Decrease in anticoagulation factors
9. How does primary thrombocytosis differ from secondary thrombocytosis?
1. It occurs in the bone marrow.
2. It has an elevated platelet count.
3. It is a development of thrombosis, which is unclear.
4. It occurs as a result of an excessive number of platelets.
10. What is the best intervention for immediately lowering the platelet count to safer levels in a client diagnosed
with severe life-threatening thrombocytosis?
1. Administering aspirin in a small dose
2. Providing clopidogrel to inhibit blood clotting
3. Administering hydroxyurea to lower the platelet count
4. Performing pheresis to remove whole blood from the donor
11. Two clients are admitted into a health-care unit for clotting-related conditions. One of the clients is prescribed
with the drug fondaparinux; whereas, the other client is prescribed dabigatran. How is fondaparinux different
from dabigatran?
1. Fondaparinux is a parenteral form of anticoagulant.
2. Fondaparinux is an oral form of anticoagulant.
3. Fondaparinux is used to prevent stroke in clients with atrial fibrillation.
4. Fondaparinux is also called factor IIa.
12. Low molecular weight heparin (LMWH) is a class of anticoagulant medications. Which is a characteristic of
low molecular weight heparin?
1. It consists of large fragments of heparin.
2. It binds to plasma proteins as strongly as standard heparin.
3. It can be administered subcutaneously.
4. It has more side effects than standard heparin.
13. A nurse is caring for a client who feels tired and weak and reports shortness of breath and pink or purple spots
on the skin. The client is diagnosed with thrombotic thrombocytopenic purpura. Which is the most effective
intervention for this client?
1. Performing plasmapheresis
2. Administering corticosteroid drugs
3. Providing direct thrombin inhibitors
4. Performing factor VIII replacement therapy
14. A client reports abdominal pain, fever, and fatigue. On assessment, the client is diagnosed with hemolyticuremic syndrome. Which abnormal diagnostic test result could further confirm the diagnosis?
1. High proteinuria and hematuria
PRIMEXAM.COM
2. High blood urea nitrogen
3. Low serum creatinine
4. Low bilirubin
15. A client reports unsteadiness, vertigo, dizziness, and seizures. On assessment, the client is diagnosed with
essential thrombocytosis. What is the abnormal result found during the diagnosis?
1. Decreased bleeding
2. Decreased number of white blood cells (WBCs)
3. Decreased number of platelets
4. Increased number of red blood cells (RBCs)
16. A 10-year-old client is brought to the hospital with complaints of bloody diarrhea. The client was learning to
swim. The vital signs of the client show a body temperature of 101°F and blood pressure of 125/85 mm Hg.
With which condition might the client be diagnosed?
1. Hemolytic-uremic syndrome
2. Von Willebrand disease
3. Essential thrombocytosis
4. Hemophilia
17. A 35-year-old male client with severe bleeding from an accident is brought to a hospital. The result of the
complete blood count report shows red blood cells (RBCs) at 4.9 millions/microliter, white blood cells
(WBCs) at 5,000/microliter, platelets at 80,000/microliter, and hemoglobin at 12 grams/deciliter. Which
condition has the client developed?
1. Leukopenia
2. Leukocytosis
3. Thrombocytopenia
4. Neutropenia
18. Which statement made by the student nurse indicates effective learning about the coagulation factors and
intrinsic pathway?
1. “The clotting time is measured by prothrombin time.”
2. “The clotting time is measured by activated partial thromboplastin time (aPTT).”
3. “TF-factor VII is formed by factor VII and tissue factor.”
4. All of the above
19. A client visits a health-care unit with acute immune thrombocytopenic purpura. Which is a unique feature of
acute immune thrombocytopenic purpura?
1. Occurs in children
2. Occurs in adults
3. Occurs in persons aged between 20 to 50 years
4. Occurs twice as often in men than in women
20. What is a supportive treatment for a client with disseminated intravascular coagulation?
1. Transfuse fresh frozen plasma.
2. Maintain fluid and electrolyte balance.
3. Start prophylactic treatment with phenytoin.
4. None of the above
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
PRIMEXAM.COM
21. Which statements are correct regarding platelets? Select all that apply.
1. Platelet formation is stimulated by the hormone thrombopoietin.
2. Platelets increase in the bone marrow.
3. Platelets have a lifespan of less than 7 days.
4. Platelets spend one-third of their lives in the spleen.
5. Platelet adhesion results in the activation of the glycoprotein.
22. A registered nurse is teaching a student nurse about the features of the extrinsic pathway of the coagulation
cascade. Asses the statements made by the student nurse and choose the ones that indicate effective learning.
Select all that apply.
1. “It is measured by the activated partial thromboplastin time (aPTT).”
2. “It is stimulated by tissue damage incurred by injury to the endothelial lining.”
3. “It is also known as tissue factor pathway.”
4. “It leads to the ultimate conversion of fibrinogen into fibrin.”
5. “It leads to the conversion of prothrombin to thrombin.”
23. Which statements are true regarding the final pathway in the coagulation cascade? Select all that apply.
1. It converts fibrinogen to fibrin.
2. It requires minerals and vitamins.
3. It stores vitamin K in fatty tissue.
4. It increases the absorption of vitamin K.
5. It converts thrombin into prothrombin.
24. How does the drug heparin compare to the drug warfarin? Select all that apply.
1. Both heparin and warfarin are based on a partial thromboplastin time (aPTT) value which
requires 30 to 45 seconds.
2. Both heparin and warfarin are administered intravenously or subcutaneously.
3. Both heparin and warfarin are anticoagulant drugs.
4. Both heparin and warfarin take same amount of time to reach therapeutic levels.
5. Both heparin and warfarin have bleeding as side effect.
25. A nurse is caring for a 50-year-old client with symptoms of trouble in speaking, sudden numbness, and
weakness of the face. The client is diagnosed with a stroke. A physician orders thrombolytic therapy. How is
thrombolytic therapy effective to treat the condition? Select all that apply.
1. It is used to dissolve the clot.
2. It is used to reestablish blood flow.
3. It is used to treat the client with more than 3 to 4 hours from the time of the acute event.
4. It is used to treat the client within 24 hours of the onset of symptoms.
5. It is used to convert plasminogen to plasmin.
PRIMEXAM.COM
Chapter 14: Disorders of Platelets, Hemostasis, and Coagulation
Answer Section
MULTIPLE CHOICE
1. ANS: 4
Chapter: Chapter 14, Disorders of Platelets, Hemostasis, and Coagulation
Page: 286
Objective: N/A
Difficulty: Moderate
Heading: Assessment of Bleeding and Clotting Disorders
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Assessment
1
2
3
4
Feedback
A fibrinogen test is used to measure the functions of fibrinogen. It measures the clotting
ability and activity of blood.
The activated partial thromboplastin time test is a medical test that evaluates the
intrinsic pathway of the coagulation cascade.
Platelet aggregation testing evaluates the platelet’s ability to adhere and form clumps.
The prothrombin time test is a medical test that evaluates the extrinsic pathway of the
coagulation cascade.
PTS: 1
CON: Assessment
2. ANS: 3
Chapter: Chapter 14, Disorders of Platelets, Hemostasis, and Coagulation
Page: 303
Objective: N/A
Difficulty: Easy
Heading: Pathophysiology of Selected Coagulation Disorders
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
1
2
3
Feedback
Hemophilia B is a genetic disorder caused due to lack of factor IX. The symptoms of
the disease include bruises, nose bleeding, gum bleeding, and hemarthrosis.
Hemophilia A is a genetic disorder caused due to lack of factor VIII. The symptoms of
the disease include gum bleeds, nose bleeds, hemarthrosis, and bruises.
Disseminated intravascular coagulation is characterized by overactivation of the
clotting mechanism commonly caused by sepsis. It is secondary to another disease. The
symptoms of the disease include shortness of breath and severe pain in the back,
muscles, and chest.
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Von Willebrand disease is a genetic disorder that involves diminished von Willebrand
factor and decreased factor VIII levels. The symptoms of the disease include excessive
bleeding with minor trauma, spontaneous nose bleeds, and gum bleeds.
PTS: 1
CON: Assessment
3. ANS: 1
Chapter: Chapter 14, Disorders of Platelets, Hemostasis, and Coagulation
Page: 299
Objective: N/A
Difficulty: Moderate
Heading: Hemolytic-Uremic Syndrome
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Assessment
1
2
3
4
Feedback
Treatment with dialysis and plasma exchange may be used for hemolytic-uremic
syndrome.
Aspirin and antiplatelet drugs are used to treat essential thrombocytosis.
Desmopressin acetate may be used in the treatment of von Willebrand disease.
Immunomodulatory drugs may be used in the treatment of thrombotic
thrombocytopenic purpura.
PTS: 1
CON: Assessment
4. ANS: 1
Chapter: Chapter 14, Disorders of Platelets, Hemostasis, and Coagulation
Page: 293
Objective: N/A
Difficulty: Easy
Heading: Assessment of Bleeding and Clotting Disorders
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Comprehension [Understanding]
Concept: Inflammation
1
2
3
4
Feedback
An increased white blood cell count indicates inflammation.
A decreased hemoglobin level indicates anemia.
A decreased platelet number indicates an increased bleeding tendency.
An abnormal D-dimer test may indicate a chronic or acute condition such as pulmonary
embolism.
PTS: 1
CON: Inflammation
5. ANS: 1
Chapter: Chapter 14, Disorders of Platelets, Hemostasis, and Coagulation
Page: 298
PRIMEXAM.COM
Objective: N/A
Difficulty: Moderate
Heading: Pathophysiology of Selected Coagulation Disorders
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Medication
1
2
3
4
Feedback
Cisplatin is a drug that is used to treat clients who have stomach cancer.
Ticlopidine is a drug that is used as an antiplatelet agent.
Cyclosporine is a drug that is used as an immunotherapeutic agent.
Tacrolimus is a drug that is used as an immunotherapeutic agent.
PTS: 1
CON: Medication
6. ANS: 2
Chapter: Chapter 14, Disorders of Platelets, Hemostasis, and Coagulation
Page: 285
Objective: N/A
Difficulty: Moderate
Heading: Epidemiology
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Clotting
1
2
3
4
Feedback
Thrombocytosis refers to an excessive number of platelets that can cause excessive
clotting.
Thrombocytopenia refers to the condition when the platelet count is less than
100,000/uL, which can cause bleeding.
Thrombus is a collection of aggregated platelets reinforced by fibrin.
Thrombosis is the generation of an occlusive clot that obstructs blood flow in an artery
or vein.
PTS: 1
CON: Clotting
7. ANS: 4
Chapter: Chapter 14, Disorders of Platelets, Hemostasis, and Coagulation
Page: 286
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts of Bleeding and Clotting Physiology
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Clotting
PRIMEXAM.COM
1
2
3
4
Feedback
Megakaryocytes are large cells present in bone marrow.
Megakaryocytes have no nucleus, deoxyribonucleic acid, or ribosomes.
Megakaryocytes cannot synthesize proteins.
Megakaryocytes mature into platelets that have powerful granules.
PTS: 1
CON: Clotting
8. ANS: 1
Chapter: Chapter 14, Disorders of Platelets, Hemostasis, and Coagulation
Page: 288
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts of Bleeding and Clotting Pathophysiology
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Clotting
1
2
3
4
Feedback
Disturbances in blood flow may cause increased platelet activity.
The activation of coagulation factors increases with stasis of blood flow.
An increase in procoagulation factors causes increased activation of coagulation
factors.
A decrease in anticoagulation factors causes increased activation of coagulation factors.
PTS: 1
CON: Clotting
9. ANS: 1
Chapter: Chapter 14, Disorders of Platelets, Hemostasis, and Coagulation
Page: 288
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts of Bleeding and Clotting Pathophysiology
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Clotting
1
2
3
4
Feedback
Primary thrombocytosis is also known as essential thrombocytosis that occurs in the
bone marrow.
Secondary thrombocytosis is an elevated platelet count caused by another primary
condition such as iron deficiency anemia, cancer, inflammation, and infection.
The exact mechanism for development of thrombocytosis is unclear in secondary
thrombocytosis.
In secondary thrombocytosis, the excessive number of platelets does not cause
excessive clotting.
PRIMEXAM.COM
PTS: 1
CON: Clotting
10. ANS: 4
Chapter: Chapter 14, Disorders of Platelets, Hemostasis, and Coagulation
Page: 293
Objective: N/A
Difficulty: Difficult
Heading: Antiplatelet, Anticoagulation, and Thrombolytic Therapy
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Evaluation [Evaluating]
Concept: Clotting
1
2
3
4
Feedback
Aspirin is an antiplatelet medication that should be administered in small doses of 70 to
150 mg daily to prevent myocardial infarction.
Clopidogrel is an antiplatelet medication that should be provided to inhibit blood clots
in coronary artery disease and to prevent myocardial infarction.
Hydroxyurea should be provided to suppress platelet production by the bone marrow in
cases where there are an excessive number of platelets, such as essential in
thrombocytosis.
Platelet pheresis is a procedure that should be performed to immediately lower the
platelet count to safer levels in cases of severe life-threatening thrombocytosis. It is the
process of removing whole blood from the client, separating its components, keeping
the platelets, and then returning the blood components to the donor without the
platelets.
PTS: 1
CON: Clotting
11. ANS: 1
Chapter: Chapter 14, Disorders of Platelets, Hemostasis, and Coagulation
Page: 293
Objective: N/A
Difficulty: Difficult
Heading: Antiplatelet, Anticoagulation, and Thrombolytic Therapy
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Medication
1
2
3
4
Feedback
Fondaparinux is a subcutaneous agent given once daily. It is a parenteral form of
anticoagulant.
Dabigatran is an anticoagulant drug given orally.
Dabigatran is the drug used to prevent stroke in clients with atrial fibrillation.
Dabigatran is a direct thrombin inhibitor, which is also known as factor IIa.
PTS: 1
12. ANS: 3
CON: Medication
PRIMEXAM.COM
Chapter: Chapter 14, Disorders of Platelets, Hemostasis, and Coagulation
Page: 293
Objective: N/A
Difficulty: Easy
Heading: Antiplatelet, Anticoagulation, and Thrombolytic Therapy
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Comprehension [Understanding]
Concept: Medication
1
2
3
4
Feedback
LMWH consists of small fragments of heparin and exerts its anticoagulant effect by
activating antithrombin.
LMWH binds to plasma proteins but not as strongly as standard heparin.
LMWH can be administered subcutaneously once or twice a day without coagulation
monitoring.
LMWH has a shorter half-life and fewer side effects than standard heparin.
PTS: 1
CON: Medication
13. ANS: 1
Chapter: Chapter 14, Disorders of Platelets, Hemostasis, and Coagulation
Page: 295
Objective: N/A
Difficulty: Difficult
Heading: Pathophysiology of Selected Coagulation Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Clotting
1
2
3
4
Feedback
Plasmapheresis is a procedure that involves removal of the blood’s plasma portion and
replacing it with fresh frozen plasma. This is the treatment given for clients with
thrombotic thrombocytopenic purpura.
Corticosteroid drugs are used to treat clients with immune thrombocytopenic purpura.
Direct thrombin inhibitors are used as treatment for heparin-induced thrombocytopenia.
Factor VIII replacement therapy is the treatment given for clients with hemophilia A.
PTS: 1
CON: Clotting
14. ANS: 2
Chapter: Chapter 14, Disorders of Platelets, Hemostasis, and Coagulation
Page: 299
Objective: N/A
Difficulty: Moderate
Heading: Hemolytic-Uremic Syndrome
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
PRIMEXAM.COM
Cognitive Level: Application [Applying]
Concept: Clotting
1
2
3
4
Feedback
A urinalysis will reveal mild proteinuria and hematuria among clients with hemolyticuremic syndrome.
Blood urea may be high, which indicates renal insufficiency among clients with
hemolytic-uremic syndrome.
Serum creatinine may be high, which indicates renal insufficiency among clients with
hemolytic-uremic syndrome.
Bilirubin levels may increase because of a large amount of hemoglobin breakdown
among clients with hemolytic-uremic syndrome.
PTS: 1
CON: Clotting
15. ANS: 2
Chapter: Chapter 14, Disorders of Platelets, Hemostasis, and Coagulation
Page: 297
Objective: N/A
Difficulty: Moderate
Heading: Pathophysiology of Selected Coagulation Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Clotting
1
2
3
4
Feedback
Excessive bleeding can be observed on a complete blood count test. The bleeding time
may be prolonged or may not be prolonged among clients with essential
thrombocytosis.
An excessive number of WBCs can be observed during the complete blood count test
among clients with essential thrombocytosis.
An excessive number of platelets are noted on the complete blood count test among
clients with essential thrombocytosis.
An increased number of RBCs can be observed during the complete blood count test
among clients with essential thrombocytosis.
PTS: 1
CON: Clotting
16. ANS: 1
Chapter: Chapter 14, Disorders of Platelets, Hemostasis, and Coagulation
Page: 298
Objective: N/A
Difficulty: Difficult
Heading: Pathophysiology of Selected Coagulation Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Perfusion
PRIMEXAM.COM
1
2
3
4
Feedback
Hemolytic-uremic syndrome is a disorder that causes renal failure and hemolytic
anemia. It is the most common cause of acute renal failure in children.
Von Willebrand disease is a genetic disorder transmitted as an autosomal trait that
causes a deficiency.
Essential thrombocytosis is a rare, chronic disorder of the bone marrow. It is a disorder
of megakaryocyte proliferation that increases the number of circulating platelets.
Hemophilia is a rare disorder that slows the blood clotting process.
PTS: 1
CON: Perfusion
17. ANS: 3
Chapter: Chapter 14, Disorders of Platelets, Hemostasis, and Coagulation
Page: 285
Objective: N/A
Difficulty: Difficult
Heading: N/A
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Hematologic Regulation
1
2
3
4
Feedback
Leukopenia is a decrease in the number of WBCs below 4,000/microliter.
Leukocytosis is a disorder of the white blood cells where the number of WBCs
increases above 11,000/microliter.
Thrombocytopenia is a disorder of platelets where the number of platelets decreases
below 100,000/microliter. Therefore, the client has developed thrombocytopenia.
Neutropenia occurs when the neutrophil count decreases below 1,500/microliter in
blood.
PTS: 1
CON: Hematologic Regulation
18. ANS: 2
Chapter: Chapter 14, Disorders of Platelets, Hemostasis, and Coagulation
Page: 286
Objective: Basic Concepts of Bleeding and Clotting Physiology
Difficulty: Difficult
Heading: Types of Inflammation
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Evaluation [Evaluating]
Concept: Perfusion
1
2
Feedback
The blood clotting time of the extrinsic pathway can be measured by the prothrombin
time.
The blood clotting time of the intrinsic pathway can be measured by the aPTT.
PRIMEXAM.COM
3
4
When blood vessels are injured by an external injury, factor VII is activated. Factor VII
comes in contact with tissue factors and these two components form TF-factor VII. The
TF-factor VII activates the factors that activate prothrombin to thrombin. Thrombin
helps stop bleeding.
The clotting time of the intrinsic pathway is measured by aPTT. So this answer option
is incorrect.
PTS: 1
CON: Perfusion
19. ANS: 1
Chapter: Chapter 14, Disorders of Platelets, Hemostasis, and Coagulation
Page: 295
Objective: N/A
Difficulty: Moderate
Heading: Pathophysiology of Selected Coagulation Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Clotting
Feedback
1
2
3
4
Acute immune thrombocytopenic purpura is most common in children.
Acute immune thrombocytopenic purpura is not common in adults.
Chronic immune thrombocytopenic purpura and not acute immune thrombocytopenic
purpura occurs in persons between 20 to 50 years of age.
Acute immune thrombocytopenic purpura is usually seen twice as often in women as it
is in men.
PTS: 1
CON: Clotting
20. ANS: 1
Chapter: Chapter 14, Disorders of Platelets, Hemostasis, and Coagulation
Page: 296
Objective: N/A
Difficulty: Moderate
Heading: Disseminated Intravascular Coagulation
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Assessment
1
2
3
4
Feedback
Transfusion of fresh frozen plasma, platelets, or fibrinogen-containing cryoprecipitate
may correct the clotting factor deficiency.
It is necessary to maintain fluid and electrolyte balance when a client is diagnosed with
hemolytic-uremic syndrome because supportive therapy is the major form of treatment.
It is necessary to start prophylactic treatment with phenytoin in clients with hemolyticuremic syndrome because 20% to 40% of clients may develop seizures.
Transfusion of fresh frozen plasma, platelets, or fibrinogen-containing cryoprecipitate
PRIMEXAM.COM
may correct the clotting factor deficiency.
PTS: 1
CON: Assessment
MULTIPLE RESPONSE
21. ANS: 1, 4, 5
Chapter: Chapter 14, Disorders of Platelets, Hemostasis, and Coagulation
Page: 286
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts of Bleeding and Clotting Physiology
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Clotting
1.
2.
3.
4.
5.
Feedback
This is correct. Thrombopoietin is a hormone that is synthesized by the liver and stimulates
platelet formation.
This is incorrect. Thrombopoietin is stimulated by the reduction in platelet numbers in bone
marrow.
This is incorrect. Platelets have a life span of 7 to 10 days.
This is correct. Platelets spend almost one-third of their lives in the spleen.
This is correct. Platelet adhesion results in the activation of the glycoprotein.
PTS: 1
CON: Clotting
22. ANS: 3, 4, 5
Chapter: Chapter 14, Disorders of Platelets, Hemostasis, and Coagulation
Page: 286
Objective: N/A
Difficulty: Difficult
Heading: Basic Concepts of Bleeding and Clotting Physiology
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Evaluation [Evaluating]
Concept: Clotting
1.
2.
3.
4.
5.
Feedback
This is incorrect. The clotting time of the extrinsic pathway can be measured by the prothrombin
time diagnostic test.
This is incorrect. The extrinsic pathway is stimulated by trauma to a blood vessel because of an
external injury.
This is correct. The extrinsic pathway is also known as the tissue factor pathway.
This is correct. The extrinsic pathway leads to the ultimate conversion of fibrinogen into fibrin.
This is correct. The activation of X factor converts prothrombin to thrombin.
PRIMEXAM.COM
PTS: 1
CON: Clotting
23. ANS: 1, 3, 5
Chapter: Chapter 14, Disorders of Platelets, Hemostasis, and Coagulation
Page: 286
Objective: N/A
Difficulty: Easy
Heading: The Coagulation Factors
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Clotting
1.
2.
3.
4.
5.
Feedback
This is correct. Thrombin has many functions; mainly the conversion of fibrinogen to
fibrin, the major building block of a clot.
This is incorrect. Calcium and vitamin K are required for the proper functioning of the
coagulation cascade.
This is correct. Vitamin K is stored in fatty tissue.
This is incorrect. Any disorder that decreases absorption of fat will decrease the absorption
of vitamin K.
This is correct. Both extrinsic and intrinsic pathways arrive at a common final pathway that
leads to the conversion of prothrombin to thrombin.
PTS: 1
CON: Clotting
24. ANS: 1, 2, 4
Chapter: Chapter 14, Disorders of Platelets, Hemostasis, and Coagulation
Page: 294
Objective: N/A
Difficulty: Difficult
Heading: Antiplatelet, Anticoagulation, and Thrombolytic Therapy
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Medication
1.
2.
3.
4.
5.
Feedback
This is correct. The partial thromboplastin time for heparin is 30 to 45 seconds; whereas,
prothrombin time for warfarin is 18 to 24 seconds.
This is correct. Heparin can be administered intravenously or subcutaneously, but warfarin
is administered orally.
This is incorrect. Both heparin and warfarin are anticoagulant drugs.
This is correct. The level of warfarin in the blood peaks about 90 minutes after drug
administration, while heparin takes more time to rise to a therapeutic level.
This is incorrect. Both heparin and warfarin have bleeding as a side effect.
PTS: 1
CON: Medication
PRIMEXAM.COM
25. ANS: 1, 2, 5
Chapter: Chapter 14, Disorders of Platelets, Hemostasis, and Coagulation
Page: 287
Objective: N/A
Difficulty: Moderate
Heading: Antiplatelet, Anticoagulation, and Thrombolytic Therapy
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Clotting
1.
2.
3.
4.
5.
Feedback
This is correct. Thrombolytic agents can be administered systematically and can be used to
dissolve the clot.
This is correct. Thrombolytic agents can be used to reestablish blood flow.
This is incorrect. Thrombolytic agents can be used to treat the client within 3 to 4 hours
from the time of the acute event.
This is incorrect. Thrombolytic agents can be used to treat the client with a new bundle
branch block presenting within 12 hours of the onset of symptoms.
This is correct. Thrombolytic agents can be used to convert plasminogen to plasmin, and
plasmin then degrades the fibrin matrix of the thrombus.
PTS: 1
CON: Clotting
PRIMEXAM.COM
Chapter 15: Arterial Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. A nurse hears a bruit while assessing the carotid artery of a client. What could be the reason behind the bruit?
1. Turbulent blood flow in the artery
2. Decreased blood flow in the artery
3. Problems in the tricuspid valve
4. None of the above
2. A registered nurse is teaching a nursing student the relationship between cardiac output (CO), blood pressure
(BP), and peripheral vascular resistances (PVR). The student nurse is asked to recap the mathematical
equation that relates the three factors. Which equation provided by the student nurse indicates the need for
further teaching?
1. “CO × PVR = BP”
2. “CO / BP = PVR”
3. “BP / PVR = CO”
4. “PVR / CO = BP”
3. A registered nurse is teaching a nursing student about the effects of glucose on the arteries. Which statement
made by the student nurse indicates effective learning?
1. “Increased serum glucose combines with carbon dioxide and causes atherosclerosis.”
2. “Increased serum glucose causes endothelial injury, which would lead to atherosclerosis.”
3. “Increased serum glucose causes the breakdown of homocysteine and leads to
atherosclerosis.”
4. All of the above
4. A client who has diabetes is diagnosed with high blood pressure. Which is the preferred medication for the
client?
1. Captopril
2. Hydrochlorothiazide
3. Amlodipine
4. All of the above
5. Which is a risk factor for hypertension?
1. Increased vitamin C in the diet
2. Increased potassium in the diet
3. Insufficient sodium in the diet
4. Insufficient vitamin D in the diet
6. A registered nurse is teaching a nursing student about the diagnostic tests for cardiovascular diseases. Which
statement made by the student nurse indicates effective learning?
1. “An elevated, high sensitivity C-reactive protein (hs-CRP) indicates the client is at a low
risk for developing atherosclerosis.”
2. “Hypohomocysteinemia places clients at a risk for developing atherosclerosis.”
3. “Hypothyroidism is a risk factor for atherosclerosis.”
4. None of the above
PRIMEXAM.COM
7. A client reports pain in the calf muscle while walking and exercising, but also reports that the pain is relieved
by resting. Which medication would the physician prescribe to the client?
1. Pentoxifylline
2. Aspirin
3. Infliximab
4. Cyclophosphamide
8. Which clinical manifestation is observed in a client who has an abdominal aortic aneurysm (AAA) rupture?
1. Increased blood pressure
2. Cool extremities
3. Hyperthermia
4. Decreased heart rate
9. A client has a pulsatile mass in the abdomen. Which assessment technique should be avoided until the
possibility of an abdominal aortic aneurysm (AAA) is ruled out?
1. Deep palpation of the abdomen
2. Auscultation of the abdomen for bruit
3. Auscultation of the abdomen for bowel motility
4. All of the above
10. Which diagnostic procedure provides details on the size and location of an aneurysm?
1. X-ray
2. Magnetic resonance angiography (MRA) scan
3. Computed tomography (CT) scan
4. All of the above
11. A client presents to the emergency room with reports of severe back pain described as a ripping sensation.
Further assessment reveals a different blood pressure in the right arm than in the left arm and pallor and
tachycardia. Which condition should a nurse suspect?
1. Myocardial infarction
2. Aortic dissection
3. Vasculitis
4. None of the above
12. A client reports severe chest pain and a rapid heart rate. A nurse observes a blood pressure difference in the
left and right arms. Which difference in blood pressure indicates an aortic dissection?
1. 10 mm Hg
2. 20 mm Hg
3. 15 mm Hg
4. 5 mm Hg
13. A registered nurse is teaching a nursing student the effects of medications that are used to treat
hyperlipidemia. Which statements of the student nurse indicates effective learning?
1. “Simvastatin blocks the absorption of fats from the intestine.”
2. “Cholestyramine blocks the bile acid absorption in the gastrointestinal (GI) tract.”
3. “Fenofibrate blocks the breakdown of fats in the tissues.”
4. All of the above
14. A nurse is caring for a child who has Kawasaki disease and is exhibiting symptoms related to this disease.
Which symptom would cause the nurse to be most concerned about the possibility of myocardial infarction?
1. Diarrhea
PRIMEXAM.COM
2. Joint pain
3. Abdominal pain accompanied by vomiting
4. Persistent fever
15. A child who has a fever of 103°F and diarrhea is admitted to the hospital. The parents state that the child has
poor oral intake and has joint pain. The diagnostic test report shows that the child has an elevated erythrocyte
sedimentation rate (ESR) and a high platelet count. Which condition has the child probably developed?
1. Kawasaki disease
2. Cryoglobulinemia
3. Raynaud’s Disease
4. Wegener's granulomatosis
16. Which is the optimal level of low-density lipoprotein (LDL) cholesterol?
1. 70 mg/dL
2. 110 mg/dL
3. 135 mg/dL
4. 170 mg/dL
17. Which is the most common type of vasculitis of small-sized arterioles?
1. Raynaud’s disease
2. Polyarteritis nodosa
3. Temporal arteritis
4. None of the above
18. A 55-year-old client reports severe headache, weight loss, fatigue, stiffness, and pain in the shoulders. Which
condition has the client developed?
1. Temporal arteritis
2. Polymyalgia rheumatic
3. Takayasu arteritis
4. None of the above
19. A registered nurse is teaching a nursing student about the diagnosis of Takayasu arteritis. Which statement
made by the student nurse indicates effective learning?
1. “A decreased level of erythrocyte sedimentation rate (ESR) will be observed in clients
who are diagnosed with Takayasu arteritis”
2. “A decreased leukocyte count will be observed in clients who are diagnosed with
Takayasu arteritis.”
3. “Normocytic anemia might be present in clients who are diagnosed with Takayasu
arteritis.”
4. All of the above
20. A nurse is teaching a client who has cardiovascular disease about the dietary sources of cholesterol and their
effects on the body. Which statement made by the client indicates the need for further teaching?
1. “I can use sesame and safflower oil for cooking.”
2. “I can have salmon and sardines in my diet.”
3. “I should avoid using peanut and canola oil.”
4. “I can have oatmeal and flaxseeds daily.”
NARRBEGIN: Exhibit
Exhibit
NARREND
PRIMEXAM.COM
21. A nurse is recording the blood pressure of four clients.
Client 1
130/90 mm Hg while
lying and 121/90
mm Hg upon standing
Client 2
118/80 mm Hg while
lying and 120/80
mm Hg upon standing
Client 3
140/90 mm Hg while
lying and 130/80
mm Hg upon standing
Client 4
112/ 76 mm Hg while
lying and 112/70
mm Hg upon standing
Which client’s blood pressure indicates that the client has orthostatic hypotension?
1. Client 1
2. Client 2
3. Client 3
4. Client 4
22. A nurse is reviewing the ankle-brachial index of four clients who are suspected of having peripheral artery
disease (PAD).
Client 1
0.6
Client 2
1.0
Client 3
1.3
Client 4
0.95
Client 3
Prednisone and
etanercept
Client 4
Warfarin and heparin
Which client has developed moderate PAD?
1. Client 1
2. Client 2
3. Client 3
4. Client 4
23. A nurse is reviewing the prescription of four clients.
Client 1
Aspirin and amlodipine
Client 2
Clopidogrel and
heparin
Which client is being treated for Takayasu arteritis?
1. Client 1
2. Client 2
3. Client 3
4. Client 4
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
24. Which factors should a nurse assess for in a client who has peripheral artery disease (PAD)? Select all that
apply.
1. Throbbing pulse in the lower extremities
2. Absence of pulsation in the lower extremities
3. Coolness in the lower extremities
4. Increased sensation in the feet
5. Paresthesias in the lower extremities
PRIMEXAM.COM
Completion
Complete each statement.
PRIMEXAM.COM
25. The average heartbeat of a client is 80 beats per minute. The volume of the blood ejected per contraction from
the client’s left ventricle is 72 mL. What is the cardiac output of the client? Record your answer as a whole
number.
Chapter 15: Arterial Disorders
Answer Section
MULTIPLE CHOICE
1. ANS: 1
Chapter: Chapter 15, Arterial Disorders
Page: 309
Objective: N/A
Difficulty: Easy
Heading: Blood Flow Regulation
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Perfusion: Assessment
Feedback
1
2
3
4
A turbulent blood flow in the carotid artery creates bruits, a type of murmur, in the
carotid artery. The turbulent blood flow produces whooshing sounds, which can be
heard on auscultation of the carotid artery.
A decreased blood flow in the carotid artery does not cause any murmur or bruits.
The tricuspid valve is located between the right atrium and right ventricle. Any problem
in the tricuspid valve does not cause a bruit in the carotid artery.
A turbulent blood flow in the carotid artery causes bruits; therefore, the option “none of
the above” is incorrect.
PTS: 1
CON: Perfusion: Assessment
2. ANS: 4
Chapter: Chapter 15, Arterial Disorders
Page: 309
Objective: N/A
Difficulty: Easy
Heading: Blood Pressure Regulation
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Perfusion: Nursing Roles
1
2
Feedback
The mathematical equation, CO × PVR = BP, is correct. The blood pressure can be
calculated by multiplying the cardiac output by the peripheral vascular resistance.
The equation, CO / BP = PVR, is correct. The peripheral vascular resistance increases
when the blood pressure decreases to maintain cardiac output.
PRIMEXAM.COM
3
4
The mathematical equation, BP / PVR = CO, is correct. The body has to adjust the
peripheral vascular resistance and blood pressure inversely to maintain the cardiac
output.
The equation, PVR / CO = BP, is incorrect and would indicate that the student nurse
requires further teaching. The correct equation is CO × PVR = BP.
PTS: 1
CON: Perfusion: Nursing Roles
3. ANS: 2
Chapter: Chapter 15, Arterial Disorders
Page: 312
Objective: N/A
Difficulty: Difficult
Heading: The Effect of Blood Composition on Arteries
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Evaluation [Evaluating]
Concept: Perfusion: Nursing Roles
1
2
3
4
Feedback
Glucose does not combine with carbon dioxide and does not cause oxygen deprivation
in tissues. Elevated serum glucose does not lead to oxygen deprivation and
atherosclerosis.
A high level of glucose in the bloodstream reacts with the endothelial cell membranes
and forms advanced glycosylation end products (AGEs). The AGEs injure the
endothelial surface. An endothelial surface injury is a precursor of endothelial
inflammation and atherosclerotic plaque.
Homocysteine is an amino acid that is involved in the metabolism of vitamin B and
folic acid, but not glucose. Glucose is not associated with the breakdown of
homocysteine.
Increased serum glucose causes injury to the endothelial surface of the arteries, which is
a precursor of atherosclerotic plaque; therefore, the answer option “all of the above” is
incorrect.
PTS: 1
CON: Perfusion: Nursing Roles
4. ANS: 1
Chapter: Chapter 15, Arterial Disorders
Page: 311
Objective: N/A
Difficulty: Moderate
Heading: Hypertension
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Medication
1
Feedback
Captopril is an angiotensin-converting enzyme (ACE) inhibitor. A low dose of an ACE
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inhibitor is the preferred treatment for hypertension in clients who have diabetes and
declining kidney function. Captopril works by relaxing blood vessels so that the blood
can flow more easily.
Hydrochlorothiazide is a thiazide-type diuretic that is used to control blood pressure. It
is not a preferred treatment for clients who have diabetes and declining kidney function.
Amlodipine is a calcium-channel blocker; however, it is not the preferred treatment for
clients who have diabetes and declining kidney function.
Captopril is the preferred medication for treating hypertension in clients who have
diabetes and declining kidney function; therefore, the answer option “all of the above”
is incorrect.
PTS: 1
CON: Medication
5. ANS: 4
Chapter: Chapter 15, Arterial Disorders
Page: 316
Objective: N/A
Difficulty: Difficult
Heading: Hypertension
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Perfusion
1
2
3
4
Feedback
Increased vitamin C in the diet is not a risk factor for the development of hypertension.
Vitamin C can help reduce high blood pressure because it acts as a natural diuretic.
A lower intake of dietary potassium is a risk factor for hypertension. Increased
potassium in the diet helps reduce high blood pressure.
Insufficient sodium in the diet is not a risk factor for hypertension. Excessive intake of
dietary sodium causes hypertension.
Vitamin D is associated with hypertension. Low or insufficient vitamin D in the diet is a
risk factor for hypertension.
PTS: 1
CON: Perfusion
6. ANS: 3
Chapter: Chapter 15, Arterial Disorders
Page: 317
Objective: N/A
Difficulty: Difficult
Heading: Atherosclerosis
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Evaluation [Evaluating]
Concept: Perfusion
1
Feedback
An elevated, hs-CRP indicates that the client is at a high risk for developing
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cardiovascular diseases (CVD). CRP is produced by the liver in response to an
inflammatory process in the body, such as those caused by atherosclerosis.
Hyperhomocysteinemia, not hypohomocysteinemia, places clients at a risk for
developing atherosclerosis and can cause endothelial injury.
Hypothyroidism is associated with atherosclerosis. A decrease in the thyroid hormone
level increases the CRP, blood pressure, and low density lipoprotein (LDL), which
causes atherosclerosis.
Hypothyroidism is a risk factor for atherosclerosis; therefore, the answer option “none
of the above” is incorrect.
PTS: 1
CON: Perfusion
7. ANS: 1
Chapter: Chapter 15, Arterial Disorders
Page: 328
Objective: N/A
Difficulty: Moderate
Heading: Peripheral Arterial Disease
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Medication
1
2
3
4
Feedback
A physician would prescribe pentoxifylline to the client because the client’s symptoms
suggest intermittent claudication and peripheral artery disease (PAD). Pentoxifylline is
a blood viscosity reducing agent. The medication is used in the treatment of PAD along
with cilostazol.
A low-dose aspirin might be used for reducing risks associated with cardiovascular
disease; however, aspirin would not be prescribed to the client because it is used to treat
mild to moderate pain and to reduce fever.
Infliximab is used to treat chronic inflammatory diseases. It blocks the inflammatorypromoting substances produced by the cells.
Cyclophosphamide is used to treat cancer. It is an immunosuppressive agent.
PTS: 1
CON: Medication
8. ANS: 2
Chapter: Chapter 15, Arterial Disorders
Page: 329
Objective: N/A
Difficulty: Easy
Heading: Aneurysm
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Perfusion
Feedback
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2
3
4
Decreased blood pressure is a clinical manifestation that is observed in clients who
have an abdominal aortic aneurysm (AAA) rupture.
A diminished blood flow to the lower extremities is a clinical manifestation that is
observed in clients who have an abdominal aortic aneurysm (AAA) rupture.
An increase in body temperature or hyperthermia is not a sign of an abdominal aortic
aneurysm (AAA) rupture.
An increased heart rate is observed in clients who have an abdominal aortic aneurysm
(AAA) rupture.
PTS: 1
CON: Perfusion
9. ANS: 1
Chapter: Chapter 15, Arterial Disorders
Page: 329
Objective: N/A
Difficulty: Difficult
Heading: Aneurysm
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Perfusion: Assessment: Nursing Roles
1
2
3
4
Feedback
If the client is suspected to have an AAA, deep palpation of the abdomen should be
avoided because deep palpation could lead to AAA rupture.
If a client is suspected to have an AAA, the abdomen should be auscultated for bruit.
Auscultation of the abdomen prior to palpation helps the primary healthcare provider to
evaluate the bowel motility and bowel obstruction.
Deep palpation of the abdomen should be avoided if the client is suspected to have an
AAA; therefore, the answer option “all of the above” is incorrect.
PTS: 1
CON: Perfusion: Assessment: Nursing Roles
10. ANS: 3
Chapter: Chapter 15, Arterial Disorders
Page: 329
Objective: N/A
Difficulty: Easy
Heading: Aneurysm
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Knowledge [Remembering]
Concept: Perfusion: Assessment
1
2
Feedback
An x-ray is used to image an aneurysm; however, an x-ray can show only the calcified
aortic silhouette. It does not indicate the size of the abdominal aortic aneurysm (AAA).
A magnetic resonance angiography (MRA) scan is used to image an aneurysm;
however, it is less accurate when compared to a computed tomography (CT) scan and
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ultrasound.
A CT scan gives detailed information on the size and location of the aneurysm. A
contrast CT is the preferred imaging modality to image an aneurysm.
A CT scan provides detailed information about the size and location of an aneurysm;
therefore, the answer option “all of the above” is incorrect.
PTS: 1
CON: Perfusion: Assessment
11. ANS: 2
Chapter: Chapter 15, Arterial Disorders
Page: 330
Objective: N/A
Difficulty: Moderate
Heading: Aortic Dissection
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Perfusion
1
2
3
4
Feedback
The symptoms exhibited by the client mimic a myocardial infarction; however, the
blood pressure differences in the right and left arm should increase the suspicion of an
aortic dissection. A rapid heart rate, pain in the chest, back, and jaw, sweating, anxiety,
shortness of breath, and vomiting are symptoms of a myocardial infarction.
The client has developed an aortic dissection. The client may report severe chest pain or
pain in the back with tearing or ripping sounds. Tachycardia and pallor are symptoms
associated with this condition. There might be a difference in the blood pressures in the
right and left arms.
Vasculitis is a condition that is characterized by the inflammation of the arterial blood
vessels. Fever, weight loss, depression, malaise, and memory impairment are the
symptoms of vasculitis.
The client has developed an aortic dissection; therefore, the answer option “none of the
above” is incorrect.
PTS: 1
CON: Perfusion
12. ANS: 2
Chapter: Chapter 15, Arterial Disorders
Page: 330
Objective: N/A
Difficulty: Easy
Heading: Aortic Dissection
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Perfusion: Assessment
1
Feedback
A blood pressure difference of 10 mm Hg between the left and right arms might
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indicate a blocked artery or cardiovascular disease; therefore, this finding must be
investigated, but may not be suggestive of an aortic dissection.
A blood pressure difference of 20 mm Hg or greater between the left and right arms
indicates an aortic dissection.
A blood pressure difference of 15 mm Hg between the left and right arms might
indicate an increased risk of peripheral vascular disease or cardiovascular disease.
A blood pressure difference of 5 mm Hg between the left and right arms needs to be
investigated because the client might be at a risk for developing cardiovascular disease.
PTS: 1
CON: Perfusion: Assessment
13. ANS: 2
Chapter: Chapter 15, Arterial Disorders
Page: 315
Objective: N/A
Difficulty: Difficult
Heading: Hyperlipidemia
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Evaluation [Evaluating]
Concept: Medication
1
2
3
4
Feedback
Simvastatin is a statin or HMG-CoA reductase inhibitor. The medication blocks the
synthesis of the liver enzyme that assists in the production of cholesterol; therefore,
simvastatin reduces cholesterol synthesis and helps reverse atherosclerotic plaque
formation. The statement by the student nurse would indicate the need for further
teaching.
Cholestyramine is a bile acid sequestrant. The medication blocks the bile absorption in
the GI tract and prevents cholesterol absorption from the intestine. This statement by
the student nurse indicates effective learning.
Fenofibrate is a fibrate. The medication decreases triglycerides secretion by the liver.
Fenofibrate is used as a first-line treatment for treating a high concentration of
triglycerides in the body. The statement by the student nurse would indicate the need for
further teaching.
Cholestyramine blocks the bile acid absorption in the GI tract and reduces cholesterol
absorption from the intestine; therefore, the answer option “all of the above” is
incorrect.
PTS: 1
CON: Medication
14. ANS: 3
Chapter: Chapter 15, Arterial Disorders
Page: 333
Objective: N/A
Difficulty: Difficult
Heading: Vasculitis
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
PRIMEXAM.COM
Cognitive Level: Analysis [Analyzing]
Concept: Perfusion: Inflammation
1
2
3
4
Feedback
Diarrhea is a clinical manifestation that is observed in clients who have Kawasaki
disease. Diarrhea can be treated with oral fluids. Diarrhea is not a symptom of
myocardial infarction.
Join pain is associated with Kawasaki disease. Joint swelling and arthritis can also
occur in Kawasaki disease. Joint pain does not indicate cardiac impairment.
Vomiting, abdominal pain, and restlessness are symptoms of myocardial infarction
(MI). The cardiac involvement places the client at a high risk of developing MI.
Fever that does not respond to antibiotics or antipyretic treatments is a symptom of
Kawasaki disease. If fever persists for a long time, it might lead to complications;
however, fever is not a symptom of myocardial infarction.
PTS: 1
CON: Perfusion: Inflammation
15. ANS: 1
Chapter: Chapter 15, Arterial Disorders
Page: 334
Objective: N/A
Difficulty: Difficult
Heading: Vasculitis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Perfusion: Inflammation
1
2
3
4
Feedback
The client has probably developed Kawasaki disease. Fever, diarrhea, poor oral intake,
joint pain, elevated erythrocyte sedimentation rate (ESR), and high platelet count are
symptoms of Kawasaki disease.
Cryoglobulinemia is condition in which protein cryoglobulins clump together and cause
vascular inflammation by depositing the clumps in the blood vessels. This occurs
mostly in colder temperatures. Weight loss, high blood pressure, and swelling of the
ankles include symptoms of cryoglobulinemia.
Raynaud’s disease causes vasospasm of the arterioles of the hands and sometimes the
feet. Cyanosis, numbness in the fingers and toes, and pain and blanching of the skin are
symptoms of Raynaud’s disease.
Wegener's granulomatosis is a vasculitis of small arterioles and venules. Shortness of
breath, joint swelling, chest pain, and cough are the symptoms of Wegener's
granulomatosis.
PTS: 1
CON: Perfusion: Inflammation
16. ANS: 1
Chapter: Chapter 15, Arterial Disorders
Page: 315
Objective: N/A
PRIMEXAM.COM
Difficulty: Easy
Heading: AHA/ACA Classification of Cholesterol Categories
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Knowledge [Remembering]
Concept: Metabolism
1
2
3
4
Feedback
An LDL level that is less than 100 mg/dL is considered to be optimal; therefore, an
LDL level of 70 mg/dL is optimal.
An LDL level of 110 mg/dL is considered to be above optimal or near optimal. An LDL
cholesterol level of 100 to 129 mg/dL is considered to be near optimal or above
optimal.
An LDL level of 135 mg/dL is considered to be borderline high because an LDL
cholesterol level of 130 to 159 mg/dL is considered as borderline high.
An LDL level of 170 mg/dL is considered to be high because an LDL cholesterol level
of 160 to 189 mg/dL is considered high.
PTS: 1
CON: Metabolism
17. ANS: 1
Chapter: Chapter 15, Arterial Disorders
Page: 331
Objective: N/A
Difficulty: Easy
Heading: Vasculitis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Perfusion
1
2
3
4
Feedback
Raynaud’s disease is the most common type of vasculitis of small-sized arterioles.
Polyarteritis nodosa is a type of vasculitis, affecting medium-sized blood vessels.
Temporal arteritis is a vasculitis of the large-sized blood vessels. It is also known as
giant cell arteritis. The condition involves inflammation of the superficial temporal
arteries.
Raynaud’s disease is the most common type of vasculitis of small-sized arterioles;
therefore, the answer option “none of the above” is incorrect.
PTS: 1
CON: Perfusion
18. ANS: 1
Chapter: Chapter 15, Arterial Disorders
Page: 331
Objective: N/A
Difficulty: Moderate
Heading: Vasculitis
Integrated Processes: Nursing Process
PRIMEXAM.COM
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Perfusion
1
2
3
4
Feedback
The client has developed temporal arteritis (TA). Headache is a typical symptom when
the temporal artery is affected by vasculitis. Fever, fatigue, and weight loss are
symptoms that are associated with temporal arteritis. Shoulder stiffness and pain are
symptoms of polymyalgia rheumatica (PMR), which is associated with TA.
Polymyalgia rheumatic is an inflammatory disorder that causes muscle pain and
stiffness. It is often found to be associated with clients who have temporal arteritis.
Takayasu arteritis is a rare, large blood vessel vasculitis that affects the aorta and its
major branches. Fever, fatigue, and general malaise are the symptoms of Takayasu
arteritis.
The client has developed temporal arteritis; therefore, the answer option “none of the
above” is incorrect.
PTS: 1
CON: Perfusion
19. ANS: 3
Chapter: Chapter 15, Arterial Disorders
Page: 332
Objective: N/A
Difficulty: Difficult
Heading: Vasculitis
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Evaluation [Evaluating]
Concept: Perfusion: Nursing Roles
1
2
3
4
Feedback
An elevated level of ESR will be observed in clients who are diagnosed with Takayasu
arteritis. An elevated ESR indicates inflammation in the body.
A slightly increased or normal leukocyte count will be observed in clients who are
diagnosed with Takayasu arteritis.
Normocytic anemia is defined as anemia that has a mean corpuscular volume within
normal range; however, the hemoglobin and hematocrit levels in clients are decreased.
Normocytic anemia is associated with the diagnosis of Takayasu arteritis in clients.
Normocytic anemia might be present in clients who are diagnosed with Takayasu
arteritis; therefore, the answer option “all of the above” is incorrect.
PTS: 1
CON: Perfusion: Nursing Roles
20. ANS: 3
Chapter: Chapter 15, Arterial Disorders
Page: 313
Objective: N/A
Difficulty: Difficult
Heading: Hyperlipidemia
PRIMEXAM.COM
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Evaluation [Evaluating]
Concept: Nutrition: Nursing Roles
1
2
3
4
Feedback
Vegetables oils, such as sesame and safflower, contain polyunsaturated fats.
Polyunsaturated fats are recommended for clients who have cardiac diseases because of
their lower low-density lipoprotein (LDL) level.
Salmon and sardines are found to reduce triglyceride levels and increase high-density
lipoprotein (HDL) levels in the body; therefore, these foods are recommended for
clients who have a cardiac condition.
Peanut and canola oil are dietary sources of monounsaturated fats. Monounsaturated
fats are recommended for clients who have a cardiac condition.
Oatmeal and flaxseeds are foods that are high in fiber. High-fiber foods are
recommended to cardiac clients to reduce hyperlipidemia.
PTS: 1
CON: Nutrition: Nursing Roles
21. ANS: 3
Chapter: Chapter 15, Arterial Disorders
Page: 311
Objective: N/A
Difficulty: Difficult
Heading: Blood Pressure Regulation
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Perfusion
1
2
3
4
Feedback
There is no considerable drop in the blood pressure readings of Clients 1, 2, and 4 when
they change position from lying to standing; therefore, Clients 1, 2, and 4 do not have
orthostatic hypotension.
There is no considerable drop in the blood pressure readings of Clients 1, 2, and 4 when
they change position from lying to standing; therefore, Clients 1, 2, and 4 do not have
orthostatic hypotension.
Client 3 has orthostatic hypotension; the client’s diastolic pressure shows a decrease of
10 mm Hg when the client moves to a standing position from a lying position. The
client’s systolic pressure also shows a drop when the client changes position.
Orthostatic hypotension is characterized by the drop in blood pressure that is observed
when a client changes position from lying to standing. Orthostatic hypotension is often
observed in clients who are taking antihypertensive medication.
There is no considerable drop in the blood pressure readings of Clients 1, 2, and 4 when
they change position from lying to standing; therefore, Clients 1, 2, and 4 do not have
orthostatic hypotension.
PTS: 1
CON: Perfusion
PRIMEXAM.COM
22. ANS: 1
Chapter: Chapter 15, Arterial Disorders
Page: 327
Objective: N/A
Difficulty: Moderate
Heading: Ankle-Brachial Index
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Perfusion: Assessment
Feedback: Ankle-brachial index (ABI) is assessed to determine the severity of PAD. ABI is a noninvasive and
simple test for detecting PAD. The ABI is calculated by dividing the ankle systolic pressure by the
corresponding branchial pressure. Client 1 has developed moderate PAD as indicated by an ABI of 0.6. An
ABI of 0.4 to 0.8 indicates moderate PAD. An ABI of 1.0 or slightly greater than 1.0 indicates that the client
is healthy and not at a risk for developing PAD. An ABI of less than 1.0 indicates PAD; therefore, Client 1 has
developed moderate PAD. Clients 2 and 3 are healthy. An ABI of 0.95 indicates that Client 4 has minimal
PAD.
PTS: 1
CON: Perfusion: Assessment
23. ANS: 3
Chapter: Chapter 15, Arterial Disorders
Page: 332
Objective: N/A
Difficulty: Moderate
Heading: Vasculitis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Medication
1
2
3
4
Feedback
Client 1 is not treated for Takayasu arteritis. Aspirin is used to relieve mild to moderate
pain and fever. Amlodipine is used to reduce high blood pressure.
Client 2 is not treated for Takayasu arteritis. Clopidogrel is an antiplatelet agent, and
heparin is used to prevent the formation of clots in the blood. These medications are
used to prevent ischemic stroke.
Client 3 is treated for Takayasu arteritis. Prednisone is a corticosteroid. Corticosteroids
are the medications used to treat active Takayasu arteritis. Etanercept is an antitumor
necrosis factor agent used in treating Takayasu arteritis.
Client 4 is not treated for Takayasu arteritis. Warfarin and heparin are anticoagulants
that are used to prevent ischemic stroke.
PTS: 1
CON: Medication
MULTIPLE RESPONSE
PRIMEXAM.COM
24. ANS: 2, 3, 5
Chapter: Chapter 15, Arterial Disorders
Page: 325
Objective: N/A
Difficulty: Moderate
Heading: Peripheral Arterial Disease
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Perfusion
1.
2.
3.
4.
5.
Feedback
This is incorrect. Reduced blood flow to the lower extremities results in a weak pulse or
the absence of pulse in clients who have peripheral artery disease (PAD).
This is correct. Diminished or absent pulses in the lower extremities on exertion is a
clinical manifestation of PAD.
This is correct. Coolness of the lower extremities is a symptom of PAD. It occurs because
of reduced blood circulation in the lower extremities.
This is incorrect. A decreased sensation or loss of sensation in the feet is a common
symptom of PAD.
This is correct. Paresthesias or abnormal sensation, such as tingling or pricking in the
lower extremities on exertion, is a clinical manifestation of PAD.
PTS: 1
CON: Perfusion
COMPLETION
25. ANS:
5,760 mL per minute
5760 mL per min
5750 mL/min
Chapter: Chapter 15, Arterial Disorders
Page: 309
Objective: N/A
Difficulty: Moderate
Heading: Blood Pressure Regulation
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Basic Care and Comfort
Cognitive Level: Application [Applying]
Concept: Perfusion
Feedback: Cardiac output can be calculated by multiplying stroke volume with heart rate. The stroke volume
of the client is 72 mL. The average heart rate of the client is 80 beats per minute.
The cardiac output of the client is = 72 × 80
= 5,760 mL/ minute
PRIMEXAM.COM
Therefore, the cardiac output of the client is 5,760 mL per minute.
PTS: 1
CON: Perfusion
PRIMEXAM.COM
Chapter 16: Ischemic Heart Disease and Conduction Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. A 65-year-old female client presents with complaints of crushing pain on the left side of the chest. After
examining the client, it is found that the client has unstable angina. Which intervention to reduce the pain is
appropriate for the client?
1. Administering nitroglycerin
2. Changing the position of the client
3. Encouraging the client to take deep breaths
4. All of the above.
2. A client presents with complaints of difficulty breathing and looks pale. The client experiences excessive
perspiration and his or her electrocardiogram shows an irregular rhythm. Which other finding will indicate
that the client may have developed myocardial infarction?
1. Nitroglycerin relieved the pain.
2. Nitroglycerin did not relieve the pain, even after taking three doses.
3. Aspirin relieved the pain.
4. None of the above
3. A client presents with chest pain. The pain has not reduced, even after administering three nitroglycerine
tablets within 10 minutes. Which diagnostic test should the primary health-care provider recommend to
confirm that the client has developed myocardial infarction?
1. Thallium stress test
2. Electrocardiogram
3. Cardiac troponin test
4. Intravascular angiosonography
4. A nurse is reviewing the results of a diagnostic test of a client who is being moved out of the intensive care
unit. A cardiac troponin T level assay was performed while the client was in the intensive care unit, which
indicated high levels of troponin. Which condition was the client diagnosed with?
1. Angina
2. Acute myocardial infarction
3. Both A and B
4. Atrioventricular block
5. A nurse is providing discharge instructions to a client who is being discharged after treatment for myocardial
infarction. Which statement made by the client indicates effective learning?
1. “I exercise every day after having my breakfast.”
2. “I have gained 4 kilograms of weight.”
3. “I have planned periods of rest in the morning and evening.”
4. None of the above
6. A nurse is reviewing a client’s cardiac rhythm in an electrocardiogram and notes that the reading shows that
the P wave and PR interval are absent. Which condition does the nurse interpret from this result?
1. Ventricular fibrillation
2. Premature ventricular contractions
3. Atrial fibrillation
4. None of the above
PRIMEXAM.COM
7. A client has frequent premature ventricular contractions. Which factor should be the priority assessment by
the nurse?
1. Sensations of palpitation
2. Causative factors
3. Blood pressure and oxygen saturation
4. None of the above
8. Which is the outer layer of the heart?
1. Myocardium
2. Endocardium
3. Pericardium
4. None of the above
9. Which is the last region in the conduction of the cardiac conduction sequence?
1. Sinoatrial node
2. Atrioventricular node
3. Purkinje fibers
4. Bundle of His
10. Which heart condition increases the demand for myocardial oxygen?
1. Stable heart rate
2. Decreased muscle mass
3. Decreased systemic blood pressure
4. None of the above
11. A client presents with chest pain that has not been relieved by nitroglycerin medication. A review of the
client’s medical record shows that the client has type 2 diabetes. The blood pressure of the client is 150/90
mm Hg. Which condition has the client developed?
1. Myocardial infarction
2. Angina
3. Pericarditis
4. Myocarditis
12. A client whose neck vein has bulged presents with a sharp pain in the chest. The electrocardiogram shows an
elevated ST segment, and the laboratory report shows an increase in the serum creatinine and blood urea
nitrogen. Which condition has the client developed?
1. Myocarditis
2. Pericarditis
3. Infective endocarditis
4. None of the above
13. A client visits the hospital with chest pain, and the vital signs are 101.5°F body temperature and 125/85 mm
HG blood pressure. The echocardiogram of the client shows valve perforation, and a new regurgitant murmur
is heard through the stethoscope on examination. Which condition has the client developed?
1. Infective endocarditis
2. Myocarditis
3. Pericarditis
4. None of the above
14. A nurse is caring for a client with infective endocarditis. Which is the appropriate nursing intervention for this
client?
PRIMEXAM.COM
1.
2.
3.
4.
Administering nitroglycerin
Administering amphicillin
Administering urokinase
None of the above
15. The nurse is caring for a client with angina pectoris. Which precautionary measures should the nurse advise
the client to follow?
1. To consume a low-fat diet
2. To exercise 3 days a week
3. To avoid taking aspirin tablets
4. To avoid high-fiber foods
16. A client complains of chest pain. On examination, a scratchy sound is heard through the stethoscope. Which
intervention should be provided to the client?
1. Administering aspirin
2. Administering amphicillin
3. Administering glucocorticoids
4. All of the above
17. A client reports myalgia and fever. On physical examination, an S3 gallop rhythm was heard through the
stethoscope. Which finding confirms that the client has developed myocarditis?
1. Elevated number of white blood cells
2. Elevated cardiac troponin
3. Elevated erythrocyte sedimentation rate
4. All of the above
18. A client presents with chest pain. Complete blood reports show an elevated level of white blood cells. Which
clinical manifestation confirms that the client has myocarditis?
1. Dyspnea
2. Tonsillitis
3. Arthralgia
4. All of the above
19. A registered nurse is teaching a student nurse about infective endocarditis. Which statements made by the
student nurse about the complication of the condition indicates effective learning?
1. “The client may develop regurgitant heart valve defects.”
2. “The client may develop heart failure.”
3. “The client may develop abscess of the heart.”
4. All of the above
20. Which condition is characterized by the deposition of immune complexes, causing inflammation and fluid
accumulation in the pericardial sac?
1. Dressler’s syndrome
2. Myocarditis
3. Infective endocarditis
4. Unstable angina
21. Which wave in the electrocardiogram represents ventricular repolarization?
1. P wave
2. Q wave
3. S wave
PRIMEXAM.COM
4. T wave
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
22. Which statements regarding angina are correct? Select all that apply.
1. “Stress is the cause of the chest pain.”
2. “The chest pain lasts for more than 15 minutes.”
3. “Taking a rest does not relieve the chest pain.”
4. “The chest pain is reduced by taking a deep breath.”
5. “The chest pain is reduced on resting.”
23. A nurse is assessing a client with pericarditis. Which assessment findings indicate pericarditis? Select all that
apply.
1. Flat neck veins
2. Increased blood pressure
3. Muffled or distant heart sounds
4. Pericardial friction rub
5. Dyspnea
24. A nurse is caring for four clients with chest pain. Which client should be treated for infective endocarditis?
Select all that apply.
1. The client with a dental implant
2. The client who shows elevated ST segment in the electrocardiogram reading
3. The client who has a swollen neck vein
4. The client who has a scratchy sound through the stethoscope upon examination
5. The client with a pacemaker
25. Which are the clinical manifestations in clients with infective endocarditis? Select all that apply.
1. Petechiae
2. Janeway lesions
3. S3 gallop rhythm
4. Lymphadenopathy
5. Pericardial friction rub
PRIMEXAM.COM
Chapter 16: Ischemic Heart Disease and Conduction Disorders
Answer Section
MULTIPLE CHOICE
1. ANS: 1
Chapter: Chapter 16, Ischemic Heart Disease and Conduction Disorders
Page: 350
Objective: N/A
Difficulty: Moderate
Heading: Ischemic Heart Disease
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Nursing Roles
1
2
3
4
Feedback
The primary health-care provider should administer nitroglycerin, since nitrates help
relieve pain.
Changing the position of the client does not reduce the intensity of pain.
Encouraging the client to take deep breaths does not reduce the intensity of pain.
The primary health-care provider should administer nitroglycerin. Therefore, “all of the
above” is incorrect.
PTS: 1
CON: Nursing Roles
2. ANS: 2
Chapter: Chapter 16, Ischemic Heart Disease and Conduction Disorders
Page: 350
Objective: N/A
Difficulty: Moderate
Heading: Ischemic Heart Disease
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Perfusion
1
2
3
4
Feedback
Pain caused by unstable angina is relieved upon taking nitroglycerin tablets.
If the pain persists, even after taking three nitroglycerin tablets within 10 minutes, then
it is assumed that the client has developed myocardial infarction.
Pain that is relieved after taking aspirin is unstable angina, since heparin is an
anticoagulant.
Persistence of pain, even after taking three nitroglycerin tablets, indicates that the client
may have developed myocardial infarction.
PTS: 1
CON: Perfusion
PRIMEXAM.COM
3. ANS: 3
Chapter: Chapter 16, Ischemic Heart Disease and Conduction Disorders
Page: 351
Objective: N/A
Difficulty: Moderate
Heading: Ischemic Heart Disease
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Perfusion
1
2
3
4
Feedback
A thallium stress test is specifically performed to identify angina. It is a nuclear scan
where the myocardial perfusion is observed during exercising.
An electrocardiogram is a diagnostic test used to identify problems in the heart. This is
not a confirmatory diagnostic test for myocardial infarction.
The client has developed myocardial infarction. The nurse should perform a cardiac
troponin test, which is a laboratory test to confirm that the client has developed
myocardial infarction.
Intravascular angiosonography is a diagnostic test used to identify angina.
PTS: 1
CON: Perfusion
4. ANS: 2
Chapter: Chapter 16, Ischemic Heart Disease and Conduction Disorders
Page: 351
Objective: N/A
Difficulty: Difficult
Heading: Ischemic Heart Disease
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Perfusion
1
2
3
4
Feedback
A thallium stress test is the diagnostic test performed to identify angina. A thallium
stress test is a nuclear scan performed while the client is exercising.
A cardiac troponin T level assay is a laboratory diagnostic test performed to confirm if
the client has developed acute myocardial infarction. Troponin I is the preferred
biomarker for the diagnosis of myocardial infarction.
A cardiac troponin T level assay is done for diagnosing myocardial infarction.
An electrocardiogram is performed to diagnose atrioventricular block.
PTS: 1
CON: Perfusion
5. ANS: 3
Chapter: Chapter 16, Ischemic Heart Disease and Conduction Disorders
Page: 360
Objective: N/A
PRIMEXAM.COM
Difficulty: Difficult
Heading: Ischemic Heart Disease
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Evaluation [Evaluating]
Concept: Perfusion
1
2
3
4
Feedback
Exercising immediately after eating is not recommended. The client should allow time
for digestion.
A weight gain of 4 kilograms is not a good sign, and the client should report to the
primary health-care provider immediately.
The client needs adequate rest, since indulging in activities that use excessive energy
may lead to hypoxia. Hypoxia is a condition in which the body is deprived of adequate
oxygen supply. This increases the risk of developing angina. Therefore, this statement
by the client indicates effective learning.
Only the statement in Answer C indicates effective learning.
PTS: 1
CON: Perfusion
6. ANS: 3
Chapter: Chapter 16, Ischemic Heart Disease and Conduction Disorders
Page: 349
Objective: N/A
Difficulty: Difficult
Heading: Ischemic Heart Disease
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Perfusion
1
2
3
4
Feedback
Ventricular fibrillation occurs when there is a lack of T wave. This indicates lack of a
refractory period and is very dangerous.
Premature ventricular contractions are arrhythmias. Arrhythmia often occurs in
myocardial infarction. The ventricles beat independently and do not wait for the
sinoatrial node to initiate conduction.
Atrial fibrillation is caused by the absence of coordinated, rhythmic atrial contractions.
Fibrillatory P waves are present on the electrocardiogram instead of the normal P wave.
Therefore, the nurse interprets the rhythm as atrial fibrillation.
The nurse interprets the rhythm as atrial fibrillation, since there is absence of the P
wave and PR interval.
PTS: 1
CON: Perfusion
7. ANS: 3
Chapter: Chapter 16, Ischemic Heart Disease and Conduction Disorders
Page: 356
Objective: N/A
PRIMEXAM.COM
Difficulty: Difficult
Heading: Ischemic Heart Disease
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Assessment
1
2
3
4
Feedback
Sensations of palpation are a symptom observed in clients with premature ventricular
contractions. This occurs due to decreased cardiac output.
Assessing the causative factor in this client is not the priority assessment.
The nurse should assess the blood pressure and oxygen saturation of the client on a
priority basis. Premature ventricular contractions can cause decreased cardiac output.
The nurse should assess the blood pressure and oxygen saturation on a priority basis.
PTS: 1
CON: Assessment
8. ANS: 3
Chapter: Chapter 16, Ischemic Heart Disease and Conduction Disorders
Page: 344
Objective: N/A
Difficulty: Easy
Heading: Ischemic Heart Disease
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiologic Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Perfusion
1
2
3
4
Feedback
The myocardium is the muscular layer of the heart that consists of a thick wall of the
cardiac muscle.
The endocardium is the thin lining of the inner portion of the heart. It is a three-layered
membrane.
The pericardium is the outermost part of the heart that covers the entire heart and
vessels.
The pericardium is the outermost part of the heart.
PTS: 1
CON: Perfusion
9. ANS: 3
Chapter: Chapter 16, Ischemic Heart Disease and Conduction Disorders
Page: 346
Objective: N/A
Difficulty: Easy
Heading: The Conduction System
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Perfusion
PRIMEXAM.COM
1
2
3
4
Feedback
The conduction process starts in the sinoatrial node within the right atrium.
The impulse from the sinoatrial node travels to the atrioventricular node, which
provides one-way conduction of the impulse.
The impulse from the bundle of His travels into the Purkinje fibers, which divide into
right and left bundles. This is the last region in the conduction of impulse.
The impulse from the atrioventricular node travels to the bundle of His, which is then
sent to the Purkinje fibers.
PTS: 1
CON: Perfusion
10. ANS: 4
Chapter: Chapter 16, Ischemic Heart Disease and Conduction Disorders
Page: 352
Objective: N/A
Difficulty: Easy
Heading: Ischemic Heart Disease
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Perfusion
1
2
3
4
Feedback
Changes in the heart rate increase the myocardial oxygen demand.
Increased muscle mass increases the myocardial oxygen demand.
Increased systemic blood pressure increases the myocardial oxygen demand.
Changes in heart rate, increased muscle mass, and increased systemic blood pressure
increase the myocardial oxygen demand.
PTS: 1
CON: Perfusion
11. ANS: 1
Chapter: Chapter 16, Ischemic Heart Disease and Conduction Disorders
Page: 352
Objective: N/A
Difficulty: Difficult
Heading: Cardiac Inflammation and Infection
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Perfusion
1
2
3
Feedback
The client has developed myocardial infarction. Diabetes and hypertension are
associated with myocardial infarction. Pain not being relieved by nitroglycerin
medication indicates that the client has developed myocardial infarction.
In angina, the chest pain is resolved by taking nitroglycerin medication.
Pericarditis is an inflammatory disease caused by viral infection. Pericarditis usually
PRIMEXAM.COM
4
occurs after myocardial infarction.
Myocarditis is an inflammatory disease caused by viral infection. Myocarditis is the
main cause of cardiac transplant rejection.
PTS: 1
CON: Perfusion
12. ANS: 2
Chapter: Chapter 16, Ischemic Heart Disease and Conduction Disorders
Page: 360
Objective: N/A
Difficulty: Difficult
Heading: Cardiac Inflammation and Infection
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Perfusion
1
2
3
4
Feedback
Myocarditis is an inflammatory disease. The complete blood count report shows the
presence of leukocytosis in clients with myocarditis.
The client has developed pericarditis. Clients with pericarditis exhibit an elevated ST
segment in the electrocardiogram, increase in serum creatinine level, and increase in
blood urea nitrogen.
Infective endocarditis is a noncontagious infection of the cardiac endothelium. Abscess
and valve perforation are observed in the electrocardiogram of clients with infective
endocarditis.
The client has developed pericarditis.
PTS: 1
CON: Perfusion
13. ANS: 1
Chapter: Chapter 16, Ischemic Heart Disease and Conduction Disorders
Page: 361
Objective: N/A
Difficulty: Difficult
Heading: Cardiac Inflammation and Infection
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Perfusion
1
2
3
4
Feedback
Fever indicates infection and a new regurgitant murmur heard through the stethoscope
indicates that the client has developed infective endocarditis.
Myocarditis is an inflammatory disease caused by viral infection. An increase in the
number of white blood cells is observed in myocarditis.
Pericarditis is an inflammatory disease caused by viral infection. A scratchy sound is
heard through the stethoscope in clients with pericarditis.
The client has developed infective endocarditis.
PRIMEXAM.COM
PTS: 1
CON: Perfusion
14. ANS: 2
Chapter: Chapter 16, Ischemic Heart Disease and Conduction Disorders
Page: 365
Objective: N/A
Difficulty: Moderate
Heading: Cardiac Inflammation and Infection
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Medication
1
2
3
4
Feedback
Aspirin is administered to clients with angina pectoris. This helps relieve chest pain,
since aspirin contains nitrate.
Infective endocarditis is an infection of the cardiac endothelium. Therefore, the nurse
should administer amphicillin to clients with infective endocarditis. Amphicillin is an
antibiotic and helps fight infection.
Urokinase is administered to clients with angina pectoris since urokinase is an
anticoagulant.
The nurse should administer amphicillin since it is an antibiotic and helps fight
infection.
PTS: 1
CON: Medication
15. ANS: 1
Chapter: Chapter 16, Ischemic Heart Disease and Conduction Disorders
Page: 365
Objective: N/A
Difficulty: Moderate
Heading: Ischemic Heart Disease
Integrated Processes: Teaching/Learning
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Perfusion
1
2
3
4
Feedback
The nurse should recommend that the client consume low-fat foods. This will reduce
the risk of developing angina.
The nurse should recommend that the client exercise daily.
The nurse should recommend that the client take one aspirin a day. Aspirin reduces the
pain caused by angina.
The nurse should recommend that the client consume fiber-rich foods to help lower
cholesterol levels.
PTS: 1
16. ANS: 4
CON: Perfusion
PRIMEXAM.COM
Chapter: Chapter 16, Ischemic Heart Disease and Conduction Disorders
Page: 358
Objective: N/A
Difficulty: Moderate
Heading: Cardiac Inflammation and Infection
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Perfusion
1
2
3
4
Feedback
The findings show that the client has developed pericarditis. Aspirin should be
administered, since this helps relieve pain and reduce inflammation.
Amphicillin should be administered since this is an antibiotic. This helps fight the
infection.
Glucocorticoid should be administered to the client since it is an antiinflammatory drug.
The client should be administered aspirin, amphicillin, and glucocorticoids.
PTS: 1
CON: Perfusion
17. ANS: 4
Chapter: Chapter 16, Ischemic Heart Disease and Conduction Disorders
Page: 363
Objective: N/A
Difficulty: Moderate
Heading: Cardiac Inflammation and Infection
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Perfusion
1
2
3
4
Feedback
An elevated number of white blood cells is observed in clients with myocarditis.
An elevated cardiac troponin level is observed in clients with myocarditis.
An elevated erythrocyte sedimentation rate is observed in clients with myocarditis.
An elevated number of white blood cells, elevated cardiac troponin, and elevated
erythrocyte sedimentation rate are observed in clients with myocarditis.
PTS: 1
CON: Perfusion
18. ANS: 4
Chapter: Chapter 16, Ischemic Heart Disease and Conduction Disorders
Page: 363
Objective: N/A
Difficulty: Moderate
Heading: Cardiac Inflammation and Infection
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
PRIMEXAM.COM
Concept: Perfusion
1
2
3
4
Feedback
Dyspnea is a clinical manifestation observed in clients with myocarditis.
Tonsillitis is a clinical manifestation observed in clients with myocarditis.
Arthralgia is a clinical manifestation observed in clients with myocarditis.
Dyspnea, tonsillitis, and arthralgia are clinical manifestations observed in clients with
myocarditis.
PTS: 1
CON: Perfusion
19. ANS: 4
Chapter: Chapter 16, Ischemic Heart Disease and Conduction Disorders
Page: 361
Objective: N/A
Difficulty: Difficult
Heading: Cardiac Inflammation and Infection
Integrated Processes: Teaching/Learning
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Evaluation [Evaluating]
Concept: Perfusion
1
2
3
4
Feedback
Regurgitant heart valve defects are a complication of infective endocarditis.
Heart failure is a complication of infective endocarditis.
Abscess of the heart is a complication of infective endocarditis.
Regurgitant heart valve defects, heart failure, and abscess of the heart are complications
of infective endocarditis.
PTS: 1
CON: Perfusion
20. ANS: 1
Chapter: Chapter 16, Ischemic Heart Disease and Conduction Disorders
Page: 363
Objective: N/A
Difficulty: Easy
Heading: Cardiac Inflammation and Infection
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Inflammation
1
2
3
4
Feedback
Dressler’s syndrome is characterized by deposition of immune complexes, causing
inflammation and fluid accumulation in the pericardial sac.
Myocarditis is an inflammatory disease caused by viral infection.
Infective endocarditis is an infection of the cardiac endothelium.
Unstable angina may lead to myocardial infarction if not treated.
PRIMEXAM.COM
PTS: 1
CON: Inflammation
21. ANS: 4
Chapter: Chapter 16, Ischemic Heart Disease and Conduction Disorders
Page: 348
Objective: N/A
Difficulty: Easy
Heading: Electrocardiogram
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Perfusion
1
2
3
4
Feedback
The P wave in the electrocardiogram represents the SA node and atrial depolarization.
The Q wave in the electrocardiogram represents ventricular depolarization.
The S wave in the electrocardiogram represents ventricular depolarization.
The T wave in the electrocardiogram represents ventricular repolarization.
PTS: 1
CON: Perfusion
MULTIPLE RESPONSE
22. ANS: 1, 5
Chapter: Chapter 16, Ischemic Heart Disease and Conduction Disorders
Page: 348
Objective: N/A
Difficulty: Easy
Heading: Ischemic Heart Disease
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Knowledge [Remembering]
Concept: Perfusion
1.
2.
3.
4.
5.
Feedback
This is correct. Chest pain in clients with angina occurs from stress or exertion.
This is incorrect. Chest pain lasts for 1 to 5 minutes in angina.
This is incorrect. Chest pain is relieved on rest and by using nitrate medication, if
prescribed.
This is incorrect. The intensity of chest pain does not change by changing the position of
the body.
This is correct. Chest pain in clients with angina usually is reduced on resting.
PTS: 1
CON: Perfusion
23. ANS: 3, 4, 5
Chapter: Chapter 16, Ischemic Heart Disease and Conduction Disorders
Page: 364
Objective: N/A
PRIMEXAM.COM
Difficulty: Difficult
Heading: Cardiac Inflammation and Infection
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Assessment
1.
2.
3.
4.
5.
Feedback
This is incorrect. In clients with pericarditis, jugular vein distention takes place due to
cardiac tamponade. The neck veins will appear swollen in pericarditis.
This is incorrect. The blood pressure of the client decreases due to cardiac tamponade. This
occurs in pericarditis.
This is correct. The client experiences muffled and distant heart sounds. This assessment
finding indicates that the client has developed pericarditis.
This is correct. Clients with pericarditis will exhibit pericardial friction rub, which is a
scratchy sound heard through a stethoscope.
This is correct. Clients with pericarditis experience shortness of breath, which is called
dyspnea.
PTS: 1
CON: Assessment
24. ANS: 1, 5
Chapter: Chapter 16, Ischemic Heart Disease and Conduction Disorders
Page: 362
Objective: N/A
Difficulty: Difficult
Heading: Cardiac Inflammation and Infection
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Perfusion
1.
2.
3.
4.
5.
Feedback
This is correct. Diagnosis for infective endocarditis is provided to the client with a dental
implant. Infective endocarditis is an infection caused by bacteria. Clients with dental
implants are at a high risk of developing this condition.
This is incorrect. An elevated ST segment of an electrocardiogram indicates that the client
may have developed pericarditis.
This is incorrect. A swollen neck vein is an indication that the client has developed
pericarditis.
This is incorrect. A scratchy sound heard through the stethoscope during examination
indicates that the client has developed pericarditis.
This is correct. Diagnosis for infective endocarditis is provided to the client with a dental
implant. Infective endocarditis is an infection caused by bacteria. Clients with pacemaker
implants are at a high risk of developing this condition.
PTS: 1
25. ANS: 1, 2
CON: Perfusion
PRIMEXAM.COM
Chapter: Chapter 16, Ischemic Heart Disease and Conduction Disorders
Page: 365
Objective: N/A
Difficulty: Easy
Heading: Cardiac Inflammation and Infection
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Infection
1.
2.
3.
4.
5.
Feedback
This is correct. Petechiae are clinical manifestations seen in clients with infective
endocarditis. Petechiae are small, red or purple spots on the skin.
This is correct. Janeway lesions are clinical manifestation seen in clients with infective
endocarditis.
This is incorrect. S3 gallop rhythm is a clinical manifestation seen in clients with
myocarditis.
This is incorrect. Lymphadenopathy is a clinical manifestation seen in clients with
myocarditis.
This is incorrect. Pericardial friction rub is a clinical manifestation observed in clients with
pericarditis.
PTS: 1
CON: Infection
PRIMEXAM.COM
Chapter 17: Heart Failure
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. Which statement best differentiates cardiac afterload from cardiac preload?
1. Cardiac afterload is the volume of blood in the heart at the end of diastole.
2. Cardiac afterload is the amount of resistance that the ventricle must overcome.
3. Cardiac afterload is the factor that affects cardiac output.
4. Cardiac afterload is the amount of blood that enters the right atrium.
2. How is stage C heart failure different from other stages of heart failure, according to the American College of
Cardiology/American Heart Association classification?
1. Clients will have unidentifiable structural or functional heart abnormalities.
2. Clients may develop structural heart disease associated with heart failure.
3. Clients may have current or prior symptoms of heart failure.
4. Clients may have advanced structural heart disease.
3. Heart failure is classified into four different stages by the American College of Cardiology/American Heart
Association. How is the condition of a client in stage B different from the condition of clients in other stages?
1. The client in stage B is supported by a mechanical circulatory assist device.
2. The client in stage B is undergoing treatment for prior symptoms of heart failure.
3. The client in stage B has a history of a previous myocardial infarction.
4. The client with diabetes mellitus has a family history of cardiomyopathy.
4. A client 50 years of age is diagnosed with Class III (moderate) heart failure. How is Class III heart failure
different from other classes of heart failure in the client, according to the New York Association of
Classification of Heart Failure?
1. The client with Class III (moderate) heart failure will feel comfortable with ordinary
physical activity.
2. The client with Class III (moderate) heart failure will feel fatigue and palpitations but only
with ordinary activity.
3. The client with Class III (moderate) heart failure will have symptoms such as fatigue,
palpitations, or dyspnea while doing less than normal physical activities.
4. The client with Class III (moderate) heart failure will be unable to carry out physical
activities comfortably.
5. How does the heart function when a client is diagnosed with heart failure?
1. The decrease in preload causes high blood volume, filling the ventricle.
2. The ventricular muscle pumps the excessive blood out.
3. The stroke volume decreases when the ventricle ejects its blood.
4. The contractility and stroke volume decreases.
6. A registered nurse is teaching nursing students about ischemic cardiomyopathy. Which statement made by one
of the student nurses indicates effective learning?
1. “Ischemic cardiomyopathy is the scarring of the heart muscle caused by coronary artery
insufficiency.”
2. “Ischemic cardiomyopathy is the enlargement and hypertrophy of the left or right
ventricles.”
3. “Ischemic cardiomyopathy is the disorder that restricts the ventricle’s ability to fully
PRIMEXAM.COM
expand.”
4. “Ischemic cardiomyopathy is a genetic predisposition for the muscular enlargement of the
interventricular septal wall.”
7. What is oncotic pressure?
1. A pressure reading within the inferior vena cava
2. A force that attempts to pull fluid from the interstitial and intracellular spaces
3. A force that attempts to push fluid out of the capillary pores into interstitial and
intracellular spaces
4. A pressure reading upon inflation of the balloon on the tip of the Swan-Ganz catheter
8. Which fluid is found at the capillary-cell interface fluid compartment that is found inside the capillary?
1. Intracellular fluid
2. Interstitial fluid
3. Extracellular fluid
4. None of the above
9. How is chronic heart failure different from acute heart failure?
1. Chronic heart failure is the rapid, sudden development of heart failure.
2. Chronic heart failure gradually develops over a long period of time.
3. Chronic heart failure is caused by substantial ventricular muscle injury.
4. Chronic heart failure is referred to as cardiogenic shock.
10. How is systolic dysfunction different from diastolic dysfunction?
1. In systolic dysfunction, the ventricle has difficulty ejecting blood out of the chamber.
2. In systolic dysfunction, the ventricle has difficulty relaxing and is unable to expand fully.
3. In systolic dysfunction, the ventricle pumps out insufficient blood volume.
4. In systolic dysfunction, the ventricle has low blood volume.
11. How is high-output failure different from low-output failure?
1. In high-output failure, the heart can weaken and the ventricle can fail.
2. In high-output failure, the heart is unable to fill with adequate amounts of blood.
3. In high-output failure, there is a lack of delivery of adequate oxygen to the tissues.
4. In high-output failure, there is a lack of sufficient blood to recirculate through the heart.
12. A registered nurse is teaching nursing students about the normal level for central venous pressure. Which
statement made by one of the student nurses indicates effective learning?
1. “The normal range for central venous pressure is 4 to 13 mm Hg.”
2. “The normal range for central venous pressure is 60 to 80 mm Hg.”
3. “The normal range for central venous pressure is 12 to 15 mm Hg.”
4. “The normal range for central venous pressure is 1 to 5 mm Hg.”
13. Which is a potent vasodilator produced by vascular endothelial cells?
1. Nitric oxide
2. Endothelin
3. Tumor necrosis factor-alpha
4. None of the above
14. A registered nurse is teaching nursing students about the renin-angiotensin-aldosterone system (RAAS).
Which statement made by the nursing student indicates effective learning?
1. “RAAS is a mechanism that regulates arterial blood pressure.”
2. “RAAS is a mechanism that decreases blood pressure.”
PRIMEXAM.COM
3. “RAAS is a mechanism that increases blood volume in response to increased renal
perfusion.”
4. “RAAS is a mechanism with detrimental effects that decrease workload for the left
ventricle.”
15. What is the term for ‘rapid irregular rhythms’ of the ventricle?
1. Tachydysrhythmias
2. Bradydysrhythmias
3. Atrial dysrhythmias
4. None of the above
16. A 78-year-old man presents to his physician for evaluation of edema. He reports a 3-month history of
peripheral edema. Which edema may have developed in the client?
1. Edema in the skin
2. Edema in the ankle
3. Edema in the feet and lower legs
4. None of the above
17. A 60-year-old client who complains of swelling in the ankles and fingers, abdominal swelling, fullness of the
stomach, and a weight gain of 2 lbs. or more per day is diagnosed with mild or moderate heart failure. What
are the symptoms that could be observed secondary to decreased cerebral perfusion?
1. Dyspnea and nocturnal cough
2. Confusion, difficulty concentrating, and headache
3. Cold, pale legs and feet
4. None of the above
18. Which condition, according to the Framingham Criteria for Diagnosis of Congestive Heart Failure is caused
by night time cough?
1. Paroxysmal nocturnal dyspnea
2. Jugular vein distension
3. Pulmonary crackles
4. Cardiomegaly
19. A registered nurse is teaching nursing students about cardiac output. Which statement indicates effective
learning by the student nurse?
1. “Cardiac output is the amount of blood that the heart pumps out of the left ventricle.”
2. “Cardiac output is increased in heart failure.”
3. “Cardiac output is unvaried by body size.”
4. “Adrenergic stimulation slows heart rate and cholinergic stimulation raises heart rate.”
NARRBEGIN: Exhibit
Exhibit
NARREND
20. A nurse is caring for four clients with heart disease in the intensive care unit. One of the clients has been
diagnosed with decreased calcium availability.
Client 1
Dobutamine
Client 2
Digoxin
Client 3
Milrinone
PRIMEXAM.COM
Client 4
Angiotensin-converting
enzyme inhibitors
Which client is administered a drug to increase calcium availability?
1. Client 1
2. Client 2
3. Client 3
4. Client 4
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
21. Which statements are true regarding cardiac contractility? Select all that apply.
1. Cardiac contractility is the ability of the myocardium to stretch and contract.
2. The muscle filaments may be unable to change the force of contraction.
3. The stroke volume decreases as the preload increases.
4. The contractibility can also be influenced by preload.
5. The heart’s workload increases as afterload increases.
22. Various test results of a 55-year-old client indicate right ventricular backward failure, jugular venous
distention, and ascites. The client also has hepatomegaly and splenomegaly. What are the other signs and
symptoms of right ventricular failure that could lead the physician to confirm the condition? Select all that
apply.
1. Cough
2. Dyspnea
3. Orthopnea
4. Confusion
5. Cool, pale extremities
Other
23. Prioritize the procedure employed to directly measure right heart pressures, using a catheter. (Enter the
number of each step in the proper sequence; do not use commas or spaces.)
A. Insert the catheter into a large vein.
B. The catheter is connected to a transducer.
C. The catheter is advanced into the inferior vena cava and right atrium.
D. The catheter is threaded into the subclavian vein.
24. Prioritize the procedure employed to directly measure the left heart pressures, using a catheter. (Enter the
number of each step in the proper sequence; do not use commas or spaces.)
A. The catheter is advanced against the flow of blood into the aorta.
B. The catheter is inserted into a femoral artery.
C. The catheter is advanced into the left ventricle.
D. The catheter is then used to measure the aortic pressure, systolic, and diastolic pressures.
25. Prioritize the steps to accurately assess jugular venous pressure in a client experiencing heart failure. (Enter
the number of each step in the proper sequence; do not use commas or spaces.)
A. Place a centimeter ruler on the sternal angle of the client’s chest.
B. Place the client on a bed with the head of the bed raised to a 45° to 60° angle.
PRIMEXAM.COM
C. Measure the distance from the sternal angle to the horizontal level of the distended neck veins.
PRIMEXAM.COM
D. Check that the sternal angle is approximately 5 cm above the right atrium.
Chapter 17: Heart Failure
Answer Section
MULTIPLE CHOICE
1. ANS: 2
Chapter: Chapter 17, Heart Failure
Page: 373
Objective: N/A
Difficulty: Easy
Heading: Basic Physiological Concepts of Heart Function
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Comprehension [Understanding]
Concept: Perfusion
1
2
3
4
Feedback
Cardiac preload is referred to as the volume of blood in the heart at the end of diastole.
Cardiac afterload is referred to as the amount of resistance that the ventricle must
overcome to pump blood out of the heart.
Cardiac preload factors affect cardiac output. They often occur before contraction.
Cardiac preload refers to the volume of blood that enters the right atrium from the
venous system.
PTS: 1
CON: Perfusion
2. ANS: 3
Chapter: Chapter 17, Heart Failure
Page: 395
Objective: N/A
Difficulty: Moderate
Heading: Classification of Heart Failure
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Perfusion
1
2
3
4
Feedback
Clients who have no identifiable structural or functional abnormalities are classified
under stage A heart failure.
Clients who have developed structural heart disease strongly associated with heart
failure are classified under stage B heart failure.
Clients with current or prior symptoms of heart failure associated with underlying
structural heart disease are classified under stage C heart failure.
Clients with advanced structural heart disease and marked symptoms of heart failure are
classified under stage D heart failure.
PRIMEXAM.COM
PTS: 1
CON: Perfusion
3. ANS: 3
Chapter: Chapter 17, Heart Failure
Page: 395
Objective: N/A
Difficulty: Moderate
Heading: Classification of Heart Failure
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Perfusion
1
2
3
4
Feedback
A client diagnosed with heart failure that is supported by a mechanical circulatory assist
device and a client who is frequently hospitalized for heart failure is categorized under
stage D heart failure.
A client undergoing treatment for prior symptoms of heart failure and fatigue caused by
systolic dysfunction is categorized under stage C heart failure.
A client with a previous myocardial infarction and asymptomatic heart disease is
categorized under stage B heart failure.
A client with diabetes mellitus and a family history of cardiomyopathy is categorized
under stage A heart disease.
PTS: 1
CON: Perfusion
4. ANS: 3
Chapter: Chapter 17, Heart Failure
Page: 395
Objective: N/A
Difficulty: Moderate
Heading: New York Association of Classification of Heart Failure
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Moderate [Application]
Concept: Perfusion
1
2
3
4
Feedback
The client with Class II (mild) heart failure will feel comfortable with ordinary physical
activity.
The client with Class I (mild) heart failure will not experience fatigue, palpitations, or
dyspnea while doing ordinary physical activity.
The client with Class III (moderate) heart failure will experience fatigue, palpitations,
or dyspnea while doing less than ordinary physical activities but may be comfortable at
rest.
The client with Class IV (severe) heart failure may not be able to carry out any physical
activities comfortably. The client may have symptoms of cardiac insufficiency at rest.
PRIMEXAM.COM
PTS: 1
CON: Perfusion
5. ANS: 4
Chapter: Chapter 17, Heart Failure
Page: 374
Objective: N/A
Difficulty: Moderate
Heading: Basic Physiological Concepts of Heart Function
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Perfusion
1
2
3
4
Feedback
An increase in preload causes high blood volume, filling the ventricle.
The weakened ventricular muscle may not have the strength to pump the excessive
volume of blood out.
The stroke volume decreases when the weakened ventricle cannot eject the blood.
The increased preload filling can decrease the contractility and stroke volume in a
failing heart.
PTS: 1
CON: Perfusion
6. ANS: 1
Chapter: Chapter 17, Heart Failure
Page: 380
Objective: N/A
Difficulty: Difficult
Heading: Basic Physiological Concepts of Heart Function
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Evaluation [Evaluating]
Concept: Perfusion
1
2
3
4
Feedback
The scarring of the heart muscle caused by coronary artery insufficiency and
myocardial infarction is known as ischemic cardiomyopathy.
The enlargement and hypertrophy of the left or right ventricles in response to chronic
injury is known as dilated cardiomyopathy.
The disorder that restricts the ventricle’s ability to fully expand is known as restrictive
cardiomyopathy.
The disorder in which the left ventricular muscle is enlarged, usually on the side of the
interventricular septum, is known as hypertrophic cardiomyopathy.
PTS: 1
CON: Perfusion
7. ANS: 2
Chapter: Chapter 17, Heart Failure
Page: 374
Objective: N/A
PRIMEXAM.COM
Difficulty: Easy
Heading: Basic Physiological Concepts of Heart Function
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Perfusion
1
2
3
4
Feedback
The pressure reading within the inferior vena cava is referred to as central venous
pressure.
The force that attempts to pull fluid from the interstitial and intracellular spaces into the
capillaries is referred to as oncotic pressure.
The force that attempts to push fluid out of the capillary pores into the interstitial and
intracellular spaces is referred to as hydrostatic pressure.
The pressure reading upon inflation of the balloon on the tip of a Swan-Ganz catheter is
referred to as pulmonary capillary wedge pressure.
PTS: 1
CON: Perfusion
8. ANS: 3
Chapter: Chapter 17, Heart Failure
Page: 374
Objective: N/A
Difficulty: Easy
Heading: Basic Physiological Concepts of Heart Function
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Perfusion
1
2
3
4
Feedback
Intracellular fluid is the fluid found inside the cells.
Interstitial fluid is the fluid that surrounds the cells.
Extracellular fluid is the fluid located inside the capillary.
Extracellular fluid is the fluid located inside the capillary. Therefore, the option “none
of the above” is incorrect.
PTS: 1
CON: Perfusion
9. ANS: 2
Chapter: Chapter 17, Heart Failure
Page: 383
Objective: N/A
Difficulty: Easy
Heading: Basic Physiological Concepts of Heart Function
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Perfusion
PRIMEXAM.COM
1
2
3
4
Feedback
Acute heart failure is the rapid and sudden development of heart failure.
Chronic heart failure is a disorder where the heart gradually suffers weakening over a
long period of time.
Acute heart failure is often caused by substantial ventricular muscle injury.
Acute heart failure is a sudden severe shock that is referred to as cardiogenic shock.
PTS: 1
CON: Perfusion
10. ANS: 1
Chapter: Chapter 17, Heart Failure
Page: 383
Objective: N/A
Difficulty: Easy
Heading: Basic Physiological Concepts of Heart Function
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Perfusion
1
2
3
4
Feedback
In systolic dysfunction, the weakened ventricle has difficulty ejecting blood out of the
chamber.
In diastolic dysfunction, the ventricle has difficulty relaxing and is unable to expand
fully.
In diastolic dysfunction, the ventricle pumps out insufficient blood volume because the
ventricle cannot fill with adequate blood.
In diastolic dysfunction, there is low blood volume in the ventricle. Therefore, the
stroke volume and cardiac output are diminished.
PTS: 1
CON: Perfusion
11. ANS: 1
Chapter: Chapter 17, Heart Failure
Page: 383
Objective: N/A
Difficulty: Easy
Heading: Basic Physiological Concepts of Heart Function
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Perfusion
1
2
3
Feedback
In high-output failure, the heart may weaken and the ventricle can fail.
In low-output failure, the heart is unable to fill with adequate amounts of blood to pump
to the tissues.
In low-output failure, insufficient blood volume is pumped into circulation, causing
PRIMEXAM.COM
4
inadequate delivery of oxygen to the tissues.
In low-output failure, there is a lack of sufficient blood to recirculate through the heart
and into the pulmonary and systemic arterial circulation, with less than adequate venous
return.
PTS: 1
CON: Perfusion
12. ANS: 4
Chapter: Chapter 17, Heart Failure
Page: 394
Objective: N/A
Difficulty: Moderate
Heading: Hemodynamic Measurement Changes in Heart Failure
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Perfusion
1
2
3
4
Feedback
The normal range for pulmonary artery pressure is 4 to 13 mm Hg.
The normal range for the systemic arterial blood pressure is 60 to 80 mm Hg.
The normal range for pulmonary capillary wedge pressure is 12 to 15 mm Hg.
The normal range for central venous pressure is 1 to 5 mm Hg.
PTS: 1
CON: Perfusion
13. ANS: 1
Chapter: Chapter 17, Heart Failure
Page: 378
Objective: N/A
Difficulty: Easy
Heading: Basic Physiological Concepts of Heart Function
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Perfusion
1
2
3
4
Feedback
Nitric oxide is a potent vasodilator produced by vascular endothelial cells.
Endothelin is a peptide secreted by the heart’s endothelium and vasculature during heart
failure.
Tumor necrosis factor-alpha is an inflammatory cytokine that stimulates hypertrophy,
fibrotic changes, and cell death, or apoptosis of the myocardium.
Nitric oxide is a potent vasodilator produced by vascular endothelial cells. Therefore,
the answer option “none of the above” is incorrect.
PTS: 1
CON: Perfusion
14. ANS: 1
Chapter: Chapter 17, Heart Failure
PRIMEXAM.COM
Page: 376
Objective: N/A
Difficulty: Difficult
Heading: Basic Physiological Concepts of Heart Function
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Evaluation [Evaluating]
Concept: Perfusion
1
2
3
4
Feedback
RAAS is a major mechanism in the regulation of arterial blood pressure.
RAAS is a compensatory mechanism that raises blood pressure.
RAAS is a compensatory mechanism that increases blood volume in response to
decreased renal perfusion.
RAAS is a vital compensatory mechanism and major regulator of blood pressure, which
has detrimental effects. The effects of RAAS increase workload for the left ventricle.
PTS: 1
CON: Perfusion
15. ANS: 1
Chapter: Chapter 17, Heart Failure
Page: 380
Objective: N/A
Difficulty: Easy
Heading: Basic Physiological Concepts of Heart Function
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Perfusion
1
2
3
4
Feedback
Tachydysrhythmias are the rapid irregular rhythms of the ventricle that reduce the time
available for ventricular filling; this can precipitate heart failure.
Bradydysrhythmias are referred to as the slow, irregular rhythms of the ventricle that
can slow the heart rate.
Atrial dysrhythmias are referred to as the abnormality that occurs in the atrium that can
slow the heart rate.
Tachydysrhythmias are the rapid irregular rhythms of the ventricle. Therefore, the
answer option “none of the above” is incorrect.
PTS: 1
CON: Perfusion
16. ANS: 2
Chapter: Chapter 17, Heart Failure
Page: 391
Objective: N/A
Difficulty: Moderate
Heading: Basic Physiological Concepts of Heart Function
Integrated Processes: Nursing Process
PRIMEXAM.COM
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Applying [Application]
Concept: Perfusion
1
2
3
4
Feedback
Edema in the sacral area is the first sign of pressure in that area. It occurs when a client
remains in the supine position for a prolonged period of time.
Ankle edema develops because of the gravitational forces in an ambulatory client.
The feet and lower legs may also develop edema as a result of right ventral failure.
Ankle edema develops because of the gravitational forces in an ambulatory client.
Therefore, the answer option “none of the above” is incorrect.
PTS: 1
CON: Perfusion
17. ANS: 2
Chapter: Chapter 17, Heart Failure
Page: 391
Objective: N/A
Difficulty: Moderate
Heading: Basic Physiological Concepts of Heart Function
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Applying [Application]
Concept: Perfusion
1
2
3
4
Feedback
Dyspnea when lying flat for more than a few minutes and nocturnal cough are the early
signs of pulmonary interstitial fluid accumulation caused by failure of the left ventricle.
Confusion, difficulty concentrating, and headache can occur with decreased cerebral
perfusion.
Cold, pale legs and feet will be noted in clients with diminished circulation in the
extremities.
Confusion, difficulty concentrating, and headache can occur with decreased cerebral
perfusion. Therefore, the answer option “none of the above” is incorrect.
PTS: 1
CON: Perfusion
18. ANS: 2
Chapter: Chapter 17, Heart Failure
Page: 393
Objective: N/A
Difficulty: Easy
Heading: Framingham Criteria for Diagnosis of Congestive Heart Failure
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Perfusion
Feedback
PRIMEXAM.COM
1
2
3
4
Bilateral extremity edema is a minor criterion that could cause paroxysmal nocturnal
dyspnea.
Night time cough is a minor criterion that could cause jugular vein distension.
Dyspnea on exertion may lead to pulmonary crackles.
Hepatomegaly is a condition that leads to cardiomegaly.
PTS: 1
CON: Perfusion
19. ANS: 1
Chapter: Chapter 17, Heart Failure
Page: 372
Objective: N/A
Difficulty: Difficult
Heading: Basic Physiological Concepts of Heart Function
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Evaluating [Evaluation]
Concept: Perfusion
1
2
3
4
Feedback
Cardiac output is the amount of blood that the heart pumps out of the left ventricle each
minute.
Cardiac output is diminished in heart failure because the left ventricle is weakened and
cannot adequately pump blood out of the chamber.
Cardiac output varies by body size. A hemodynamic measurement termed cardiac index
can be calculated to give a more accurate assessment of each individual’s cardiac
output.
Adrenergic stimulation raises heart rate and cholinergic stimulation slows heart rate.
PTS: 1
CON: Perfusion
20. ANS: 3
Chapter: Chapter 17, Heart Failure
Page: 397
Objective: N/A
Difficulty: Difficult
Heading: Basic Physiological Concepts of Heart Function
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Perfusion
1
2
3
Feedback
Client 1 is administered dobutamine, which is a synthetic catecholamine that acts on the
heart’s beta-1 receptors.
Client 2 is administered digoxin, which is one of the most commonly used inotropic
drugs, since it increases the contractile force of the heart muscle.
Client 3 is administered milrinone, which is a drug that increases the calcium
availability to the cardiac myocytes and increases the muscle’s overall force of
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4
contraction.
Client 4 is administered angiotensin-converting enzyme inhibitors that reduce retention
of sodium in the blood stream in order to lower blood volume and blood pressure to
ease the heart’s work.
PTS: 1
CON: Perfusion
MULTIPLE RESPONSE
21. ANS: 1, 4, 5
Chapter: Chapter 17, Heart Failure
Page: 373
Objective: N/A
Difficulty: Easy
Heading: Basic Physiological Concepts of Heart Function
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Perfusion
1.
2.
3.
4.
5.
Feedback
This is correct. Cardiac contractility refers to the ability of the myocardium to stretch and
contract in response to the heart filling with blood.
This is incorrect. The muscle filaments can change the force of contraction with varying
amounts of stretch caused by blood volume or preload.
This is incorrect. The stroke volume increases as preload increases and the actin-myosin
filaments in the heart wall stretch to accommodate the increased volume.
This is correct. The contractility can also be influenced by afterload.
This is correct. The heart’s workload increases as afterload increases, which can negatively
affect contractility.
PTS: 1
CON: Perfusion
22. ANS: 1, 2, 3
Chapter: Chapter 17, Heart Failure
Page: 384
Objective: N/A
Difficulty: Moderate
Heading: Signs and Symptoms of Biventricular Heart Failure
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Applying [Application]
Concept: Perfusion
1.
2.
Feedback
This is correct. A client diagnosed with left ventricular backward failure may have a cough
with pink, frothy sputum.
This is correct. Shortness of breath, which is referred to as dyspnea, is also a condition than
PRIMEXAM.COM
3.
4.
5.
can lead to left ventricular backward failure.
This is correct. Orthopnea is a shortness of breath that occurs when lying flat and can be
observed in a client with left ventricular backward failure.
This is incorrect. Confusion and disorientation may be symptoms of left ventricle forward
failure.
This is incorrect. A client diagnosed with left ventricular forward failure may have cool and
pale skin.
PTS: 1
CON: Perfusion
ORDERED RESPONSE
23. ANS:
BADC
Chapter: Chapter 17, Heart Failure
Page: 375
Objective: N/A
Difficulty: Moderate
Heading: Basic Physiological Concepts of Heart Function
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and parenteral therapies.
Cognitive Level: Application [Applying]
Concept: Perfusion
Feedback: The catheter is first connected to a transducer that converts the pressure waves into a digital read
that can be seen on a monitor screen. The catheter is then inserted into a large vein for right heart
hemodynamic assessment and the femoral artery for left heart hemodynamic assessment. The catheter is
threaded into the subclavian vein to directly measure the right heart pressures. The catheter is then advanced
into the inferior vena cava and right atrium.
PTS: 1
CON: Perfusion
24. ANS:
BACD
Chapter: Chapter 17, Heart Failure
Page: 375
Objective: N/A
Difficulty: Moderate
Heading: Basic Physiological Concepts of Heart Function
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and parenteral therapies.
Cognitive Level: Application [Applying]
Concept: Perfusion
Feedback: The catheter is first inserted into the femoral or radial artery. The catheter is then advanced against
the flow of blood into the aorta. The catheter is advanced into the left ventricle. The catheter tip is then used
to take measurements of aortic, systolic, and diastolic pressures.
PRIMEXAM.COM
PTS: 1
CON: Perfusion
25. ANS:
BADC
Chapter: Chapter 17, Heart Failure
Page: 390
Objective: N/A
Difficulty: Moderate
Heading: Measuring Jugular Venous Pressure
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Basic Care and Comfort
Cognitive Level: Applying [Application]
Concept: Perfusion
Feedback: The client should be placed on the bed with the head of the bed raised to a 45° to 60° angle. The
clinician should place a centimeter ruler on the sternal angle of the client’s chest. The sternal angle should be
approximately 5 cm above the right atrium. The clinician should measure the distance in centimeters from the
sternal angle to the horizontal level of the highest visible pulsations of the distended neck veins.
PTS: 1
CON: Perfusion
PRIMEXAM.COM
Chapter 18: Valvular Heart Disease
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. At which intercostal space is auscultation of the pulmonic valve best heard?
1. The second intercostal space in the left sternal border
2. The second intercostal space in the right sternal border
3. The fifth intercostal space in the midclavicular line
4. The fourth intercostal space in the left sternal border
2. A registered nurse is teaching a group of nursing students the preventive measures to be adopted for
thromboemboli. Which response by a student nurse indicates effective learning?
1. “Thromboemboli is prevented through the use of antibiotics.”
2. “Thromboemboli is prevented through the use of diuretics.”
3. “Thromboemboli is prevented through the use of anticoagulants.”
4. “Thromboemboli is prevented through the use of beta-adrenergic blockers.”
3. How should a nurse document a client’s heart murmur that begins just before S2 and ends at S2?
1. Late systolic
2. Early systolic
3. Late diastolic
4. Early diastolic
4. A client is evaluated for a heart murmur in which the murmur is found to be loud. How should the heart
murmur be rated?
1. 1/6
2. 3/6
3. 2/6
4. 6/6
5. A left ventricular impulse is seen through the chest wall of a client. On palpation, a diastolic thrill is palpated
along the left sternal border and a systolic thrill is palpable in the jugular notch. To which pathological
condition could these symptoms be attributed?
1. Aortic valve insufficiency
2. Mitral valve insufficiency
3. Tricuspid valve stenosis
4. Mitral valve prolapse
6. A nurse is caring for a client who has an artificial heart valve and is scheduled for a dental procedure. Which
precautionary measure should the nurse take before the dental procedure?
1. Administering diuretics
2. Administering anticoagulant therapy
3. Administering beta-blockers
4. Administering antibiotic therapy
7. Which condition would likely be the cause of a new heart murmur in an older adult client?
1. Aortic valve sclerosis
2. Myocardial infarction
3. High blood pressure
PRIMEXAM.COM
4. Low blood pressure
8. A client presents with dyspnea, cough, fatigue, and orthopnea. On auscultation, there is an opening snap, and
a diastolic murmur heard at the fifth intercostal space in the left sternal border. The client undergoes an
echocardiogram to validate a pathologic condition. Which pathologic condition would the client most likely
have?
1. Mitral valve stenosis
2. Hypertrophic cardiomyopathy
3. Aortic valve stenosis
4. Aortic valve insufficiency
9. Which event needs to be ruled out in a client who has a longstanding history of mitral valve stenosis and
presents with tachycardia, an irregular pulse, and left-sided weakness?
1. Ischemic stroke
2. Myocardial ischemia
3. Left ventricular ischemia
4. Right ventricular failure
10. A nurse is auscultating a client’s heart sounds and notices a murmur. What would differentiate a heart murmur
that is caused by mitral valve stenosis than one that is caused by other mitral valve disorders?
1. Mid-systolic murmur
2. Opening snaps following a diastolic murmur
3. Holosystolic murmur
4. Late systolic murmur
11. A client presents with paroxysmal nocturnal dyspnea (PND) and chest pain. On auscultation, the client is
found to have a holosystolic murmur at the fifth intercostal space in the left sternal border. Which condition
would warrant the client to undergo an echocardiogram for validation of the disease?
1. Aortic valve insufficiency
2. Mitral valve insufficiency
3. Tricuspid valve stenosis
4. Mitral valve prolapse
12. A nurse who is trained in the gold standards for coronary care has to use the most sensitive method to evaluate
an intracardiac lesion. Which method should the nurse choose?
1. Electrocardiogram
2. Coronary angiography
3. Echocardiography
4. Chest x-ray
13. How does Ebstein’s anomaly lead to a small right ventricular chamber?
1. The mitral valve leaflets push into the right ventricle, creating a small right ventricular
chamber.
2. A displaced tricuspid valve lowers into the right ventricle, creating a small right
ventricular chamber.
3. The pulmonic valve pushes into the right ventricle, creating a small right ventricular
chamber.
4. The aortic valve pushes into the right ventricle, creating a small right ventricular chamber.
PRIMEXAM.COM
14. A client presents with dyspnea, exertional dyspnea, and exertional syncope. An echocardiogram shows a
diminished left ventricular ejection fraction. What would be the reason for prescribing dobutamine to the
client?
1. To enhance arterial circulation
2. To reduce the risk of coagulation
3. To augment the cardiac output
4. To diminish the effects of ventricular failure
15. While evaluating a client for a heart murmur, a nurse auscultates the murmur with the bell of a stethoscope
and not with the diaphragm of a stethoscope. Which type of heart murmur is this considered?
1. A high-pitched murmur.
2. A low-pitched murmur.
3. A crescendo murmur.
4. A decrescendo murmur.
16. How should a nurse distinguish a grade 5 heart murmur from a grade 6 heart murmur?
1. A grade 5 heart murmur is heard with the diaphragm of a stethoscope, while a grade 6
heart murmur is heard with the bell of a stethoscope.
2. A grade 5 heart murmur may be heard when a stethoscope is partly off the chest wall,
while a grade 6 heart murmur is heard when a stethoscope is off the chest wall.
3. A grade 5 heart murmur is moderately loud, while a grade 6 heart murmur is loud and has
a palpable thrill.
4. A grade 5 heart murmur is faint, while a grade 6 heart murmur is moderately loud.
17. What would a nurse hear when auscultating heart sounds in a client who has hypertrophic cardiomyopathy?
1. A high-pitched, blowing, decrescendo murmur.
2. An opening snap after S2.
3. A harsh, diamond-shaped systolic murmur.
4. A blowing holosystolic murmur.
18. A client is diagnosed with mitral annular calcification and has regurgitation of blood into the left atrium and
the pulmonary vasculature. What treatment should the nurse anticipate for the client?
1. Beta-blockers
2. Angiotensin converting enzyme (ACE) inhibitors
3. Diuretics
4. Digitalis
19. A nurse is caring for a client who has aortic valve stenosis and has failed diuretic treatment. The client is not a
candidate for surgery. What procedure will likely be prescribed for the client next?
1. Aortic valve replacement
2. Pacemaker insertion
3. Defibrillator therapy
4. Percutaneous aortic balloon valvuloplasty
20. A registered nurse is teaching a nursing student about aortic valve insufficiency. Which statement made by the
student nurse indicates effective learning?
1. “It is a high-pitched, blowing, diastolic decrescendo murmur.”
2. “It is a harsh, systolic, crescendo-decrescendo murmur.”
3. “It is a high-pitched, decrescendo, blowing murmur.”
4. “It is a blowing, holosystolic murmur.”
PRIMEXAM.COM
21. A client is found to have a disproportionately enlarged interventricular septum with an eccentrically
hypertrophied left ventricle. Which condition would be indicated in the client?
1. Aortic valve stenosis
2. Mitral valve insufficiency
3. Hypertrophic cardiomyopathy
4. Mitral valve prolapse
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
22. What are the clinical manifestations of aortic valve stenosis? Select all that apply.
1. Bibasilar pulmonary crackles
2. Systolic ejection murmur
3. Blowing holosystolic murmur
4. Graham Steell murmur
5. Split S2
23. A registered nurse is teaching a nursing student about physiologic heart murmurs. Which statements made by
the student nurse indicate effective learning? Select all that apply.
1. “Physiologic murmurs are loud.”
2. “Physiologic murmurs are faint.”
3. “Physiologic murmurs do not cause symptoms.”
4. “Physiologic murmurs are consistent.”
5. “Physiologic murmurs are intermittent.”
24. A registered nurse is educating a nursing student about the causes of pathologic heart murmurs. Which
statements made by the student nurse indicates effective learning? Select all that apply.
1. “They are sounds caused by heart wall defects.”
2. “They are sounds caused by valvular dysfunction.”
3. “They are sounds caused by rib cage abnormalities.”
4. “They are sounds caused by sternal bone defects.”
5. “They are sounds caused by valvular deformities.”
Other
25. Arrange the stages of the pathophysiology of mitral valve insufficiency in the proper order. (Enter the number
of each stage in the proper sequence; do not use commas or spaces.)
A. Diminished blood flow to the coronary arteries
B. Backflow of blood into the left atrium
C. Less blood is pumped into the aorta
PRIMEXAM.COM
D. The client suffers from a myocardial ischemia
Chapter 18: Valvular Heart Disease
Answer Section
MULTIPLE CHOICE
1. ANS: 1
Chapter: Chapter 18, Valvular Heart Disease
Page: 405
Objective: N/A
Difficulty: Easy
Heading: Cardiac Valve Auscultation
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Knowledge [Remembering]
Concept: Perfusion
1
2
3
4
Feedback
The pulmonic valve is heard best at the second intercostal space in the left sternal
border.
The aortic valve is heard best at the second intercostal space in the right sternal border.
The mitral valve is heard best at the fifth intercostal space in the midclavicular line.
The tricuspid valve is heard best at the fourth intercostal space in the left sternal border.
PTS: 1
CON: Perfusion
2. ANS: 3
Chapter: Chapter 18, Valvular Heart Disease
Page: 413
Objective: N/A
Difficulty: Easy
Heading: Assessment of Cardiac Valve Dysfunction
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Evaluation [Evaluating]
Concept: Clotting
1
2
3
4
Feedback
Antibiotics are used for the prophylactic treatment in clients who have deformed or
artificial valves.
Diuretics are used to treat heart failure that is associated with valve disorders.
Thromboemboli are prevented with the use of anticoagulants.
Beta-adrenergic blockers are used to treat tachydysrhythmias.
PTS: 1
CON: Clotting
3. ANS: 1
Chapter: Chapter 18, Valvular Heart Disease
PRIMEXAM.COM
Page: 408
Objective: N/A
Difficulty: Easy
Heading: Assessment of Cardiac Valve Dysfunction
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Perfusion
1
2
3
4
Feedback
A heart murmur that begins just before S2 and ends at S2 is termed as a late systolic
murmur.
A heart murmur that begins after S1 and ends before S2 is termed as an early systolic
murmur.
A heart murmur that begins after S2 and continues up to S1 is termed as a late diastolic
murmur.
A heart murmur that begins at S2 and fades before S1 is termed as an early diastolic
murmur.
PTS: 1
CON: Perfusion
4. ANS: 4
Chapter: Chapter 18, Valvular Heart Diseases
Page: 408
Objective: N/A
Difficulty: Moderate
Heading: Assessment of Cardiac Valve Dysfunction
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Perfusion
1
2
3
4
Feedback
A rating of 1/6 indicates a faint heart murmur.
A rating of 2/6 indicates a faint heart murmur.
A rating of 3/6 indicates a medium-loud heart murmur.
A rating of 6/6 indicates a loud heart murmur.
PTS: 1
CON: Perfusion
5. ANS: 1
Chapter: Chapter 18, Valvular Heart Diseases
Page: 417
Objective: N/A
Difficulty: Difficult
Heading: Aortic valve disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
PRIMEXAM.COM
Concept: Perfusion: Assessment
1
2
3
4
Feedback
Aortic valve insufficiency is characterized by a palpable, systolic thrill in the jugular
notch and a diastolic thrill in the left sternal border. A left ventricular impulse is often
seen through the chest wall.
Mitral valve insufficiency is characterized by a holosystolic murmur at the fifth
intercostal space.
Tricuspid valve stenosis is characterized by an opening snap after S2 and a diastolic
murmur over the lower left sternal border.
Mitral valve prolapse is characterized by a mid-systolic or late systolic murmur after a
mid-systolic click at left lower sternal border.
PTS: 1
CON: Perfusion: Assessment
6. ANS: 4
Chapter: Chapter 18, Valvular Heart Disorders
Page: 419
Objective: N/A
Difficulty: Difficult
Heading: Assessment of Cardiac Valve Dysfunction
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Safety
1
2
3
4
Feedback
Diuretics are used when edema is present in clients.
Anticoagulation therapy is used when there is a risk of a thrombus formation in clients.
Beta-blockers are used to control abnormal heart rhythms in clients.
Antibiotic therapy is used prophylactically before invasive procedures in clients whose
valves are deformed or are artificial because such valves are prone to bacterial
infections.
PTS: 1
CON: Safety
7. ANS: 1
Chapter: Chapter 18, Valvular Heart Disorders
Page: 419
Objective: N/A
Difficulty: Easy
Heading: Assessment of Cardiac Valve Dysfunction
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Knowledge [Remembering]
Concept: Perfusion
1
Feedback
Aortic valve sclerosis, which results in the narrowing and calcification of the aortic
PRIMEXAM.COM
2
3
4
valve, would likely be the cause of a new heart murmur in older adults.
A myocardial infarction would not cause a new heart murmur in an older adult.
High blood pressure would not cause heart murmurs.
Low blood pressure would not cause heart murmurs.
PTS: 1
CON: Perfusion
8. ANS: 1
Chapter: Chapter 18, Valvular Heart Diseases
Page: 419
Objective: N/A
Difficulty: Difficult
Heading: Mitral Valve Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Perfusion
1
2
3
4
Feedback
An opening snap and diastolic murmur at fifth intercostal space is a characteristic of
mitral valve stenosis.
A harsh, diamond-shaped murmur is characteristic of hypertrophic cardiomyopathy.
A systolic ejection murmur at the second intercostal space is characteristic of aortic
valve stenosis.
A diastolic murmur at the third intercostal space is characteristic of an aortic
insufficiency.
PTS: 1
CON: Perfusion
9. ANS: 1
Chapter: Chapter 18, Valvular Heart Diseases
Page: 411
Objective: N/A
Difficulty: Moderate
Heading: Mitral Valve Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Perfusion
1
2
3
4
Feedback
An ischemic stroke is highly suspected in a client who has mitral valve stenosis and
presents with unilateral weakness, tachycardia, and an irregular pulse.
Myocardial ischemia is more common in clients who have mitral valve insufficiency.
Left ventricular ischemia is a common result of aortic valve stenosis.
Right ventricular failure occurs in clients who have aortic valve insufficiency.
PTS: 1
10. ANS: 2
CON: Perfusion
PRIMEXAM.COM
Chapter: Chapter 18, Valvular Heart Diseases
Page: 411
Objective: N/A
Difficulty: Moderate
Heading: Mitral Valve Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Perfusion
1
2
3
4
Feedback
A mid-systolic murmur is seen in mitral valve prolapse.
An opening snap followed by a diastolic murmur is heard in mitral valve stenosis.
A holosystolic murmur is heard in mitral valve insufficiency.
A late systolic murmur is heard in mitral valve prolapse.
PTS: 1
CON: Perfusion
11. ANS: 2
Chapter: Chapter 18, Valvular Heart Diseases
Page: 419
Objective: N/A
Difficulty: Difficult
Heading: Assessment of Cardiac Valve Dysfunction
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Perfusion
1
2
3
4
Feedback
Aortic valve stenosis is characterized by a diastolic murmur at the third intercostal
space.
Mitral valve insufficiency is characterized by a holosystolic murmur at fifth intercostal
space
Tricuspid valve stenosis is characterized by an opening snap after an S2 diastolic
murmur over the lower left sternal border.
A mitral valve prolapse is characterized by a mid-systolic or late systolic murmur after
a mid-systolic click at the lower left sternal border.
PTS: 1
CON: Perfusion
12. ANS: 3
Chapter: Chapter 18, Valvular Heart Diseases
Page: 419
Objective: N/A
Difficulty: Moderate
Heading: Assessment of Cardiac Valve Dysfunction
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
PRIMEXAM.COM
Cognitive Level: Application [Applying]
Concept: Perfusion
1
2
3
4
Feedback
An electrocardiogram (ECG) is used to monitor the electrical activity of the heart.
A coronary angiography is used to determine the health of the coronary arteries.
An echocardiography is the gold standard for the diagnosis of valvular heart disease.
A chest x-ray is used to diagnose the dilation of the heart.
PTS: 1
CON: Perfusion
13. ANS: 2
Chapter: Chapter 18, Valvular Heart Diseases
Page: 418
Objective: N/A
Difficulty: Easy
Heading: Aortic Valve Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
Feedback
1
2
3
4
The mitral valve is located between the left atrium and left ventricle and has no relation
to the right ventricle.
The tricuspid valve’s leaflets are displaced lower into the right ventricle in clients who
have Ebstein’s anomaly. This results in the creation of a small right ventricular chamber.
The pulmonic valve pushes blood from the right ventricle into the pulmonary artery, so
it cannot create a chamber in the right ventricle even if it is displaced.
The aortic valve is located between the left ventricle and aorta; therefore, it has no
relation to right ventricle.
PTS: 1
CON: Assessment
14. ANS: 2
Chapter: Chapter 18, Valvular Heart Diseases
Page: 420
Objective: N/A
Difficulty: Moderate
Heading: Mitral Valve Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Perfusion, Medication
1
2
3
Feedback
Vasodilators are used to enhance arterial circulation.
Anticoagulants are used to reduce the risk of coagulation.
Dobutamine is used to augment the cardiac output.
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4
Angiotensin converting enzyme (ACE) inhibitors are used to diminish the effects of
ventricular failure.
PTS: 1
CON: Perfusion, Medication
15. ANS: 2
Chapter: Chapter 18, Valvular Heart Diseases
Page: 409
Objective: N/A
Difficulty: Moderate
Heading: Assessment of Cardiac Valve Dysfunction
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Perfusion
1
2
3
4
Feedback
A high-pitched heart murmur is heard best with the diaphragm of a stethoscope.
A low-pitched heart murmur is heard best with the bell of a stethoscope.
A crescendo heart murmur is louder in intensity over time and describes the shape of
the murmur.
A decrescendo heart murmur becomes fainter in intensity over time and describes the
shape of the murmur.
PTS: 1
CON: Perfusion
16. ANS: 2
Chapter: Chapter 18, Valvular Heart Diseases
Page: 408
Objective: N/A
Difficulty: Difficult
Heading: Heart Murmur Grading
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Analysis [Analyzing]
Concept: Assessment
1
2
3
4
Feedback
A high-pitched heart murmur is heard with the diaphragm of a stethoscope and a lowpitched heart murmur is heard with the bell of a stethoscope.
A grade 5 heart murmur may be heard when a stethoscope is partly off the chest wall,
whereas a grade 6 heart murmur is heard when a stethoscope is completely off the chest
wall.
Grade 5 and grade 6 heart murmurs are very loud.
Grade 5 and grade 6 heart murmurs are very loud.
PTS: 1
CON: Assessment
17. ANS: 3
Chapter: Chapter 18, Valvular Heart Diseases
PRIMEXAM.COM
Page: 416
Objective: N/A
Difficulty: Easy
Heading: Aortic Valve Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
1
2
3
4
Feedback
Pulmonic valve insufficiency produces a high-pitched, blowing, decrescendo murmur.
Tricuspid valve stenosis produces an opening snap after S2.
Hypertrophic cardiomyopathy is characterized by a harsh, diamond-shaped, systolic
murmur.
Tricuspid valve insufficiency causes a blowing, holosystolic murmur.
PTS: 1
CON: Assessment
18. ANS: 3
Chapter: Chapter 18, Valvular Heart Diseases
Page: 413
Objective: N/A
Difficulty: Moderate
Heading: Pathophysiology of Selected Heart Valve Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential; Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Assessment
1
2
3
4
Feedback
Beta-blockers are used to treat atrial fibrillation that arises from valvular disorders.
Angiotensin converting enzyme (ACE) inhibitors are used to treat ventricular failure
that arises from valvular disorders.
Diuretics are utilized to treat fluid volume overload, including pulmonary edema.
Digitalis is used to treat atrial fibrillation that arises from valvular disorders.
PTS: 1
CON: Assessment
19. ANS: 4
Chapter: Chapter 18, Valvular Heart Diseases
Page: 415
Objective: N/A
Difficulty: Moderate
Heading: Aortic Valve Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Safety
PRIMEXAM.COM
1
2
3
4
Feedback
Aortic valve replacement is a surgical procedure and is not recommended in clients who
are not candidates for surgery.
Pacemaker insertion is considered in hypertrophic cardiomyopathy.
Defibrillator therapy is considered in hypertrophic cardiomyopathy.
Percutaneous aortic balloon valvuloplasty is an option for treating aortic valve stenosis
in clients who are not candidates for surgery and have not responded to diuretic therapy.
PTS: 1
CON: Safety
20. ANS: 1
Chapter: Chapter 18, Valvular Heart Diseases
Page: 417
Objective: N/A
Difficulty: Difficult
Heading: Aortic Valve Disorders
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Evaluation [Evaluating]
Concept: Perfusion
1
2
3
4
Feedback
A high-pitched, blowing, diastolic, decrescendo murmur is a characteristic of aortic
valve insufficiency.
Pulmonic valve stenosis is characterized by a harsh, systolic, crescendo-decrescendo
murmur.
A high-pitched, decrescendo, blowing murmur is a characteristic of pulmonic valve
insufficiency.
A blowing, holosystolic murmur is a characteristic of tricuspid valve insufficiency.
PTS: 1
CON: Perfusion
21. ANS: 3
Chapter: Chapter 18, Valvular Heart Diseases
Page: 420
Objective: N/A
Difficulty: Moderate
Heading: Aortic Valve Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Perfusion
1
2
3
Feedback
Aortic valve stenosis is characterized by a narrowing of the aortic valve.
Mitral valve insufficiency is characterized by incompetent mitral valves that cannot
close. .
Hypertrophic cardiomyopathy is characterized by an eccentrically hypertrophied left
ventricle and a disproportionately enlarged interventricular septum. .
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4
Mitral valve prolapse is characterized by floppy mitral valve leaflets.
PTS: 1
CON: Perfusion
MULTIPLE RESPONSE
22. ANS: 2, 5
Chapter: Chapter 18, Valvular Heart Diseases
Page: 420
Objective: N/A
Difficulty: Easy
Heading: Aortic Valve Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Comprehension [Understanding]
Concept: Perfusion
1.
2.
3.
4.
5.
Feedback
This is incorrect. Bibasilar pulmonary crackles are a clinical manifestation of mitral valve
stenosis.
This is correct. A systolic ejection murmur is a clinical manifestation of aortic valve
stenosis.
This is incorrect. A blowing, holosystolic murmur is a clinical manifestation of tricuspid
valve insufficiency.
This is incorrect. A Graham Steell murmur is a clinical manifestation of pulmonic
insufficiency.
This is correct. A split S2 is a clinical manifestation of aortic valve stenosis.
PTS: 1
CON: Perfusion
23. ANS: 2, 3, 5
Chapter: Chapter 18, Valvular Heart Diseases
Page: 405
Objective: N/A
Difficulty: Difficult
Heading: Basic Pathophysiological Concepts of Heart Valve Dysfunction
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Evaluation [Evaluating]
Concept: Perfusion
1.
2.
3.
4.
5.
Feedback
This is incorrect. Physiologic murmurs are not loud.
This is correct. Physiologic murmurs are faint.
This is correct. Physiologic murmurs do not cause symptoms.
This is incorrect. Physiologic murmurs are not consistently present.
This is correct. Physiologic murmurs are intermittent and may occur in clients who have
symptoms such as fever and conditions such as pregnancy and an overactive thyroid.
PRIMEXAM.COM
PTS: 1
CON: Perfusion
24. ANS: 1, 2, 5
Chapter: Chapter 18, Valvular Heart Diseases
Page: 406
Objective: N/A
Difficulty: Difficult
Heading: Basic Pathophysiological Concepts of Heart Valve Dysfunction
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Evaluation [Evaluating]
Concept: Perfusion
1.
2.
3.
4.
5.
Feedback
This is correct. Pathologic murmurs can be caused by defects in the heart wall.
This is correct. Pathologic murmurs can be caused by valvular dysfunction.
This is incorrect. Pathologic murmurs of the heart are not related to rib cage abnormalities.
This is incorrect. Pathologic murmurs of the heart are not related to sternal bone defects.
This is correct. Pathologic murmurs of the heart can be caused by valvular deformities.
PTS: 1
CON: Perfusion
ORDERED RESPONSE
25. ANS:
BCAD
Chapter: Chapter 18, Valvular Heart Diseases
Page: 408
Objective: N/A
Difficulty: Easy
Heading: Mitral Valve Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Comprehension [Understanding]
Concept: Perfusion
Feedback: In mitral insufficiency, the mitral valve does not work adequately, which, in turn, causes an
increase in the volume of blood to back up into the left atrium when the left ventricle contracts. The left
ventricle cannot pump enough of the blood into the aorta, which results in a diminished blood flow to the
coronary arteries. As a result, the client suffers from myocardial ischemia, which is characterized by pallor,
diaphoresis, dyspnea, and chest pain.
PTS: 1
CON: Perfusion
PRIMEXAM.COM
Chapter 19: Disorders of the Venous System
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. A registered nurse is teaching a group of nursing students about Homan’s sign. Which statement made by the
student nurse indicates effective learning?
1. “Place the client in the supine position with a straight knee and dorsiflex the client’s foot.”
2. “Place the client in a prone position and flex the knee to a right angle.”
3. “Place the client such that the back is rested and knees are flexed, and then dorsiflex the
ankle.
4. “Place the client in a sitting position and extend the legs one at a time, and then both
together.
2. A client with left lower extremity swelling and tenderness along a vein has to be assessed to rule out deep
vein thrombosis (DVT). Which criteria would rule out DVT?
1. A negative D-dimer assay and Wells criteria score of 3
2. A positive D-dimer assay and Wells criteria score of less than 1
3. A negative D-dimer assay and Wells criteria score of less than 2
4. A positive D-dimer assay and Wells criteria score of 0
3. What is the purpose of a Greenfield filter?
1. To prevent the formation of a blood clot
2. To help burst a blood clot
3. To prevent a blood clot from traveling
4. To detect a blood clot
4. The nurse uses Homan’s sign to assess a client for the presence of deep venous thromboembolism (DVT).
Pain in what area is an indication of positive Homan’s sign?
1. Hip
2. Calf
3. Knee
4. Thighs
5. A 60-year-old client is seen at the clinic with skin inflammation. There is dusky discoloration around the
ankle and in the lower leg of the client. What might be the cause of this condition?
1. Reduced blood pressure in the veins
2. Insufficient oxygenation to the tissues
3. Buildup of hemosiderin
4. Blockage of sweat gland
6. A nurse is caring for a client with chronic venous insufficiency. Which instruction is appropriate to include in
the client’s care plan?
1. Try to reduce your walking throughout the day.
2. Wear constriction garments.
3. Apply a cold compression.
4. Elevate your legs periodically during the day.
7. Which diagnostic test is used to identify the pattern of collateral blood flow?
1. Venography
PRIMEXAM.COM
2. Ultrasonography
3. Photoplethysmography
4. None of the above
8. A client reports to the hospital with a swollen mass on the left leg. Physical examination reveals that the
swollen mass is red, tender, and is textured like a rope. A review of the client’s records show that the client
has recently undergone an orthopedic surgery on his right leg. Which condition has the client developed?
1. Deep venous thromboembolism
2. Pulmonary embolism
3. Chronic venous insufficiency
4. Varicose vein
9. Which test is most commonly used to diagnose varicose vein?
1. D-dimer test
2. Duplex ultrasound
3. Wells criteria
4. Magnetic resonance imaging
10. Which drug administered to clients with deep venous thromboembolism (DVT) requires an international
normalized ratio monitoring?
1. Low molecular weight heparin
2. Factor Xa inhibitor
3. Warfarin
4. None of the above
11. A client works as a sales associate in a garment outlet and has to stand for the duration of each work shift.
Clinical examination reveals a presence of a dusky discoloration around the ankle, instep, and lower leg. What
condition do these findings indicate?
1. Deep venous thromboembolism
2. Pulmonary embolism
3. Chronic venous insufficiency
4. Varicose vein
12. A client presents with a painful, swollen mass at the ankle of the right leg. Physical examination revealed that
the edema is dark red in color, with drainage just above the medial malleolus of the leg. Which condition has
the client developed?
1. Deep venous thromboembolism
2. Pulmonary embolism
3. Venous ulcer
4. Varicose vein
13. Which is a cause for the occurrence of varicose veins?
1. Valvular incompetence in the legs
2. Sluggish circulation
3. Poor tissue oxygenation
4. Impaired removal of fluid and waste products
14. What is the outermost layer of the walls of a vein?
1. Tunica adventitia
2. Parietal layer
3. Tunica intima
PRIMEXAM.COM
4. Visceral layer
5. Tunica media
15. The tunica media is
1. an endothelial cell lining.
2. the smooth muscle layer of the wall of a vein.
3. made up of connective tissue.
4. also called the tunica adventitia.
16. What condition can develop from a deep venous thrombosis (DVT) if it is not caught and treated early
enough?
1. Necrosis
2. Skin breakdown
3. Tissue damage
4. Pulmonary embolism
17. A client comes to the clinic with dark red edema on the lower leg, with irregular margins of skin breakdown
especially in the medial ankle region. The primary health-care provider diagnoses necrosis and tissue damage
surrounding the affected area. What treatment would the nurse expect to be prescribed for this client?
1. Sclerotherapy
2. Antiplatelet drugs
3. Topical medications
4. Pneumatic compression device
18. Which specific sign or symptom indicates that a client is suffering from varicose veins?
1. Itching and aching lower leg muscles
2. Ropiness over a vein in the leg
3. Tenderness in the vein
4. Irregular margins in the medial ankle region
NARRBEGIN: Exhibit
Exhibit
NARREND
19. A nurse is assessing four clients for deep vein thromboembolism (DVT).
D- dimer level
Well’s criteria
score
Client 1
Elevated
2
Client 2
Normal
1
Client 3
Low
0
Client 4
Elevated
1
Which client is at a risk of developing DVT?
1. Client 1
2. Client 2
3. Client 3
4. Client 4
20. A nurse is reviewing the prescription records of four clients being treated for deep vein thromboembolism
(DVT).
PRIMEXAM.COM
Client 1
Low molecular weight
heparin
Client 2
Warfarin
Client 3
Bivalirudin
Client 4
Rivaroxaban
Which client needs a prothrombin time lab test to monitor the therapeutic effects of the drug?
1. Client 1
2. Client 2
3. Client 3
4. Client 4
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
21. Which of the risk factors form part of Virchow’s triad? Select all that apply.
1. Venous stasis
2. Smoking
3. Vascular damage
4. Obesity
5. Hypercoagulability
22. What are the diagnostic tests used for peripheral venous disorders? Select all that apply.
1. Magnetic Resonance Imaging (MRI)
2. Photoplethysmography
3. Computed tomography (CT)
4. Doppler ultrasonography
5. Venography
23. A student nurse is learning to care for a variety of clients in a hospital setting. Which clients are most at risk
for developing venous insufficiency? Select all that apply.
1. An obese client
2. A client with pulmonary embolism
3. A pregnant client at 30 weeks gestation
4. A client who is recovering from a shoulder surgery
5. A client who uses a walker for support
Other
24. Arrange the pathophysiological changes involved in a pulmonary embolism (A-D). (Enter the number of each
step in the proper sequence; do not use commas or spaces.)
A. The thrombus becomes an embolus and travels into the inferior vena cava.
B. The thrombus travels into the right side of the heart.
C. Inflammation and thrombus form in the vein.
D. The thrombus then enters the pulmonary artery.
25. Arrange the symptoms in the proper order to describe the pathophysiology of varicose veins (A-D). (Enter the
number of each step in the proper sequence; do not use commas or spaces.)
A. Damaged valves
B. Pressure on the valves
PRIMEXAM.COM
C. Blood stagnation and pooling in the lower extremities
PRIMEXAM.COM
D. Compromised venous return
Chapter 19: Disorders of the Venous System
Answer Section
MULTIPLE CHOICE
1. ANS: 1
Chapter: Chapter 19, Disorders of the Venous System
Page: 428
Objective: N/A
Difficulty: Difficult
Heading: Deep Venous Thromboembolism
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Evaluation [Evaluating]
Concept: Nursing Roles
1
2
3
4
Feedback
Homan’s sign is tested with the client in the supine position with knees straight and
having the client dorsiflex the foot.
Placing the client in a prone position and flexing the knee at a right angle is performed
when testing the Achilles tendon.
Placing the client in a sitting position with knees flexed and having the client dorsiflex
the ankle is performed when testing the gastrocnemius and soleus.
Placing the client with the back rested and extending the legs one at a time, and then
both together is performed to test for sciatica.
PTS: 1
CON: Nursing Roles
2. ANS: 3
Chapter: Chapter 19, Disorders of the Venous System
Page: 428
Objective: N/A
Difficulty: Moderate
Heading: Basic Assessment of Cardiac Valve Dysfunction
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Assessment
1
2
3
Feedback
A negative D-dimer assay alone will not rule out DVT. It has to be in combination with
a Wells score of less than 2.
A Wells criteria score of less than 1 alone will not rule out DVT. It has to be in
combination with a negative D-dimer.
A negative D-dimer assay in combination with a Wells score of less than 2 rules out
DVT.
PRIMEXAM.COM
4
A Wells score of 0 alone cannot rule out DVT. It has to be combined with a negative Ddimer assay.
PTS: 1
CON: Assessment
3. ANS: 3
Chapter: Chapter 19, Disorders of the Venous System
Page: 428-429
Objective: N/A
Difficulty: Easy
Heading: Deep Venous Thromboembolism
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Comprehension [Understanding]
Concept: Safety
1
2
3
4
Feedback
Antithrombotic therapy, which uses specialized stockings, to prevent the formation of a
blood clot.
Thrombolytic agents will help to burst a blood clot.
The Greenfield filter is used to prevent a blood clot from traveling up and forming a
pulmonary embolus.
Specialized tests, such as a ventilation perfusion, scan to detect for a blood clot.
PTS: 1
CON: Safety
4. ANS: 2
Chapter: Chapter 19, Disorders of the Venous System
Page: 428
Objective: N/A
Difficulty: Moderate
Heading: Deep Venous Thromboembolism
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
Feedback
1
2
3
4
Pain in the hip does not indicate positive Homan’s sign.
Homan’s sign is used as a sign of DVT. If DVT is present, the client would experience
pain in the calf muscles.
Pain in the knee does not indicate positive Homan’s sign.
Pain in the thighs does not indicate positive Homan’s sign.
PTS: 1
CON: Assessment
5. ANS: 3
Chapter: Chapter 19, Disorders of the Venous System
Page: 429
Objective: N/A
PRIMEXAM.COM
Difficulty: Moderate
Heading: Chronic Venous Insufficiency
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Clotting: Perfusion
Feedback
1
2
3
4
The dusky discoloration around the ankles and in lower leg is called stasis dermatitis.
Stasis dermatitis is caused by increased blood pressure in the veins. Venous pooling
causes the pressure inside the veins to be higher than normal. Thus, it results in venous
hypertension.
Insufficient oxygenation to tissues causes cyanosis or bluish discoloration.
Buildup of hemosiderin in the tissues causes stasis dermatitis, which is a dusky
discoloration of the skin noted in the ankle, lower leg, and instep.
Sweat gland blockage does not cause stasis dermatitis or dusky discoloration of skin.
PTS: 1
CON: Clotting: Perfusion
6. ANS: 4
Chapter: Chapter 19, Disorders of the Venous System
Page: 432
Objective: N/A
Difficulty: Moderate
Heading: Making the Connections
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Clotting: Perfusion: Oxygenation: Nursing Roles
Feedback
1
2
3
4
The client should walk as much as possible to promote blood flow and reduce venous
stasis.
The client should avoid wearing constrictive garments that will reduce blood flow in the
legs.
The client should not apply a cold compress because this will cause vasoconstriction.
The client should elevate his or her legs periodically throughout the day to improve
blood flow to the legs.
PTS: 1
CON: Clotting: Perfusion: Oxygenation: Nursing Roles
7. ANS: 1
Chapter: Chapter 19, Disorders of the Venous System
Page: 432
Objective: N/A
Difficulty: Easy
Heading: Chronic Venous Insufficiency
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Knowledge [Remembering]
PRIMEXAM.COM
Concept: Clotting: Perfusion: Oxygenation
Feedback
1
2
3
4
Venography is used to identify the patterns of collateral blood flow.
Ultrasonography is used to determine venous blood flow but not the pattern of collateral
blood flow.
Photoplethysmography is used to determine venous blood flow but not the pattern of
collateral blood flow.
Venography is used to identify patterns of collateral blood flow, so the answer option,
“none of the above”, is incorrect.
PTS: 1
CON: Clotting: Perfusion: Oxygenation
8. ANS: 1
Chapter: Chapter 19, Disorders of the Venous System
Page: 427
Objective: N/A
Difficulty: Difficult
Heading: Deep Venous Thromboembolism
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Clotting: Assessment
Feedback
1
2
3
4
The client has developed deep venous thromboembolism (DTV). Clients who have
undergone orthopedic surgeries are at greater risk of developing DTV, which is
associated with a tenderness, redness, and ropiness over a vein.
A venous thrombus, which travels from the leg to the inferior vena cava to enter the
pulmonary arterial circulation causes pulmonary embolism. This condition is not
consistent with the findings described.
Chronic venous insufficiency occurs in the deep veins of the legs as a result of valve
damage. This condition does not manifest with the symptoms described.
A varicose vein occurs as a result of abnormally dilated vein, which commonly occurs
in the leg. This condition is not associated with the symptoms described.
PTS: 1
CON: Clotting: Assessment
9. ANS: 2
Chapter: Chapter 19, Disorders of the Venous System
Page: 432
Objective: N/A
Difficulty: Easy
Heading: Pathophysiology of Selected Venous Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Knowledge [Remembering]
Concept: Clotting: Assessment
PRIMEXAM.COM
1
2
3
4
Feedback
The D-dimer test is used to diagnose deep venous thromboembolism.
A duplex ultrasound is used to diagnose varicose vein.
The Wells criteria are used to diagnose deep venous thromboembolism.
Magnetic resonance imaging is used to diagnose iliac vein or inferior vena cava
thrombosis.
PTS: 1
CON: Clotting: Assessment
10. ANS: 3
Chapter: Chapter 19, Disorders of the Venous System
Page: 433
Objective: N/A
Difficulty: Easy
Heading: Pathophysiology of Selected Venous Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Knowledge [Remembering]
Concept: Clotting: Assessment
1
2
3
4
Feedback
Low molecular weight heparin is administered to clients with DVT, but does not require
an international normalized ratio monitoring.
Factor Xa inhibitor is administered to clients with DVT, but does not require an
international normalized ratio monitoring.
Warfarin is administered to clients with DVT and it requires an international normalized
ratio monitoring. An effective international normalized ratio for prophylaxis of deep
venous thromboembolism is 2 to 3.
Warfarin administration for clients with DVT requires an international normalized ratio
monitoring, so the answer “None of the above” is not correct.
PTS: 1
CON: Clotting: Assessment
11. ANS: 3
Chapter: Chapter 19, Disorders of the Venous System
Page: 432
Objective: N/A
Difficulty: Difficult
Heading: Pathophysiology of Selected Venous Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Clotting: Assessment
1
2
Feedback
Deep venous embolism risk occurs in clients who have undergone an orthopedic
surgery, but this condition is not caused by prolonged standing.
A venous thrombus which travels from the leg to the to the pulmonary arterial
circulation causes pulmonary embolism.
PRIMEXAM.COM
3
4
The client has developed chronic venous insufficiency. The major causes for chronic
venous insufficiency are trauma, pregnancy, and prolonged standing. The presence of a
dusky discoloration around the ankle, instep, and lower leg are indications of chronic
venous insufficiency.
Varicose vein is the abnormal dilation of veins in the leg and this condition does not
cause the symptoms described.
PTS: 1
CON: Clotting: Assessment
12. ANS: 3
Chapter: Chapter 19, Disorders of the Venous System
Page: 433
Objective: N/A
Difficulty: Difficult
Heading: Pathophysiology of Selected Venous Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Clotting: Assessment
1
2
3
4
Feedback
Deep venous thromboembolism is associated with tenderness, redness, and ropiness
over a vein.
Pulmonary embolism occurs when a venous thrombus enter the pulmonary arterial
circulation.
The client has developed venous ulcer. Venous ulcer is usually dark red, with drainage
just above the medial malleolus of the leg. Clients with venous ulcer experience pain in
the place of development of edema.
Varicose vein is caused mainly by low levels of physical activity.
PTS: 1
CON: Clotting: Assessment
13. ANS: 1
Chapter: Chapter 19, Disorders of the Venous System
Page: 430
Objective: N/A
Difficulty: Easy
Heading: Pathophysiology of Selected Venous Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Knowledge [Remembering]
Concept: Clotting: Assessment
1
2
3
4
Feedback
Varicose veins are caused by valvular incompetence in the legs.
Venous ulcers are caused by sluggish circulation.
Venous ulcers are caused by poor tissue oxygenation.
Venous ulcers are caused by impaired removal of fluid and waste products.
PRIMEXAM.COM
PTS: 1
CON: Clotting: Assessment
14. ANS: 1
Chapter: Chapter 19, Disorders of the Venous System
Page: 425
Objective: N/A
Difficulty: Easy
Heading: Basic concepts of Venous Structure and Function
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Perfusion
1
2
3
4
5
Feedback
The outermost layer of the vein wall is called the tunica adventitia.
The parietal layer is part of a serous membrane and not the outermost layer of the vein
wall.
The inner wall of a vein is called the tunica intima.
The visceral layer is the wall of a serous membrane and not the outermost layer of the
vein wall.
The middle layer of the wall of a vein is called tunica media.
PTS: 1
CON: Perfusion
15. ANS: 2
Chapter: Chapter 19, Disorders of the Venous System
Page: 425
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts of Venous Structure and Function
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Hematologic Regulation
1
2
3
4
Feedback
Tunica intima is the lining of endothelial cell.
The tunica media is the smooth muscle layer of a vein wall.
Tunica externa is the outer layer of the vein wall and is made up of connective tissue
instead of smooth muscle tissue.
Tunica adventitia is another name for tunica externa, the outermost layer of the vein
wall. It is made up of connective tissue instead of smooth muscle tissue.
PTS: 1
CON: Hematologic Regulation
16. ANS: 4
Chapter: Chapter 19, Disorders of the Venous System
Page: 426
Objective: N/A
Difficulty: Easy
PRIMEXAM.COM
Heading: Deep Venous Thromboembolism Integrated Processes: Nursing Process
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Comprehension [Understanding]
Concept: Skin Integrity
1
2
3
4
Feedback
Necrosis is caused by a venous ulcer and not caused by DVT.
Skin breakdown is a symptom of venous ulcer and is not caused by DVT.
Tissue damage is caused by injury or venous ulcer but it is not caused by DVT.
Pulmonary embolism is correct because, in DVT, the venous thrombus can travel from
the leg into the pulmonary arterial circulation through the heart
PTS: 1
CON: Skin Integrity
17. ANS: 3
Chapter: Chapter 19, Disorders of the Venous System
Page: 431
Objective: N/A
Difficulty: Moderate
Heading: Venous Ulcers
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Skin Integrity
1
2
3
4
Feedback
Sclerotherapy helps destroy the endothelial layer of the distended vein as a treatment of
varicose vein, but it would not be used to treat necrosis and tissue damage.
Antiplatelet drugs along with low molecular weight heparin, or unfractionated heparin
is used as the treatment of deep vein thrombophlebitis. This is not an effective treatment
for necrosis.
The client’s symptoms, including edema, necrosis, and tissue damage, indicate venous
ulcer. Topical medications with epidermal, fibroblastic, and platelet- derived growth
factors help establish new tissue growth and are helpful in the treatment of venous
ulcers.
A pneumatic compression device helps with graduated compression of the lower legs in
cases of venous insufficiency. This is not an effective treatment for necrosis and tissue
damage.
PTS: 1
CON: Skin Integrity
18. ANS: 1
Chapter: Chapter 19, Disorders of the Venous System
Page: 432
Objective: N/A
Difficulty: Easy
Heading: Making the Connections
Integrated Processes: Nursing Process
PRIMEXAM.COM
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Mobility
1
2
3
4
Feedback
Itching and aching of the lower leg muscles is an indication of varicose veins.
Ropiness over a vein in the leg is an indication of deep vein thrombophlebitis but not of
varicose veins.
Tenderness in the vein is a symptom of deep vein thrombophlebitis, but not necessarily
varicose veins.
Irregular margins in the medial ankle region that are caused by tissue damage and skin
breakdown is a symptom of venous ulcer.
PTS: 1
CON: Mobility
19. ANS: 1
Chapter: Chapter 19, Disorders of the Venous System
Page: 428
Objective: N/A
Difficulty: Difficult
Heading: Deep Venous Thromboembolism
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Clotting: Oxygenation: Perfusion
1
2
3
4
Feedback
Client 1 is at a risk of developing DVT because the client’s D-dimer level is elevated.
The D-dimer test is a blood test used to detect the presence of fibrin clot degeneration
products in the blood. Well’s criteria is used to evaluate the clinical signs of DVT such
as leg swelling. In addition, client 1 has a Well’s criteria score over 2, which indicates a
risk of developing DVT.
Client 2 has a normal D-dimer level, which means there is little fibrin clot degeneration
products in the blood. A Well’s criteria score of 1 rules out the possibility of DVT. A
low D-dimer level indicates there is very little fibrin clot degeneration products in the
blood, which means blood-clotting complications are less likely in this client.
Client 3 has a Well’s criteria score of 0, which rules out the possibility of DVT.
Client 4 has an elevated D-dimer level indicates that the client has blood clotting
problems. It is used to determine if the further testing is necessary to diagnose
conditions that cause hypercoagulability. A Well’s criteria score of 1 rules out the
possibility of DVT.
PTS: 1
CON: Clotting: Oxygenation: Perfusion
20. ANS: 2
Chapter: Chapter 19, Disorders of the Venous System
Page: 428
Objective: N/A
Difficulty: Difficult
PRIMEXAM.COM
Heading: Deep Venous Thromboembolism
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Clotting: Oxygenation: Perfusion: Safety
1
2
3
4
Feedback
Client 1 is taking low molecular weight heparin, which does not require a lab test to
monitor the therapeutic effects of the drug because it is more predictable than
unfractionated heparin.
Warfarin might not prevent clotting completely, so Client 2’s dose is adjusted to
maintain the clotting time within the target range based on the prothrombin time lab
test.
Client 3 is taking bivalirudin, which is a direct thrombin inhibitor and does not require
any lab test to monitor the therapeutic effects of the drug.
Client 4 is taking rivaroxaban), which is a factor Xa inhibitor used for treating DVT.
Rivaroxaban has a predictable blood-thinning effect, so lab testing may not be required
to monitor the therapeutic effects of the drug.
PTS: 1
CON: Clotting: Oxygenation: Perfusion: Safety
MULTIPLE RESPONSE
21. ANS: 1, 3, 5
Chapter: Chapter 19, Disorders of the Venous System
Page: 427
Objective: N/A
Difficulty: Easy
Heading: Deep Venous Thromboembolism
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Knowledge [Remembering]
Concept: Safety
1.
2.
3.
4.
5.
Feedback
This is correct. Venous stasis is a risk factor for deep vein thrombosis (DVT), and forms
part of Virchow’s triad.
This is incorrect. Smoking increases the risk for blood clot formation, but it is not a part of
Virchow’s triad.
This is correct. Vascular damage is a risk factor for DVT and forms part of Virchow’s triad.
This is incorrect. Obesity can increase the risk of blood clot formation, but it is not a part
of Virchow’s triad.
This is correct. Hypercoagulability is a risk factor for DVT and is part of Virchow’s triad.
PTS: 1
CON: Safety
22. ANS: 2, 4, 5
Chapter: Chapter 19, Disorders of the Venous System
PRIMEXAM.COM
Page: 429
Objective: N/A
Difficulty: Easy
Heading: Chronic Venous Insufficiency
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Knowledge [Remembering]
Concept: Assessment
1.
2.
3.
4.
5.
Feedback
This is incorrect. MRI is a diagnostic test used for hypertrophic cardiomyopathy, but not
for determining venous insufficiency.
This is correct. Photoplethysmography is used as a diagnostic test for peripheral venous
disorders because it determines blood flow.
This is incorrect. CT is used as an optional diagnostic test for hypertrophic
cardiomyopathy, but it is not used for determining venous insufficiency.
This is correct. Doppler ultrasonography is used as a diagnostic test for peripheral venous
disorders because it determines blood flow.
This is correct. Venography is used as a diagnostic test for peripheral venous disorders
because it determines collateral blood flow.
PTS: 1
CON: Assessment
23. ANS: 1, 3
Chapter: Chapter 19, Disorders of the Venous System
Page: 430
Objective: N/A
Difficulty: Easy
Heading: Chronic Venous Insufficiency
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
1.
2.
3.
4.
5.
Feedback
This is incorrect. Pulmonary embolism is unrelated to venous insufficiency.
This is correct. Obesity is a risk factor for developing venous insufficiency.
This is correct. Pregnancy is a risk factor for developing venous insufficiency.
This is incorrect. A client recovering from a shoulder surgery would not have an increased
risk of developing venous insufficiency.
This is incorrect. A client who uses a walker would not necessarily be at increased risk of
developing venous insufficiency.
PTS: 1
CON: Assessment
ORDERED RESPONSE
24. ANS:
PRIMEXAM.COM
CABD
Chapter: Chapter 19, Disorders of the Venous System
Page: 427
Objective: N/A
Difficulty: Difficult
Heading: Venous Ulcers
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Oxygenation
Feedback: A pulmonary embolism begins with a thrombus formation in the vein. The thrombus then becomes
an embolus and travels up into the inferior vena cava, and then into the right side of the heart, from where it
enters the pulmonary artery to become a pulmonary embolus.
PTS: 1
CON: Oxygenation
25. ANS:
CBAD
Chapter: Chapter 19, Disorders of the Venous System
Page: 430
Objective: N/A
Difficulty: Moderate
Heading: Varicose Veins
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Perfusion
Feedback: Blood stagnation and pooling in the lower extremities that are caused by prolonged standing and
gravitational pull put pressure on the valves. With pressure, the valves are damaged and are not able to
prevent the backflow of blood. This condition results in dilated superficial veins called varicose veins.
PTS: 1
CON: Perfusion
PRIMEXAM.COM
Chapter 20: Respiratory Inflammation and Infection
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. Which unique respiratory infection is caused by a resilient bacterial organism that can remain dormant in the
body?
1. Dyspnea
2. Tuberculosis(TB)
3. Pulmonary aspiration
4. Cough
2. Which is the process of coughing up sputum?
1. Expectoration
2. Hemoptysis
3. Atelectasis
4. Hypoxia
3. Which test involves the continuous monitoring of the oxygen saturation of hemoglobin?
1. Bronchoscopy
2. Computed tomography
3. Pulse oximetry
4. Arterial blood gases
4. Which condition results in lung tissue filling up with fluid or pus, inflammatory cells, and fibrin?
1. Pneumonia
2. Acute bronchitis
3. Tracheitis
4. Acute rhinitis
5. Which bacterium is responsible for pneumonia in a client with HIV infection?
1. Pneumocystis carinii
2. Pneumocystis jiroveci
3. Mycobacterium tuberculosis
4. Mycoplasma pneumoniae
6. Which pulmonary condition is caused by infiltration of bacteria, resulting in a localized area of purulent
inflammation, tissue necrosis, and central area of liquefaction?
1. Lung abscess
2. Myringitis
3. Tuberculosis
4. Tracheitis
7. .Which symptom is related to tuberculosis (TB)?
1. Cachexia
2. Night sweats
3. Hemoptysis
4. Both B and C
PRIMEXAM.COM
8. The nursing instructor is teaching a group of nursing students about pneumonia. Which statement shows
proper learning about pneumonia by the nursing students?
1. “Pneumonia causes more deaths in the United States than any other infection.”
2. “Hospital-associated pneumonia (HAP) is a lung infection that is contracted immediately
when the client is admitted to the hospital.”
3. “The pseudomonas microorganism is responsible for pneumonia that is spread by water.”
4. All of the above
9. While examining a client, the primary health-care provider finds that the client has symptoms that include
cough, fever, and sore throat, and general malaise. Physical assessment findings include mucus production
and rhonchi. Which treatment should the primary health-care provider administer to the client?
1. Bronchodilator and antibiotics
2. Intravenous (IV) fluids and humidified oxygen
3. Antibiotics and surgical treatment
4. Adequate hydration and nutrition
10. The nurse is teaching a group of nursing students about acute sinusitis. Which statement by the student
indicates proper learning about sinusitis?
1. “Sinusitis can be divided into acute and subacute sinusitis.”
2. “Chronic sinusitis involves inflammation of the sinuses, which is cured within a week.”
3. “Virus, bacteria, or both organism types may be responsible for acute sinusitis.”
4. “Mucolytic agents are used to treat the infection.”
11. While going through one of the client prescriptions, the nurse finds that the primary health-care provider has
prescribed antihistamines and antipyretics. The nurse observes that a corticosteroid anti-inflammatory nasal
spray has also been advised in the prescription. What condition can the nurse infer from the prescription?
1. The prescription provides medication for pharyngitis.
2. The prescription provides medication for sinusitis.
3. The prescription provides medication for rhinitis.
4. The prescription provides medication for tonsillitis.
12. On assessing the physical findings of a client, the nurse discovers that the client has red, swollen, inflamed
pharynx and tonsils. What condition can the nurse suspect from the findings?
1. Laryngitis
2. Acute bronchitis
3. Lung abscess
4. Epiglottitis
13. While going through the physical assessment finding of a particular client, the primary health-care provider
observes facial pain in the client. The client complains that the pain gets worse when he or she leans forward.
What inference can the primary health-care provider draw from these findings?
1. Sinusitis
2. Pharyngitis
3. Epiglottitis
4. Tonsillitis
14. In the prescription of a client, the nurse observes treatment involving decongestants, antihistamines, saline
sprays, and heated mists. Which condition, according to the nurse, can be treated by these types of
medications?
1. Pharyngitis
2. Sinusitis
PRIMEXAM.COM
3. Tracheitis
4. Acute bronchitis
15. While studying the vocal resonance in the client’s physical assessment report, the nurse observes that the
egophony, bronchophony, and whispered pectoriloquy are bringing out crackle in the client. Which condition
can the nurse infer from the readings?
1. The client is suffering from acute bronchitis.
2. The client is suffering from pneumonia.
3. The client is suffering from lung abscess.
4. The client is suffering from tuberculosis (TB).
16. The nursing instructor is teaching student nurses about the pathophysiology of tuberculosis (TB). Which
statement confirms proper learning of the student nurse?
1. “The M. tuberculi bacterium gets absorbed through the perspiration of an individual.”
2. “The calcified lesion in TB is called the Ghon’s focus.”
3. “The cheese-like necrotic lung tissue is called the caseous necrosis.”
4. “The TB organism is anaerobic.”
17. The nursing instructor is teaching the student nurses about the origin and risk factors leading to lung abscess.
Which statement confirms proper learning of the student nurse about the subject?
1. “One of the most prominent risk factors includes obesity.”
2. “Lung abscesses lead to the complication of bacterial pneumonia.”
3. “Intraoral drug use poses a risk factor for lung abscess.”
4. “Staphylococcal endocarditis is the initial stage of lung abscesses.”
18. A client is diagnosed with allergic rhinitis. Which medication should the primary health-care provider
prescribe as a treatment?
1. Penicillin
2. Corticosteroid anti-inflammatory nasal spray
3. Intravenous fluids
4. Acetaminophen
19. A client admitted with a lung abscess has developed an area of pulmonary tissue necrosis. What is the most
appropriate treatment to manage this complication?
1. Surgical treatment
2. Adequate hydration and nutrition
3. Humidified oxygen
4. Intravenous fluids
20. The primary health-care provider orders decongestants for a client. Which condition may be present?
1. Tonsillitis
2. Rhinitis
3. Pharyngitis
4. Sinusitis
21. While diagnosing a client, the primary health-care provider finds the cervical lymph nodes to be extremely
tender. Which condition does the primary health-care provider write in the client’s prescription?
1. Lung abscess
2. Myringitis
3. Acute pharyngitis
4. Tracheitis
PRIMEXAM.COM
22. The nursing instructor is teaching lung anatomy to a group of students. Which statement relates appropriately
to the students’ learning of lung anatomy?
1. “The lung receives air from the lower respiratory tract.”
2. “There are three lobes in the lung tissue on the left.”
3. “There are three lobes in the lung tissue on the right.”
4. “The two main bronchi and bronchioles are part of the lungs.”
23. Which specialized cellular mechanism comprises ciliated pseudocolumnar epithelial cells and goblet cells?
1. Mucociliary apparatus
2. Alveoli
3. Oxyhemoglobin
4. Erythropoietin
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
24. The primary health-care provider, while examining the test report of a client, finds that the client is producing
foul-smelling sputum with a cough. This sign is accompanied by chills, fever, and chest pain. Which
treatments should be prescribed by the primary health-care provider? Select all that apply.
1. Antibiotic therapy
2. Antimicrobial medications such as isoniazid, rifampin, pyrazinamide, ethambutol, and
streptomycin
3. Respiratory isolation until the client is no longer infected
4. Surgical intervention
5. Bronchoscopy
25. The nurse is treating a client who has the symptoms of pharyngeal erythema, lymphadenopathy, and
rhinorrhea on physical examination. The inspiratory stridor of the client shows mucous obstruction within the
trachea. Which would the nurse expect the primary health-care provider to prescribe or carry out? Select all
that apply.
1. Symptomatology
2. Complete blood count (CBC)
3. Throat culture and sensitivity
4. Mantoux tuberculin skin test
5. Palpate the frontal and transmaxillary sinuses
PRIMEXAM.COM
Chapter 20: Respiratory Inflammation and Infection
Answer Section
MULTIPLE CHOICE
1. ANS: 2
Chapter: Chapter 20, Respiratory Inflammation and Infection
Page: 452
Objective: N/A
Difficulty: Easy
Heading: Epidemiology
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Infection
1
2
3
4
Feedback
Dyspnea is a sensation in which a person feels shortness of breath.
TB is a unique respiratory infection caused by a resilient bacterial organism that can
remain dormant in the body as latent TB.
Pulmonary aspiration occurs when materials from the oropharynx enter the lower
respiratory tract.
Cough is an involuntary response to mechanical or chemical stimulation of the
bronchial tree.
PTS: 1
CON: Infection
2. ANS: 1
Chapter: Chapter 20, Respiratory Inflammation and Infection
Page: 441
Objective: N/A
Difficulty: Easy
Heading: Cough
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Infection
1
2
3
4
Feedback
Expectoration is the process of coughing up sputum.
Hemoptysis refers to the production of sputum that contains blood.
Atelectasis is the collapse of a small number of alveoli, resulting in reduced gas
exchange in the body.
Hypoxia occurs when there are insufficient oxygen levels in the blood to meet the needs
of the tissue.
PTS: 1
CON: Infection
PRIMEXAM.COM
3. ANS: 3
Chapter: Chapter 20, Respiratory Inflammation and Infection
Page: 445
Objective: N/A
Difficulty: Easy
Heading: Pulse Oximetry
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
1
2
3
4
Feedback
Bronchoscopy helps direct visualization of the larynx, trachea, and bronchi.
A computed tomography scan shows a more specific picture of the respiratory system,
identifying different pathological conditions, such as lung abscesses and tumors.
Pulse oximetry can continuously monitor the oxygen saturation of hemoglobin.
Arterial blood gases provide information about the exchange of gases.
PTS: 1
CON: Assessment
4. ANS: 1
Chapter: Chapter 20, Respiratory Inflammation and Infection
Page: 441
Objective: N/A
Difficulty: Easy
Heading: Pneumonia
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Infection
1
2
3
4
Feedback
Pneumonia is the inflammation of the lung tissues, leading to the alveolar air spaces
filling with purulent, inflammatory cells, and fibrin.
Acute bronchitis is an inflammation of the bronchi and the bronchioles caused by either
bacterial or viral infection.
Tracheitis is infection and inflammation of the trachea, commonly caused by bacteria.
Acute rhinitis results in the inflammation and irritation of the mucous membranes of the
nose.
PTS: 1
CON: Infection
5. ANS: 2
Chapter: Chapter 20, Respiratory Inflammation and Infection
Page: 449
Objective: N/A
Difficulty: Easy
Heading: Pneumonia
Integrated Processes: Nursing Process
PRIMEXAM.COM
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Infection
Feedback
1
2
3
4
Pneumocystis carinii is the former name for the yeast-like fungal organism called
Pneumocystis carinii.
Pneumocystis jiroveci is responsible for causing pneumonia.
Mycobacterium tuberculosis is responsible for tuberculosis (TB).
Mycoplasma pneumoniae is responsible for _neumoniaia, or myringitis, which is the
inflammation of the tympanic membrane.
PTS: 1
CON: Infection
6. ANS: 1
Chapter: Chapter 20, Respiratory Inflammation and Infection
Page: 451
Objective: N/A
Difficulty: Easy
Heading: Lung Abscess
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Infection
1
2
3
4
Feedback
Lung abscess is caused by infiltration of infective organisms, resulting in necrosis of
the pulmonary tissue and formation of cavities containing necrotic debris or fluid.
Myringitis, or otitis media, is an inflammation of the tympanic membrane that results
from Mycoplasma pneumoniae infection.
Tube_neumonias an infection caused by the bacillus Mycobacterium tuberculosis that
is found in the lungs.
Tracheitis is the inflammation of the trachea that is caused mainly by Haemophilus
influenza.
PTS: 1
CON: Infection
7. ANS: 4
Chapter: Chapter 20, Respiratory Inflammation and Infection
Page: 441
Objective: N/A
Difficulty: Easy
Heading: Tuberculosis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Infection
Feedback
PRIMEXAM.COM
1
2
3
4
Cachexia is a symptom related to lung abscess.
Night sweats are a symptom of TB.
Hemoptysis is also a symptom for TB.
Both option B and C are correct; night sweats and hemoptysis are related to TB.
PTS: 1
CON: Infection
8. ANS: 1
Chapter: Chapter 20, Respiratory Inflammation and Infection
Page: 443
Objective: N/A
Difficulty: Difficult
Heading: Pneumonia
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Oxygenation
1
2
3
4
Feedback
Statement A is correct because pneumonia is the cause of most death and disease in the
USA.
Statement B is incorrect because HAP is a lung infection contracted more than 48 hours
after the client is admitted to the hospital.
Statement C is incorrect because pseudomonas is one of the microorganisms
responsible for ventilator-associated pneumonia (VAP), as well as HAP.
Only the first statement is correct.
PTS: 1
CON: Infection
9. ANS: 1
Chapter: Chapter 20, Respiratory Inflammation and Infection
Page: 448
Objective: N/A
Difficulty: Moderate
Heading: Acute Bronchitis
Integrated Processes: Nursing Process
Client Need: Physiologic Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Medication
1
2
3
4
Feedback
These symptoms are related to acute bronchitis. Therefore, the primary health-care
provider would administer a bronchodilator and antibiotics.
IV fluids and humidified oxygen are the prescribed treatments for epiglottitis.
Antibiotics and surgical treatment are used to treat lung abscess.
Adequate hydration and nutrition are prescribed to treat a client diagnosed with
tuberculosis.
PTS: 1
CON: Medication
PRIMEXAM.COM
10. ANS: 3
Chapter: Chapter 20, Respiratory Inflammation and Infection
Page: 446-447
Objective: N/A
Difficulty: Difficult
Heading: Acute Sinusitis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Infection
Feedback
1
2
3
4
This statement is incorrect because sinusitis can be divided into three categories: acute,
subacute, or chronic sinusitis.
This statement is also incorrect because chronic sinusitis involves an inflammation of
the sinuses that persists for more than 12 weeks.
This statement is correct because it shows that the nursing student has appropriate
learning.
Mucolytic agents are administered to decrease secretion, but they do not treat the
infection.
PTS: 1
CON: Infection
11. ANS: 3
Chapter: Chapter 20, Respiratory Inflammation and Infection
Page: 446
Objective: N/A
Difficulty: Difficult
Heading: Acute Rhinitis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Infection
1
2
3
4
Feedback
The prescription does not provide medication for pharyngitis. The prescriptions for
pharyngitis may recommend penicillin, erythromycin, and cephalosporin. Treatments
also include symptomatic relief, antipyretics and nonsteroidal anti-inflammatory drugs
(NSAIDs).
The prescription does not provide medications for sinusitis, since the prescription for
sinusitis may include decongestants, antihistamines, saline sprays, and heated mists.
The prescription provides medication for rhinitis since it provides symptomatic
treatment involving antihistamines and antipyretics, combined with a corticosteroid
anti-inflammatory nasal spray meant for allergic rhinitis.
The prescription does not provide medication for tonsillitis because tonsillitis is treated
with antibiotics when group A beta-hemolytic streptococcus (GABHS) is noted. The
prescription may comprise tonsillectomy in the occurrence of infections or severe tissue
hypertrophy.
PRIMEXAM.COM
PTS: 1
CON: Infection
12. ANS: 4
Chapter: Chapter 20, Respiratory Inflammation and Infection
Page: 447
Objective: N/A
Difficulty: Difficult
Heading: Epiglottitis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Assessment
1
2
3
4
Feedback
Laryngitis is a condition in which the client has hoarseness or a complete loss of voice,
along with an irritating, high-pitched, brassy cough.
Bronchitis involves fever combined with cough. Rhonchi can also be heard over the
lungs.
A lung abscess is a condition that includes fever and a copious amount of foul-smelling
sputum. Decreased breath sound can be heard in the area of the abscess.
Epiglottitis is a condition where the client has red, swollen, inflamed pharynx and
tonsils. A swollen epiglottis can also be observed.
PTS: 1
CON: Infection
13. ANS: 1
Chapter: Chapter 20, Respiratory Inflammation and Infection
Page: 446-447
Objective: N/A
Difficulty: Difficult
Heading: Acute Sinusitis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Assessment
1
2
3
4
Feedback
The physical assessment findings of clients with sinusitis show facial pain or pressure
over the sinus area, which worsens when leaning forward or sitting in the head-down
position.
A client diagnosed with pharyngitis has red, swollen pharyngeal membrane and tonsils.
In addition, the lymphoid follicles become swollen and are covered with white
exudates.
A client diagnosed with epiglottitis has red, swollen, inflamed pharynx and tonsils,
along with a swollen epiglottis.
A client diagnosed with tonsillitis has a red, inflamed pharynx, tonsillar tissues,
edematous, and erythematous, as well as a white exudate over the tonsillar tissue.
PRIMEXAM.COM
PTS: 1
CON: Infection
14. ANS: 2
Chapter: Chapter 20, Respiratory Inflammation and Infection
Page: 447
Objective: N/A
Difficulty: Difficult
Heading: Acute Sinusitis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Infection
1
2
3
4
Feedback
Pharyngitis may be treated with antibiotics such as penicillin, erythromycin,
antipyretics, and non-steroidal anti-inflammatory drugs (NSAIDS).
The prescription for sinusitis involves decongestants, antihistamines, saline sprays, and
heated mists.
A prescription for tracheitis may suggest that the client rest the voice, apply
bronchodilators, and take antibiotics.
A prescription for bronchitis comprises expectorants, cough suppressants, antibiotics,
bronchodilator, and antipyretics.
PTS: 1
CON: Infection
15. ANS: 2
Chapter: Chapter 20, Respiratory Inflammation and Infection
Page: 449
Objective: N/A
Difficulty: Difficult
Heading: Pneumonia
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Assessment
1
2
3
4
Feedback
The client is not suffering from acute bronchitis because the physical assessment
findings of pneumonia involve fever, cough, and mucous production.
The client is suffering from pneumonia because the vocal resonance report, which is a
physical assessment finding, involves egophony, bronchophony, and whispered
pectoriloquy eliciting crackle.
The physical examination of a client with lung abscess involves fever and copious
amounts of foul-smelling sputum.
The physical assessment of TB indicates cough with purulent sputum or hemoptysis.
PTS: 1
CON: Assessment
16. ANS: 3
Chapter: Chapter 20, Respiratory Inflammation and Infection
PRIMEXAM.COM
Page: 449
Objective: N/A
Difficulty: Difficult
Heading: Pneumonia
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Assessment
1
2
3
4
Feedback
Statement A is not correct because M. tuberculi is inhaled from another person’s cough
or sneeze, and the droplets pass down the airway, which leads to the formation of the
bronchial tree.
Statement B is not correct because the calcified lesion in TB is called the Ranke
complex.
Statement C is correct because the cheese-like necrotic lung tissue is called caseous
necrosis.
Statement D is not correct because the TB organism is aerobic.
PTS: 1
CON: Infection
17. ANS: 4
Chapter: Chapter 20, Respiratory Inflammation and Infection
Page: 451
Objective: N/A
Difficulty: Difficult
Heading: Lung Abscess
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Infection
1
2
3
4
Feedback
Statement A is incorrect because the prominent risk factors involve advanced age,
alcoholism, debilitation, malnutrition, HIV infection or other forms of
immunosuppressive therapy, and malignancy, but not obesity.
Statement B is incorrect because lung abscess can develop as a complication of
bacterial pneumonia.
Statement C is incorrect because intravenous drug use is a risk factor specifically for
staphylococcal lung abscesses.
Statement D is correct because staphylococcal endocarditis usually occurs initially,
followed by the development of septic emboli.
PTS: 1
CON: Infection
18. ANS: 2
Chapter: Chapter 20, Respiratory Inflammation and Infection
Page:446
Objective: N/A
PRIMEXAM.COM
Difficulty: Moderate
Heading: Acute Rhinitis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Medication
1
2
3
4
Feedback
Penicillin is an antibiotic used for pharyngitis.
Corticosteroid anti-inflammatory nasal spray is used for allergic rhinitis.
Intravenous fluids are used for the treatment of epiglottitis.
Acetaminophen is used for the treatment of laryngitis, tracheitis, acute bronchitis, and
pneumonia.
PTS: 1
CON: Medication
19. ANS: 1
Chapter: Chapter 20, Respiratory Inflammation and Infection
Page: 451
Objective: N/A
Difficulty: Moderate
Heading: Lung Abscess
Integrated Processes: Nursing Process
Client Need: Physiologic Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Medication
1
2
3
4
Feedback
A client diagnosed with lung abscess or a localized area of infection and purulent
inflammation that has resulted in tissue necrosis should be treated with surgical
intervention.
Adequate hydration and nutrition are essential for the treatment for tuberculosis (TB).
Humidified oxygen is used for the treatment of pneumonia.
Intravenous fluids are required for a client with epiglottitis.
PTS: 1
CON: Medication
20. ANS: 4
Chapter: Chapter 20, Respiratory Inflammation and Infection
Page: 446-447
Objective: N/A
Difficulty: Moderate
Heading: Acute Sinusitis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Infection
Feedback
PRIMEXAM.COM
1
2
3
4
Tonsillitis is not treated by decongestants. Antibiotics and tonsillectomy help in treating
tonsillitis.
A condition like rhinitis is treated with acetaminophen, antihistamines, and antipyretics,
to name a few medications, but not decongestants.
Pharyngitis is treated with antibiotics, as well as antipyretics and nonsteroidal antiinflammatory drugs, but not decongestants.
Sinusitis is treated with decongestants.
PTS: 1
CON: Infection
21. ANS: 3
Chapter: Chapter 20, Respiratory Inflammation and Infection
Page: 446
Objective: N/A
Difficulty: Moderate
Heading: Acute Pharyngitis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Infection
1
2
3
4
Feedback
The physical assessment finding of lung abscess involves copious amounts of foulsmelling sputum.
Otitis media or myringitis is inflammation of the tympanic membranes.
The physical assessment of acute pharyngitis involves cervical lymph nodes.
The physical assessment of tracheitis involves hoarseness or complete loss of voice.
PTS: 1
CON: Infection
22. ANS: 3
Chapter: Chapter 20, Respiratory Inflammation and Infection
Page: 437
Objective: N/A
Difficulty: Moderate
Heading: Lung Anatomy
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Oxygenation
1
2
3
4
Feedback
The first statement is incorrect because the lung receives air from the upper respiratory
tract.
The second statement is incorrect because there are two lobes in the lung tissue on the
left, specifically the upper lobes and the lower lobes.
The third statement is correct because there are three lobes: the upper, middle, and
lower lobes.
The fourth statement is incorrect because the two main bronchi and bronchioles form
PRIMEXAM.COM
part of the upper respiratory tract.
PTS: 1
CON: Oxygenation
23. ANS: 1
Chapter: Chapter 20, Respiratory Inflammation and Infection
Page: 438
Objective: N/A
Difficulty: Easy
Heading: Mucociliary Apparatus
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Oxygenation
1
2
3
4
Feedback
Mucociliary apparatus is a specialized cellular mechanism that comprises the ciliated
pseudo-columnar epithelial cells and goblet cells.
Alveoli are thin-walled, balloon-like structures surrounded by pulmonary capillaries.
Oxyhemoglobin is the combination of oxygen with the heme portion of hemoglobin.
Erythropoietin stimulates the bone marrow to produce more red blood cells that can
carry more oxygen to the tissues.
PTS: 1
CON: Oxygenation
MULTIPLE RESPONSE
24. ANS: 1, 4, 5
Chapter: Chapter 20, Respiratory Inflammation and Infection
Page: 451
Objective: N/A
Difficulty: Moderate
Heading: Lung Abscess
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Infection
1.
2.
3.
4.
5.
Feedback
This is correct. These symptoms are indicative of lung abscess. The primary health-care
provider should prescribe an antibiotic therapy for the treatment.
This is incorrect. Antimicrobial medications such as isoniazid, rifampin, pyrazinamide,
ethambutol, and streptomycin are used for the treatment of tuberculosis.
This is incorrect. Tuberculosis is contagious, but not a lung abscess. Therefore, the primary
health-care provider should not prescribe respiratory isolation.
This is correct. The primary health-care provider should prescribe surgical intervention,
which is a part of the lung abscess treatment.
This is correct. Bronchoscopy is required in the treatment of lung abscess to drain the
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abscess.
PTS: 1
CON: Infection
25. ANS: 1, 4
Chapter: Chapter 20, Respiratory Inflammation and Infection
Page: 448
Objective: N/A
Difficulty: Moderate
Heading: Acute Bronchitis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Assessment
1.
2.
3.
4.
5.
Feedback
This is correct. Because all the above symptoms suggest a case of acute bronchitis,
symptomatology should be advised as a diagnostic test for the client.
This is correct. A CBC is useful for distinguishing bacterial infections from nonbacterial
infections in the case of acute bronchitis.
This is incorrect. Throat culture and sensitivity show the presence of beta-hemolytic
streptococcus (GABHS) in the case of pharyngitis.
This is incorrect. A Mantoux tuberculin test is one of the diagnostic tests used for the
diagnosis of tuberculosis (TB), not acute bronchitis.
This is incorrect. Visual inspection and palpation of the frontal and maxillary sinuses is
used for the diagnosis of acute sinusitis.
PTS: 1
CON: Assessment
PRIMEXAM.COM
Chapter 21: Skin Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. Which condition is also known as hypoventilation syndrome?
1. Obstructive sleep apnea (OSA)
2. Bronchiectasis
3. Pneumocystis jiroveci infection
4. Pulmonary hypertension
2. What is a clot that has traveled to the pulmonary arterial circulation and caused obstruction of the arterial
blood flow through the lungs known as?
1. Pulmonary edema
2. Pulmonary embolism
3. Idiopathic pulmonary fibrosis
4. Pleural effusion
3. Which lung condition is common in clients with a genetic disorder such as Marfan syndrome as well as
frequent smokers?
1. Secondary spontaneous pneumothorax
2. Traumatic pneumothorax
3. Tension pneumothorax
4. Primary spontaneous pneumothorax
4. A primary health-care provider finds that a client is suffering from symptoms such as jugular venous
distension, ascites, hepatomegaly, and ankle or sacral edema. What condition does the health-care provider
interpret from this situation?
1. Pulmonary hypertension
2. Cor pulmonale
3. Asthma
4. Chronic hypoxia
5. A nurse suspects a client may have obstructive sleep apnea (OSA). What should the nurse utilize as a
diagnostic tool to diagnose OSA?
1. Chest x-ray
2. CT scan
3. Ultrasound
4. Polysomnography
6. While assessing the reports of a client, a nurse finds that there has been an abnormal collection of fluid within
the pleural cavity. What remedy can the nurse infer about the condition based on the symptoms?
1. Applying mucolytic agents and bronchodilators along with oxygen
2. Thoracotomy as well as a chest tube attached for suctioning
3. Administering corticosteroid treatment
4. Focus on the treatment based on orthopedic bracing
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7. After assessing a client’s reports, a nurse finds that the client is suffering from wheezing, prolonged
exhalations, and rhonchi. The client uses accessory muscles during breathing. As a treatment, the primary
health-care provider prescribes bronchodilators and corticosteroids in the form of inhalers as treatment. What
disorder can the nurse infer from the symptoms of the client and the treatment that has been provided to the
client?
1. The client is suffering from idiopathic pulmonary fibrosis.
2. The client is suffering from bronchiectasis.
3. The client is suffering from asthma.
4. The client is suffering from pleural effusion.
8. A nurse is assessing a 28-year-old client who is a smoker and has inherited Marfan syndrome as a genetic
disorder. The previous medical reports of the client do not suggest any evidence of an underlying lung
disease. Which condition is possible in the client according to the nurse’s prediction?
1. Traumatic pneumothorax
2. Tension pneumothorax
3. Iatrogenic pneumothorax
4. Primary spontaneous pneumothorax
9. A victim of a motor vehicle accident comes to a medical facility with a rib fracture that has punctured the
pleural membrane. The open wound allows the pleural cavity to pull air into the opening of the wound, thus
building a pleural space. What treatment can a nurse expect from the primary health-care provider?
1. A large bore needle to be inserted to the affected side
2. The process of pleurodesis to be performed on the client
3. A chest tube with suction to be applied on the affected side
4. Surgical intervention of the affected side
10. A nurse is preparing a client for a central venous catheter insertion. Which condition during the operating
procedure should the nurse be most alert of?
1. Secondary spontaneous pneumothorax (SSP)
2. Tension pneumothorax
3. Iatrogenic pneumothorax
4. Traumatic pneumothorax
11. After assessing the recent chest x-rays of a client, a nurse finds nodules and honeycomb lung patterns. On
assessing the client’s previous chest x-ray report, the nurse finds diffused “ground glass” markings in the
lower lung fields. What condition can the nurse infer from these observations?
1. Idiopathic pulmonary fibrosis
2. Thoracic cage deformity
3. Pleural effusion
4. Pulmonary embolism
12. A nurse is assessing a client diagnosed with secondary pulmonary hypertension. The increase in the
pulmonary artery pressure has led to the client’s elevated pulmonary venous pressure. Which condition does
the nurse predict to occur in the client?
1. Pulmonary edema
2. Anthracosis
3. Collagen vascular disease
4. Bronchiectasis
13. A nurse is assessing a client with a short but thick neck circumference. Which form of cardiopulmonary
disorder can the nurse suspect in the client?
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1.
2.
3.
4.
Pickwickian syndrome
Allergic bronchopulmonary aspergillosis
Cor pulmonale
Marfan syndrome
14. A primary health-care provider is assessing a client who is a minor and has been constantly exposed to silica.
What immediate test does a nurse expect the primary health-care provider to carry on the client for detecting
tuberculosis (TB)?
1. Transthoracic echocardiogram
2. Mantoux test
3. Polysomnogram
4. Pulmonary function test (PFT)
15. A nurse has been assessing a client who has been working as a butcher for an extensive period. The client had
a prolonged and intense exposure to inhaled organic dust in the form of animal protein. What disorder,
according to the nurse, can affect the client the most?
1. Idiopathic pulmonary fibrosis
2. Hypersensitivity pneumonitis
3. Anthracosis
4. Primary spontaneous pneumothorax (PSP)
16. A nurse is assessing a client who has been working in the paint factory for an extensive period. The client has
been constantly exposed to mineral crystals in the form of asbestos. The client has been a chain smoker as
well. What prevalent disease, according to the nurse, is the client prone to?
1. Hypoxemia
2. Mesothelioma
3. Tuberculosis (TB)
4. Pneumothorax
17. A nurse is advising a client about adult respiratory distress syndrome (ARDS). Which statement shows best
that the nurse properly understands the disorder?
1. “The illness develops within 48 to 72 hours of the inciting event.”
2. “ARDS leads to acute pancreatitis or aspiration.”
3. “An individual developing ARDS has multiple organ failure and becomes critically ill.”
4. “ARDS is a genetic disorder that is caused by the abnormal structure of the pulmonary
blood vessels.”
18. A nurse instructor is teaching a group of student nurses about obstructive sleep apnea (OSA). Which
treatment, according to the nurse, should be most appropriate to keep the airways from closing?
1. Continuous positive airway pressure (CPAP)
2. Polysomnography
3. Central nervous system stimulants
4. Leukotriene antagonists
19. A nurse is teaching a group of student nurses about the administration of asthma medication. Which statement
by a student nurse shows appropriate learning?
1. “Asthma medication generally falls under three categories.”
2. “A common short-acting maintenance medication is a combination of adrenergic beta-2
agonist and corticosteroid.”
3. “An oral leukotriene antagonist should not be used by the client on a daily basis if the
asthma attack is acute.”
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4. “An oral corticosteroid is added to the regimen of rescue medications when short-acting
bronchodilators are not acting against asthma attacks.”
20. A primary health-care provider finds a client complaining of chest pain, dyspnea, and an increased respiratory
rate. On closer inspection, the chest expansion is found to be asymmetrical. On percussion, the primary
health-care provider finds chest hyperresonance. What condition can the primary health-care provider
interpret from this situation?
1. The client is suffering from pneumothorax or collapsed lungs.
2. The client is suffering from pleural effusion.
3. The client is suffering from asbestosis.
4. The client is suffering from thoracic cage deformity.
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
21. Which area of the body should a nurse focus on when palpating the thoracic cage of a client when assessing
for any pulmonary disease? Select all that apply.
1. Clavicles
2. Axillary nodes
3. Ribs
4. Supraclavicular
5. Cervical nodes
22. A nurse is assessing a child with chronic asthma. Which microorganisms, according to the nurse, are
responsible for causing asthma in the child? Select all that apply.
1. Rhinovirus
2. Adenovirus
3. Pseudomonas aeruginosa
4. Respiratory syncytial virus
5. Staphylococcus aureus
23. Which diseases fall under restrictive pulmonary diseases? Select all that apply.
1. Diseases that lead to formation of excessive mucous
2. Diseases that prevent complete ventilation
3. Diseases that lead to loss of lung elastic recoil
4. Diseases that reduce the total lung capacity
5. Diseases that act as an impediment to alveoli
24. Which procedures are specifically utilized for the treatment of pleural effusion? Select all that apply
1. Surgery for the reduction of the pharyngeal tissues
2. Administration of mucolytic agents
3. Drainage
4. Chest tube attached to suction
5. Orthopedic bracing
25. What is the diagnostic outcome of coal miner’s pneumoconiosis? Select all that apply.
1. Decreased FEV count during PFT
2. Chest x-ray reveals fluid in pleural space
3. Hypoxemia is found in an arterial blood gas (ABG) test
4. Collapsed lung and air in the pleural space
PRIMEXAM.COM
5. Computed tomography scan shows dilated, fibrotic airways
PRIMEXAM.COM
Chapter 21: Skin Disorders
Answer Section
MULTIPLE CHOICE
1. ANS: 1
Chapter: Chapter 21, Restrictive and Obstructive Pulmonary Disorders
Page: 471
Objective: N/A
Difficulty: Easy
Heading: Obstructive Sleep Apnea
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Oxygenation
1
2
3
4
Feedback
OSA, also called hypoventilation syndrome, is characterized by intermittent cessation
of airflow from the nose and mouth during sleep.
Bronchiectasis is considered to be an uncommon disease. The disease is an outcome of
untreated infections that lead to chronic inflammation and dilatation of the bronchi.
A Pneumocystis jiroveci infection is associated with emphysematous changes in the
lungs in an individual who has AIDS.
Pulmonary hypertension is characterized by abnormally high pressure in the pulmonary
arteries.
PTS: 1
CON: Oxygenation
2. ANS: 2
Chapter: Chapter 21, Restrictive and Obstructive Pulmonary Disorders
Page: 476
Objective: N/A
Difficulty: Easy
Heading: Pulmonary Edema
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Oxygenation
1
2
3
4
Feedback
Pulmonary edema is the accumulation of fluid around the alveoli that inhibits oxygen
transfer at the alveolar-capillary interface.
Pulmonary embolism is a condition where a clot has traveled to the pulmonary arterial
circulation and caused obstruction of the arterial blood flow through the lungs.
Idiopathic pulmonary fibrosis is a restrictive lung disease caused by the repeated
injury of the lung tissue by an unidentified agent.
Pleural effusion is a condition that is characterized by the accumulation of fluid within
PRIMEXAM.COM
the pleural space.
PTS: 1
CON: Oxygenation
3. ANS: 4
Chapter: Chapter 21, Restrictive and Obstructive Pulmonary Disorders
Page: 472
Objective: N/A
Difficulty: Easy
Heading: Pneumothorax
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Oxygenation
1
2
3
4
Feedback
Secondary spontaneous pneumothorax is an underlying pathological process that occurs
in the lungs.
Traumatic pneumothorax is commonly caused by a penetrating wound of the thoracic
cage and underlying pleural membrane.
Tension pneumothorax occurs in a case of escalating build-up of air within the pleural
cavity that compresses the lungs, bronchioles, cardiac structures, and vena cava.
Primary spontaneous pneumothorax is a common finding in people who have Marfan
syndrome, which is a genetic disorder. It also commonly occurs in frequent smokers.
PTS: 1
CON: Oxygenation
4. ANS: 2
Chapter: Chapter 21, Restrictive and Obstructive Pulmonary Disorders
Page: 468
Objective: N/A
Difficulty: Moderate
Heading: Chronic Obstructive Pulmonary Disease
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Oxygenation
1
2
3
4
Feedback
Pulmonary hypertension is defined by abnormally high pressure within the pulmonary
arteries caused either due to an abnormal structure of the blood vessels, or by an
increase in the pulmonary venous pressure.
These all are the symptoms of cor pulmonale. Failure of the right side of the heart is
caused by a pulmonary disorder known as cor pulmonale.
Asthma has the symptoms of wheezing, coughing, dyspnea, and chest tightness.
Chronic hypoxia involves symptoms such as dyspnea and erythropoietin secretion by
the kidneys.
PTS: 1
CON: Oxygenation
PRIMEXAM.COM
5. ANS: 4
Chapter: Chapter 21, Restrictive and Obstructive Pulmonary Disorders
Page: 471
Objective: N/A
Difficulty: Moderate
Heading: Obstructive Sleep Apnea
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Sleep, Rest, and Activity
1
2
3
4
Feedback
A chest x-ray is used for the diagnosis of pleural effusion, pneumothorax, coal worker’s
pneumoconiosis, hypersensitivity pneumonitis, and several other lung diseases.
A CT scan is used as a diagnostic procedure for pulmonary hypertension, coal worker’s
pneumoconiosis, asbestosis, silicosis, pulmonary hypertension, and other lung
conditions.
An ultrasound is a diagnostic method used for pleural effusion and pulmonary
hypertension.
Polysomnography is the only diagnostic test that shows OSA.
PTS: 1
CON: Sleep, Rest, and Activity
6. ANS: 2
Chapter: Chapter 21, Restrictive and Obstructive Pulmonary Disorders
Page: 474
Objective: N/A
Difficulty: Difficult
Heading: Pleural Effusion
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Oxygenation
1
2
3
4
Feedback
Mucolytic agents and bronchodilators along with oxygen should be applied for the
treatment of bronchiectasis.
Thoracotomy as well as a chest tube attached for suctioning of the fluid from the
pleural cavity is a treatment for pleural effusion.
Idiopathic pulmonary fibrosis and hypersensitivity pneumonitis are both treated by
administering corticosteroids.
Orthopedic bracing is a treatment for thoracic deformity in a client.
PTS: 1
CON: Oxygenation
7. ANS: 3
Chapter: Chapter 21, Restrictive and Obstructive Pulmonary Disorders
Page: 465-466
Objective: N/A
PRIMEXAM.COM
Difficulty: Difficult
Heading: Asthma
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Oxygenation
1
2
3
4
Feedback
The client is not suffering from idiopathic pulmonary fibrosis because the assessment
finding of the disease includes dyspnea, cough, tachypnea, crackles, and cyanosis. The
treatment involves similar medication such as bronchodilators, corticosteroids, and
pulmonary vasodilators.
This is not a case of bronchiectasis because the assessment findings of the condition
show dyspnea, coughing, and wheezing throughout the lung field. The treatment for the
condition includes mucolytic agents, bronchodilators, oxygen, and antibiotics when
necessary.
The client is suffering from asthma as wheezing, prolonged exhalations, rhonchi, and
use of accessory muscles during breathing are included in the assessment study of the
client. Bronchodilators and corticosteroids in the form of an inhaler is a common
treatment for asthma.
This is not a case of pleural effusion because the assessment study of the condition
involves the lack of breath sounds over an area of effusion, asymmetric chest expansion
with inhalation, and percussion of dullness over an area of effusion. The treatment of
pleural effusion includes thoracotomy and a chest tube attached to suction.
PTS: 1
CON: Oxygenation
8. ANS: 4
Chapter: Chapter 21, Restrictive and Obstructive Pulmonary Disorders
Page: 472
Objective: N/A
Difficulty: Difficult
Heading: Pneumothorax
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Oxygenation
1
2
3
4
Feedback
The client does not have risk of traumatic pneumothorax, which is a condition in the
lungs caused by the penetrating wound of the thoracic cavity.
The client does not have risk of from tension pneumothorax, which is defined by an
escalating build-up of air within the pleural cavity. This further compresses the
bronchioles, cardiac structure, and vena cava.
The client will not have iatrogenic pneumothorax because this condition is
characterized by complications from a medical or surgical procedure.
The client does have a risk of developing primary spontaneous pneumothorax because
the client shows all the symptoms, including smoking and inheriting a genetic disorder
PRIMEXAM.COM
like Marfan syndrome.
PTS: 1
CON: Oxygenation
9. ANS: 3
Chapter: Chapter 21, Restrictive and Obstructive Pulmonary Disorders
Page: 472-473
Objective: N/A
Difficulty: Moderate
Heading: Pneumothorax
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Oxygenation
1
2
3
4
Feedback
The process of a large bore inserted into the affected side to pull out air from the chest
relieves the accumulated pressure on the mediastinal structures as a treatment in case of
tension pneumothorax.
The process of pleurodesis should be performed on a client to prevent reoccurrence of
spontaneous pneumothorax. The process causes intentional chemical or surgical
irritation of the layers of the pleural membrane, thus causing the visceral and parietal
pleural membrane layers to adhere to each other and close off the pleural space.
In case of open traumatic pneumothorax, a chest tube with suction should be applied on
the client’s affected side. The chest tube apparatus pulls the air out of the pleural cavity
allowing the collapsed lung to re-expand.
Surgical intervention is required for effusions that cannot be drained adequately by a
needle or small-bore catheters.
PTS: 1
CON: Oxygenation
10. ANS: 3
Chapter: Chapter 21, Restrictive and Obstructive Pulmonary Disorders
Page: 472
Objective: N/A
Difficulty: Moderate
Heading: Pneumothorax
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Perioperative
1
2
3
Feedback
The nurse should not be worried about SSP because it involves the air entering the
pleural space via overly distended and damaged alveoli.
The nurse should not be worried about tension pneumothorax because it involves an
escalating build-up of air in the pleural cavity that compresses the lungs, bronchioles,
cardiac structures, and vena cava.
The nurse should be alert about iatrogenic pneumothorax during the process of central
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4
venous catheter insertion as this kind of collapse of the lungs leads from complication
from a medical or surgical procedure.
The nurse should not be alert about traumatic pneumothorax, which is caused by a
penetrating wound of the thoracic cage and the underlying pleural membrane caused by
an accident.
PTS: 1
CON: Perioperative
11. ANS: 1
Chapter: Chapter 21, Restrictive and Obstructive Pulmonary Disorders
Page: 475
Objective: N/A
Difficulty: Difficult
Heading: Idiopathic Pulmonary Fibrosis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Assessment
1
2
3
4
Feedback
Idiopathic pulmonary fibrosis is a restrictive lung disease caused by repeated injury of
the lung tissues by an unidentified agent. The chest x-ray of idiopathic pulmonary
fibrosis reveals diffused “ground glass” markings in the lower lung fields primarily. The
next phase of the disease involves nodules and a honeycomb lung pattern that can be
observed in the x-ray plates.
A thoracic cage deformity can be noticed with one shoulder or hip higher than the other
and hunched posture. This is also known as kyphoscoliosis.
The chest x-ray of pleural effusion shows that the mediastinal structures are pushed
away from the side.
Pulmonary embolism is a condition where a clot has traveled to the pulmonary arterial
circulation and is caused by the obstruction of arterial blood flow through the lungs.
PTS: 1
CON: Assessment
12. ANS: 3
Chapter: Chapter 21, Restrictive and Obstructive Pulmonary Disorders
Page: 476
Objective: N/A
Difficulty: Moderate
Heading: Pulmonary Hypertension
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Assessment
1
Feedback
Pulmonary edema is one of the manifestations of a heart attack. The condition occurs
due to the accumulation of fluid around the alveoli that inhibits the transfer of oxygen
at the alveolar-capillary interface.
PRIMEXAM.COM
2
3
4
Coal worker’s pneumoconiosis is also known as anthracosis, which is characterized by
the presence of coal particles of 1 to 2 mm in diameter and larger coal nodules in the
lungs.
Collagen vascular disease is one of the outcomes of secondary pulmonary hypertension,
which is a resultant effect of a client’s elevated pulmonary venous pressure.
Bronchiectasis involves abnormal and permanent dilatation of the bronchi, fibrotic
changes of the bronchioles, and static and thick purulent secretions.
PTS: 1
CON: Assessment
13. ANS: 1
Chapter: Chapter 21, Restrictive and Obstructive Pulmonary Disorders
Page: 471
Objective: N/A
Difficulty: Moderate
Heading: Obstructive Sleep Apnea
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Assessment
1
2
3
4
Feedback
The client can be prone to Pickwickian syndrome, which is a specific form of
obstructive sleep apnea due to a short but thick neck circumference.
Allergic bronchopulmonary aspergillosis is caused by the same aspergillus organism
responsible for bronchiectasis.
The failure of the right side of the heart caused by pulmonary disorder is known as cor
pulmonale.
Marfan syndrome is not a cardiopulmonary disorder, but a genetic disorder.
PTS: 1
CON: Assessment
14. ANS: 2
Chapter: Chapter 21, Restrictive and Obstructive Pulmonary Disorders
Page: 475
Objective: N/A
Difficulty: Moderate
Heading: Environmental Lung Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Evidence-based Practice
1
2
3
Feedback
A transthoracic echocardiogram is the preferred test to screen for pulmonary
hypertension.
The Mantoux test is the most appropriate test given to clients who are exposed to silica
for detecting TB.
A polysomnogram is a test that helps in ruling out pulmonary hypertension related
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4
to sleep-disordered breathing.
A PFT helps in clinically classifying most kinds of lung diseases.
PTS: 1
CON: Evidence-based Practice
15. ANS: 2
Chapter: Chapter 21, Restrictive and Obstructive Pulmonary Disorders
Page: 475
Objective: N/A
Difficulty: Difficult
Heading: Hypersensitivity Pneumonitis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Evidence-based Practice
1
2
3
4
Feedback
Idiopathic pulmonary fibrosis is a restrictive lung disease caused by the repeated injury
of the lung tissues by some unidentified agent. In this, the alveoli undergo repeated
bouts of inflammation that eventually involves fibroblastic proliferation.
The client is prone to hypersensitivity pneumonitis, which is an immunologically
mediated lung disorder that is caused by prolonged, intense exposure to inhaled organic
dusts that act as antigens. This dust is made of bacterial spores, fungi, or animal
proteins.
Coal worker’s pneumoconiosis, also known as anthracosis, is categorized by the size of
the coal particles found in the lungs.
PSP is characterized by the air present in the intrapleural space without preceding
trauma and without underlying the clinical or radiological evidence of lung disease.
PTS: 1
CON: Evidence-based Practice
16. ANS: 2
Chapter: Chapter 21, Restrictive and Obstructive Pulmonary Disorders
Page: 475
Objective: N/A
Difficulty: Difficult
Heading: Environmental Lung Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Oxygenation
1
2
3
4
Feedback
Hypoxemia is the resultant effect of decreased ventilation in cases of idiopathic
pulmonary fibrosis.
Mesothelioma is a tumor that is specifically associated with asbestos. The client is
prone to develop a cacogenic tumor like mesothelioma.
Silicosis increases the susceptibility to medical conditions like TB.
Pneumothorax is associated with the collapsing of the lungs due to different reasons.
PRIMEXAM.COM
PTS: 1
CON: Oxygenation
17. ANS: 3
Chapter: Chapter 21, Restrictive and Obstructive Pulmonary Disorders
Page: 477
Objective: N/A
Difficulty: Difficult
Heading: Adult Respiratory Distress Syndrome
Integrated Processes: Teaching and Learning Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Evaluation [Evaluating]
Concept: Oxygenation
1
2
3
4
Feedback
The illness develops within 12 to 48 hours after an inciting event in most cases.
ARDS follows diseases such as acute pancreatitis or aspiration.
This statement that an individual developing ARDS has multiple organ failure and
becomes critically ill shows proper understanding of the disease by the nurse.
Primary pulmonary hypertension is a genetic disorder.
PTS: 1
CON: Oxygenation
18. ANS: 1
Chapter: Chapter 21, Restrictive and Obstructive Pulmonary Disorders
Page: 471
Objective: N/A
Difficulty: Difficult
Heading: Obstructive Sleep Apnea
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Oxygenation
1
2
3
4
Feedback
CPAP, or specifically nasal CPAP, prevents airways from closing.
Polysomnography is the study of sleep to diagnose OSA.
Central nervous system stimulants are usually used for clients who have daytime
sleepiness.
Leukotriene antagonists are used for first-line or add-on asthma-controller therapy.
PTS: 1
CON: Oxygenation
19. ANS: 4
Chapter: Chapter 21, Restrictive and Obstructive Pulmonary Disorders
Page: 466
Objective: N/A
Difficulty: Difficult
Heading: Asthma
Integrated Processes: Teaching and Learning
PRIMEXAM.COM
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Evaluation [Evaluating]
Concept: Medication
1
2
3
4
Feedback
Asthma medication generally falls under two categories that include maintenance and
rescue medication.
A common long-acting maintenance medication is a combination of adrenergic beta-2
agonist and corticosteroids. Maintenance medications are generally long-acting.
A client should use an oral leukotriene antagonist for acute asthma attacks on a daily
basis.
An oral corticosteroid should be added to the regimen of rescue medications when
short-acting bronchodilators are not acting against asthma attacks.
PTS: 1
CON: Medication
20. ANS: 1
Chapter: Chapter 21, Restrictive and Obstructive Pulmonary Disorders
Page: 472
Objective: N/A
Difficulty: Difficult
Heading: Pneumothorax
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Assessment
Feedback
1
2
3
4
The client is suffering from pneumothorax or collapsed lungs because the clinical
presentation of the client involves chest pain, dyspnea, and an increased respiratory
rate. On closer inspection, the chest expansion is found to be asymmetrical. Chest
percussion leads to hyperresonance.
The clinical presentation of pleural effusion includes dyspnea, tachypnea, sharp
pleuritic chest pain, dullness to percussion, and diminished breath sounds on the
affected side. Breathing sounds are absent in the area with pleural effusion.
The clinical presentation of asbestosis involves a decrease in lung volume.
Mesothelioma, a tumor specifically associated with asbestos, is found in the pleural
membrane.
The clinical manifestation of thoracic cage deformity such as kyphoscoliosis involves a
noticeable deformity in which a client has one shoulder or hip higher than the other, and
also has a hunched posture.
PTS: 1
CON: Assessment
MULTIPLE RESPONSE
21. ANS: 1, 3
PRIMEXAM.COM
Chapter: Chapter 21, Restrictive and Obstructive Pulmonary Disorders
Page: 462
Objective: N/A
Difficulty: Easy
Heading: Assessment
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Assessment
1.
2.
3.
4.
5.
Feedback
This is correct. The nurse should put focus on the clavicles when palpating the bony
structures of the thoracic cage.
This is incorrect. The axillary nodes are points of focus when palpating the lymph nodes.
This is correct. The nurse should focus on the ribs as well when palpating the bony
structures of the thoracic cage.
This is incorrect. The supraclavicular nodes are also points of focus when palpating the
lymph nodes.
This is incorrect. The cervical nodes are also points of focus when palpating the lymph
nodes when assessing for a pulmonary disease.
PTS: 1
CON: Assessment
22. ANS: 1, 4
Chapter: Chapter 21, Restrictive and Obstructive Pulmonary Disorders
Page: 464
Objective: N/A
Difficulty: Easy
Heading: Asthma
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Oxygenation
1.
2.
3.
4.
5.
Feedback
This is correct. Rhinovirus is responsible for causing asthma in children.
This is incorrect. Adenovirus is responsible for causing bronchiectasis in a client, but not
asthma.
This is incorrect. Pseudomonas aeruginosa is responsible for infections leading to
bronchiectasis in a client.
This is correct. Respiratory syncytial virus is responsible for causing asthma in children.
This is incorrect. An infection caused by the virus Staphylococcus aureus is also
responsible for bronchiectasis in a client.
PTS: 1
CON: Oxygenation
23. ANS: 2, 4, 5
Chapter: Chapter 21, Restrictive and Obstructive Pulmonary Disorders
Page: 471
PRIMEXAM.COM
Objective: N/A
Difficulty: Easy
Heading: Pathophysiology of Selected Restrictive Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Oxygenation
1.
2.
3.
4.
5.
Feedback
This is incorrect. Diseases that lead to the creation of excessive mucous in the body fall
under the category of obstructive pulmonary disease.
This is correct. Diseases that prevent complete ventilation fall under the category of
restrictive pulmonary disease.
This is incorrect. Diseases that lead to the loss of lung elastic recoil fall under the category
of obstructive pulmonary disease.
This is correct. Diseases that reduce the total lung capacity fall under the category of
restrictive pulmonary disease.
This is correct. Diseases that act as an impediment to alveoli fall under the category of
restrictive pulmonary disease.
PTS: 1
CON: Oxygenation
24. ANS: 3, 4
Chapter: Chapter 21, Restrictive and Obstructive Pulmonary Disorders
Page: 474
Objective: N/A
Difficulty: Easy
Heading: Pleural Effusion
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Oxygenation
1.
2.
3.
4.
5.
Feedback
This is incorrect. Surgery for the reduction of the pharyngeal tissues is a treatment
implemented for obstructive sleep apnea.
This is incorrect. Mucolytic agents are administered in cases of bronchiectasis.
This is correct. Drainage is a treatment that is implemented for pleural effusion.
This is correct. A chest tube attached to suction is a treatment for pleural effusion.
This is incorrect. Orthopedic bracing is a treatment that is related to thoracic deformity.
PTS: 1
CON: Oxygenation
25. ANS: 1, 3
Chapter: Chapter 21, Restrictive and Obstructive Pulmonary Disorders
Page: 474
Objective: N/A
Difficulty: Easy
Heading: Environmental Lung Disorders
PRIMEXAM.COM
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
1.
2.
3.
4.
5.
Feedback
This is correct. A decreased FEV count during PFT is a diagnostic outcome of coal miner’s
pneumoconiosis.
This is incorrect. A chest x-ray that reveals fluid in the pleural space is the diagnostic
outcome of pleural effusion.
This is correct. Hypoxemia found in an arterial blood gas (ABG) test is a diagnostic
outcome of coal miner’s pneumoconiosis.
This is incorrect. A collapsed lung and air in the pleural space is a diagnostic outcome of a
client with pneumothorax.
This is incorrect. A computed tomography scan showing dilated fibrotic airways is a
diagnostic outcome of a client with bronchiectasis.
PTS: 1
CON: Assessment
PRIMEXAM.COM
Chapter 22: Renal Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. What percentage of the body’s cardiac output is received by the kidneys?
1. 5% to 10%
2. 20% to 25%
3. 30% to 35%
4. 45% to 50%
2. At what age does the peak function of the kidneys occur in a healthy adult?
1. 20 years
2. 25 years
3. 30 years
4. 35 years
3. What percentage of filtered electrolytes is reabsorbed at the loop of Henle?
1. 15%
2. 25%
3. 40%
4. 60%
4. Which is a likely cause of elevated blood urea nitrogen (BUN) in a client?
1. An increase in the glomerular filtration rate
2. Dehydration
3. Low protein diet
4. Very frail body structure
5. Which is the most common condition associated with the formation of renal calculi?
1. Hyperabsorption of calcium and oxalate from the gastrointestinal tract
2. Chronic urinary tract infection
3. Gout
4. Failure of renal tubular reabsorption of cystine
6. A nurse is teaching student nurses about the epidemiology of renal calculi. Which statement made by a
student nurse indicates the need for further training?
1. “The lifetime risk of developing nephrolithiasis is around 7% for men in the United
States.”
2. “Renal calculi develop most commonly in adults aged 20 to 49 years.”
3. “The risk of developing renal calculi doubles if there is a family history.”
4. “Renal calculi can recur, with a chance of 52% recurrence within 10 years.”
7. Which statement made by a student nurse pertains to the theory of protein deficiency as a possible cause of
formation of renal calculi?
1. “A kidney stone is formed when crystalline constituents settle on uropontin.”
2. “Calcium phosphate deposition in the renal papilla leads to formation of a kidney stone.”
3. “A Randall plaque is formed when a calcium phosphate compound settles in the renal
papilla.”
4. “Nephrocalcin inhibits kidney stone formation.”
PRIMEXAM.COM
8. What percentage of clients suffering from Goodpasture’s syndrome has clinically apparent manifestations of
pulmonary and renal disease?
1. 60% to 80%
2. 20% to 40%
3. Fewer than 10%
4. More than 90%
9. Individuals with which tissue types are at high risk for developing Goodpasture’s syndrome in the kidney and
lungs?
1. HLA-DR2
2. HLA-DR3
3. Both A and B
4. None of the above
10. A client presents with a specific type of renal calculi that is not widely prevalent. The nurse knows that this
client has been undergoing chemotherapy as part of his or her treatment for cancer. Which is an associated
characteristic of the type of renal calculi that is most likely to be present in this client?
1. Urine supersaturated with cystine
2. High purine levels in the bloodstream
3. Alkaline pH of urine
4. Pseudomonas infection in the urinary tract
11. The nurse is assessing the urinalysis report of a client of average build. Which observation definitely indicates
an illness state in the client?
1. A serum creatinine level of 10 mg/dL
2. A blood urea nitrogen (BUN) level of 15 mg/dL
3. Casts in the urine
4. Slightly hazy urine
12. Which statement made by a student nurse demonstrates understanding about the secretory functions of the
kidney?
1. “Clients with renal failure have higher hemoglobin levels because of constant secretion of
erythropoietin.”
2. “Kidneys create glucose from amino acids in case of excessive consumption of animal
proteins.”
3. “The juxtaglomerular apparatus secretes renin in response to high sodium levels in the
blood.”
4. “Clients with impaired renal function have disrupted calcium balance in the bloodstream
due to inactive vitamin D.”
13. Which statement made by a student nurse demonstrates understanding of the basic pathology of renal
disorders?
1. “Postrenal dysfunction can be accompanied by an increased risk of infection.”
2. “Prerenal dysfunction can be caused by excessive consumption of nonsteroidal antiinflammatory drugs (NSAIDs).”
3. “Intrarenal dysfunction can lead to hydronephrosis.”
4. “Postrenal dysfunction can result from severe hypovolemia.”
14. Which urinalysis finding indicates that the client could be suffering from renal dysfunction?
1. Urine is odorless and slightly hazy.
PRIMEXAM.COM
2. Urine is clear and amber-colored.
3. Urine is yellow, with a specific gravity of 1.001.
4. Urine contains crystals.
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
15. A health-care provider is evaluating the urine and blood test reports of a client with a muscular body structure.
Which observations are most likely to indicate that the client is suffering from renal impairment? Select all
that apply.
1. High amount of leukocyte esterase
2. A blood urea nitrogen (BUN) of 25 mg/dL
3. Increased creatinine clearance
4. Decreased creatinine clearance
5. High specific gravity of dilute urine
16. Which statements does the nurse identify as correct after contrasting peritoneal dialysis (PD) with
hemodialysis and continuous renal replacement therapy (CRRT)? Select all that apply.
1. In CRRT, the dialysis solution pulls wastes and extra fluid from the blood into the
abdominal cavity.
2. The dwell time in PD is 4 hours.
3. In hemodialysis, the entire blood volume circulates through the dialyzer in 30 to 40
minutes.
4. PD is a slower process used for clients who are hemodynamically unstable.
5. The process of draining and filling in PD takes about 30 to 40 minutes.
17. A nurse notices that the glomerular filtration rate of a client has decreased. What are the possible reasons for
this? Select all that apply.
1. A disease process has decreased the client’s blood pressure.
2. A disease process has increased the client’s blood pressure.
3. A disease process has decreased the client’s renal perfusion.
4. A disease process has increased the client’s renal perfusion.
5. The normal aging process
18. The nurse assesses a client for the presence of proteinuria. What observations indicate that the client is
suffering from this condition? Select all that apply.
1. Protein excretion in urine of 130 mg/day
2. Protein excretion in urine of 200 mg/day
3. Foamy urine
4. Tea-colored urine
5. Presence of crystals in the urine
19. A nurse is teaching student nurses about the treatment of nephrolithiasis. Which statements made by a student
nurse indicate the need for further learning? Select all that apply.
1. “A low-sodium diet is recommended to limit fluid overload.”
2. “Pain management is the major part of treatment.”
3. “Clients are instructed to drink at least 3 liters of fluid a day.”
4. “Most renal stones are treated with lithotripsy.”
5. “Drinking cranberry juice is beneficial in certain types of renal calculi.”
PRIMEXAM.COM
20. The nurse is assessing a client with suspected nephrolithiasis. Which factors would the nurse identify as
possible causes for the disease? Select all that apply.
1. The client excretes excess uric acid in the urine.
2. The client drinks over 3 liters of water every day.
3. The client has a family history of renal calculi.
4. The client does not take calcium supplements.
5. The client suffers from hyperparathyroidism.
21. What constitutes the net effects of the renin-angiotensin-aldosterone system (RAAS) of the kidneys? Select
all that apply.
1. Sodium reabsorption
2. Water reabsorption
3. Potassium reabsorption
4. Potassium excretion
5. Arterial vasodilation
22. A client presents a colicky type of flank pain that radiates into the groin. On assessment, the nurse finds
edema and distention of the renal pelvis in the client, caused by the build-up of urine. Which conditions is the
client at a risk of developing if he or she continues to suffer from edema and distention of the renal pelvis for
a prolonged period of time? Select all that apply.
1. Compression of the kidney tissue
2. Ischemia
3. Hematuria
4. Crystalluria
5. Pleural effusion
Other
23. Arrange in order the steps that lead to the formation of a kidney stone according to the second theory of the
formation of renal calculi (A-E). (Enter the letter of each step in the proper sequence; do not use commas or
spaces.)
A. The calculus erodes through the urothelium of the renal pelvis.
B. Calcium phosphate compound collects layers of collagenous material and cellular debris.
C. Calcium phosphate deposits in the renal papilla.
D. The plaque collects layers of crystalline elements to become a calculus.
E. Randall plaque forms within the subepithelial membrane.
24. Arrange in order the mechanism of the occurrence of edema in a client suffering from acute
glomerulonephritis (A-F). (Enter the letter of each step in the proper sequence; do not use commas or
spaces.)
A. The low colloid oncotic pressure (COP) is overcome by hydrostatic pressure.
B. Loss of albumin and RBCs in the urine takes place.
C. The antigen-antibody complexes damage the structure of the glomeruli.
D. Hyperpermeability of the capillaries occurs.
E. Diminished COP occurs throughout the body.
F. Antigen enters the body and stimulates antibody synthesis.
PRIMEXAM.COM
25. Arrange in order the changes that occur in the kidneys during polycystic kidney disease (A-G). (Enter the
letter of each step in the proper sequence; do not use commas or spaces.)
A. Blood leaks into the cysts.
B. An outpocketing of the nephron tubule walls takes place.
C. The cysts develop blood vessels.
D. Hyperplasia of renal epithelial cells occurs.
E. The cystic walls stretch causing excruciating pain.
F. Gross hematuria occurs.
PRIMEXAM.COM
G. Glomerular filtrate accumulates in cysts.
Chapter 22: Renal Disorders
Answer Section
MULTIPLE CHOICE
1. ANS: 2
Chapter: Chapter 22, Renal Disorders
Page: 487
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts of Renal Function
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Urinary Elimination
1
2
3
4
Feedback
The percentage of the body’s cardiac output that is received by the kidneys is more than
5% to 10%.
The percentage of the body’s cardiac output that is received by the kidneys is 20% to
25%.
The percentage of the body’s cardiac output that is received by the kidneys is less than
30% to 35%.
The percentage of the body’s cardiac output that is received by the kidneys is less than
45% to 50%.
PTS: 1
CON: Urinary Elimination
2. ANS: 3
Chapter: Chapter 22, Renal Disorders
Page: 487
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts of Renal Function
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Urinary Elimination
1
2
3
4
Feedback
The peak function of the kidneys occurs later than 20 years of age in a healthy adult.
The peak function of the kidneys occurs later than 25 years of age in a healthy adult.
The peak function of the kidneys occurs at 30 years of age in a healthy adult.
The peak function of the kidneys occurs earlier than 35 years of age in a healthy adult.
PTS: 1
CON: Urinary Elimination
PRIMEXAM.COM
3. ANS: 2
Chapter: Chapter 22, Renal Disorders
Page: 488
Objective: N/A
Difficulty: Easy
Heading: Excretory Functions
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Urinary Elimination
1
2
3
4
Feedback
The percentage of filtered water reabsorbed at the loop of Henle is 15%.
The percentage of filtered electrolytes reabsorbed at the loop of Henle is 25%.
The percentage of filtered electrolytes reabsorbed at the loop of Henle is not 40%.
The percentage water reabsorbed at the proximal tubule is 60%.
PTS: 1
CON: Urinary Elimination
4. ANS: 2
Chapter: Chapter 22, Renal Disorders
Page: 491
Objective: N/A
Difficulty: Easy
Heading: Diagnosis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Urinary Elimination
1
2
3
4
Feedback
A decrease in the glomerular filtration rate can lead to accumulation of nitrogenous
waste products in the blood, causing elevated BUN in the client.
Dehydration is a nonrenal condition that can result in high BUN, since the urea in the
urine is highly concentrated as a result of dehydration.
A high protein diet can result in elevated BUN, since the large load of protein
breakdown into amino acids raises nitrogen in the bloodstream.
An extremely muscular body structure can be accompanied by high nitrogen in the
bloodstream because of high muscle breakdown, which raises the BUN.
PTS: 1
CON: Urinary Elimination
5. ANS: 1
Chapter: Chapter 22, Renal Disorders
Page: 497
Objective: N/A
Difficulty: Easy
Heading: Nephrolithiasis
Integrated Processes: Nursing Process
PRIMEXAM.COM
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Urinary Elimination
1
2
3
4
Feedback
Calcium stones are the most common type of renal calculi. They account for 75% of the
total renal calculi. The formation of this type of stones is attributed to hyperabsorption
of calcium and oxalate from the gastrointestinal tract.
Chronic urinary tract infection, coupled with specific urine pH, is associated with
struvite stones, or magnesium ammonium phosphate stones. These are the second most
prevalent form of renal calculi, accounting for 15% of all renal calculi.
Gout is present in approximately 25% of clients with uric acid stones. Uric acid stones
account for 6% of renal calculi. Therefore, gout is not the most common condition
associated with the formation of renal calculi.
Failure of renal tubular reabsorption of cystine is associated with the formation of
cystine stones, which account for 2% of renal calculi.
PTS: 1
CON: Urinary Elimination
6. ANS: 1
Chapter: Chapter 22, Renal Disorders
Page: 496
Objective: N/A
Difficulty: Difficult
Heading: Nephrolithiasis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Evaluation [Evaluating]
Concept: Urinary Elimination
1
2
3
4
Feedback
The lifetime risk of developing nephrolithiasis is around 12% for men in the United
States; whereas, it is 7% for women. Therefore, this statement by the nursing student is
incorrect.
Renal calculi develop most commonly in adults aged 20 to 49 years, with a peak
incidence in adults aged 35 to 45 years. Therefore, this statement by the nursing student
does not indicate the need for further learning.
Individuals can be genetically predisposed to nephrolithiasis. The risk of developing
renal calculi doubles if there is a family history. Therefore, this statement is correct.
Recurrence of nephrolithiasis is common, and an individual who has already suffered
from the condition has a 52% chance of suffering another stone within 10 years.
Therefore, this statement by the nursing student is correct.
PTS: 1
CON: Urinary Elimination
7. ANS: 4
Chapter: Chapter 22, Renal Disorders
Page: 497
Objective: N/A
PRIMEXAM.COM
Difficulty: Moderate
Heading: Nephrolithiasis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Urinary Elimination
1
2
3
4
Feedback
One of the theories regarding the formation of renal calculi proposes that there is
supersaturation of the urine by stone-forming crystalline constituents. Crystals can act
as a nucleus, upon which more crystalline constituents settle and build into a calculus.
Uropontin is a stone-inhibitor, the deficiency of which causes kidney stones. Uropontin
does not act as a nucleus for the settling of crystalline components.
Calcium phosphate deposition in the renal papilla leads to formation of a kidney stone,
according to one of the theories of formation of kidney stones. However, this theory
does not point to protein deficiency as a possible cause of nephrolithiasis.
A Randall plaque is formed when a calcium phosphate compound settles in the renal
papilla, according to one of the theories of formation of kidney stones. This theory
posits that the plaque collects layers of crystalline elements and becomes a calculus; it
is unrelated to the theory that points to protein deficiency as a possible cause of
nephrolithiasis.
One of the theories regarding the formation of renal calculi proposes that these stones
are formed in individuals who have a deficiency of one or all proteins that inhibit stone
formation. Nephrocalcin is one of these stone inhibitors. Therefore, the statement
associated with the theory that points to protein deficiency as a possible cause of
nephrolithiasis is that nephrocalcin inhibits kidney stone formation.
PTS: 1
CON: Urinary Elimination
8. ANS: 1
Chapter: Chapter 22, Renal Disorders
Page: 501
Objective: N/A
Difficulty: Easy
Heading: Goodpasture’s Syndrome
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Urinary Elimination
1
2
3
4
Feedback
Around 60% to 80% of clients suffering from Goodpasture’s syndrome have clinically
apparent manifestations of pulmonary and renal disease.
Around 20% to 40% of clients suffering from Goodpasture’s syndrome have only renal
manifestations of the disease.
Fewer than 10% of clients suffering from Goodpasture’s syndrome have only
pulmonary manifestations of the disease.
Clinically apparent manifestations of pulmonary and renal disease are not present in
PRIMEXAM.COM
over 90% of clients suffering from Goodpasture’s syndrome; the actual percentage is
lower than 80%.
PTS: 1
CON: Urinary Elimination
9. ANS: 1
Chapter: Chapter 22, Renal Disorders
Page: 501
Objective: N/A
Difficulty: Moderate
Heading: Goodpasture’s Syndrome
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Urinary Elimination
1
2
3
4
Feedback
Individuals with tissue type HLA-DR2, along with HLA-DR and HLA-B7, are at high
risk for Goodpasture’s syndrome in the kidney and lungs.
Individuals with tissue type HLA-DR3 are not at high risk for Goodpasture’s syndrome
in the kidney and lungs.
Individuals with tissue type HLA-DR2 are at high risk, but those with tissue type HLADR3 are not.
Individuals with tissue type HLA-DR2 are at high risk for Goodpasture’s syndrome.
PTS: 1
CON: Urinary Elimination
10. ANS: 2
Chapter: Chapter 22, Renal Disorders
Page: 497
Objective: N/A
Difficulty: Difficult
Heading: Nephrolithiasis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Urinary Elimination
1
2
Feedback
Urine that is supersaturated with cystine causes crystal deposition and results in failure
of renal tubular reabsorption of cystine. This causes cystine stones. While this type of
calculi is seen in only 2% of the cases, it has no special association with treatment of
malignancy; therefore, urine supersaturated with cystine crystals is not the most likely
associated characteristic in this case.
Purines are derived from the DNA of animal cells or cancer cells. High purine levels in
the bloodstream occur with high ingestion of meats or whenever there is a high rate of
cellular breakdown, as in treatment of malignancy. High purine levels cause uric acid
stones. Uric acid stone is also not a very common type of renal calculi and is seen in
6% of the cases. Therefore, the client undergoing treatment for cancer is most likely to
PRIMEXAM.COM
3
4
have uric acid stones, and the associated condition present in the client would be high
purine levels in the bloodstream.
Alkaline pH of urine, typically greater than 7, is seen in the case of chronic urinary tract
infections. Struvite stones are associated with alkaline pH of urine. This type of renal
calculi is seen in 15% of the cases. Struvite stones have no particular association with
the treatment of malignancy. Therefore, the client is not likely to be suffering from
struvite stones in this case, and the associated condition is not the alkaline pH of urine.
Pseudomonas is one of the common types of bacteria that cause chronic urinary tract
infections. Struvite stones are the type of calculi associated with chronic urinary tract
infections. These stones have no relation with the treatment of malignancy. Therefore,
the client is not likely to be suffering from struvite stones in this case, and the
associated condition is not the presence of Pseudomonas in the urinary tract.
PTS: 1
CON: Urinary Elimination
11. ANS: 1
Chapter: Chapter 22, Renal Disorders
Page: 492
Objective: N/A
Difficulty: Moderate
Heading: Diagnosis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Urinary Elimination
1
2
3
4
Feedback
Serum creatinine is a reliable indicator of kidney function, and its accumulation
indicates decreased filtering of creatinine at the glomerulus. The normal range of serum
creatinine is approximately 0.5 to 1.5 mg/dL. However, serum creatinine is based on
muscle tissue breakdown, and its value can vary, depending on the client’s muscle
mass. Therefore, in extremely muscular individuals and very frail individuals, the
serum creatinine values would lie outside this range, even when there is no renal
dysfunction. The client in this case is of average build, so a serum creatinine level of 10
mg/dL definitely indicates an illness state in the client.
The client’s BUN is within the normal range, which is 5 to 20 mg/dL. Also, even if the
level of BUN had been high, it would not necessarily be an indicator of kidney
dysfunction, since a high BUN level can result from dehydration, which highly
concentrates the urea in the urine. Therefore, a BUN level of 15 mg/dL is not indicative
of an illness state in the client.
Casts are substances that secrete into the nephron tubules and retain the shape of the
tubules. They can either be benign or signify kidney disease. Therefore, the presence of
casts in the urine does not necessarily indicate an illness state.
Normal urine can either be clear or slightly hazy. Therefore, a slightly hazy urine does
not indicate that the client is suffering from an illness state.
PTS: 1
CON: Urinary Elimination
PRIMEXAM.COM
12. ANS: 4
Chapter: Chapter 22, Renal Disorders
Page: 489
Objective: N/A
Difficulty: Difficult
Heading: Secretory Functions
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Evaluation [Evaluating]
Concept: Urinary Elimination
1
2
3
4
Feedback
The synthesis of red blood cells in the bone marrow is stimulated by erythropoietin
secreted by the kidneys. Clients with renal failure have deficient erythropoietin, leading
to lower hemoglobin levels.
Kidneys create glucose from amino acids in the process known as gluconeogenesis.
This occurs in states of prolonged fasting or starvation, and it is not due to excess
consumption of animal proteins.
The juxtaglomerular apparatus is a specialized region of the nephron that is sensitive to
sodium. Renin is secreted by these cells when they sense low sodium levels, and this
mechanism is associated with the control of systemic blood pressure and blood volume
by the kidneys.
Clients with impaired renal function have inactive vitamin D, since the kidneys
synthesize components that comprise vitamin D. Since calcium is absorbed by the
facilitation of vitamin D, a lack of vitamin D disrupts calcium balance in the
bloodstream.
PTS: 1
CON: Urinary Elimination
13. ANS: 1
Chapter: Chapter 22, Renal Disorders
Page: 490
Objective: N/A
Difficulty: Difficult
Heading: Postrenal Dysfunction
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Evaluation [Evaluating]
Concept: Urinary Elimination
1
2
3
Feedback
Postrenal dysfunction is caused by obstructive uropathy, a problem that prevents urine
outflow from the kidney. Urine backs up within the ureter and into the kidney, which
can lead to hydronephrosis, a fluid-filled, swollen kidney. Urine is toxic to the nephron,
and urine stagnation increases the risk of infection.
Excessive consumption of NSAIDs causes nephrotoxicity. This toxic effect to the renal
tissue leads to nephron damage, known as intrarenal dysfunction.
Hydronephrosis is a fluid-filled, swollen kidney. It can occur in postrenal kidney
PRIMEXAM.COM
4
dysfunction, when the urine backs up within the ureter and into the kidney.
Severe hypovolemia, or low blood volume, causes prerenal dysfunction.
PTS: 1
CON: Urinary Elimination
14. ANS: 4
Chapter: Chapter 22, Renal Disorders
Page: 491
Objective: N/A
Difficulty: Moderate
Heading: Diagnosis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Urinary Elimination
1
2
3
4
Feedback
Normally, urine is odorless and clear, or slightly hazy. Therefore, odorless and slightly
hazy urine does not indicate that the client is suffering from renal dysfunction.
Normally, urine is clear or slightly hazy, and it ranges from yellow to amber in color,
depending on its concentration. Therefore, clear and amber-colored urine indicates that
the client might be dehydrated, but it does not indicate that the client is suffering from
renal dysfunction.
Normally, urine is yellow if the individual is well-hydrated, and its specific gravity is
between 1.001 when dilute and 1.035 when highly concentrated. Therefore, yellow
urine with a specific gravity of 1.001 does not indicate that the client is suffering from
renal dysfunction.
Crystals are often seen in the urine of clients with renal calculi. Therefore, the presence
of crystals in urine indicates that the client is suffering from a kidney disease.
PTS: 1
CON: Urinary Elimination
MULTIPLE RESPONSE
15. ANS: 1, 4
Chapter: Chapter 22, Renal Disorders
Page: 491, 492
Objective: N/A
Difficulty: Difficult
Heading: Diagnosis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Urinary Elimination
1.
Feedback
This is correct. A positive leukocyte esterase measures the amount of enzyme secreted by
PRIMEXAM.COM
2.
3.
4.
5.
white blood cells; a high amount is indicative of either a bladder or kidney infection.
However, this is not the only correct choice.
This is incorrect. The normal level for BUN is 5 to 20 mg/dL. While an elevated BUN,
such as 25 mg/dL, can occur when there is a decrease in the glomerular filtration rate, a
high BUN level is not always an indicator of kidney dysfunction. In extremely muscular
individuals, there is high nitrogen in the bloodstream because of high muscle breakdown,
leading to higher than normal BUN levels.
This is incorrect. Increased creatinine clearance indicates there is more creatinine in the
urine than normal. This can be seen in pregnant women, clients with diabetes mellitus, or
those with large dietary protein intake. It is not indicative of renal dysfunction.
This is correct. The creatinine clearance test is often used to assess the glomerular filtration
rate (GFR). A decreased creatinine clearance indicates decreased GFR and impaired renal
function.
This is incorrect. In case of kidney dysfunction, routine urinalyses will show low
specific gravity of dilute urine.
PTS: 1
CON: Urinary Elimination
16. ANS: 2, 5
Chapter: Chapter 22, Renal Disorders
Page: 492, 493
Objective: N/A
Difficulty: Difficult
Heading: Treatment
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Evaluation [Evaluating]
Concept: Urinary Elimination
1.
2.
3.
Feedback
This is incorrect. In PD, the client’s peritoneum is filled with a dialysis solution that pulls
wastes and extra fluid from the blood into the abdominal cavity. In contrast, CRRT is a
slower type of hemodialysis, which is a process in which the client’s blood is drawn out of
the body and passed through a dialyzer.
This is correct. The dwell time in PD, which is the time for which the fluid sits in the
peritoneal cavity, is approximately 4 hours.
This is incorrect. In hemodialysis, the entire blood volume circulates through the
4.
dialyzer every 15 minutes. Instead, in PD, the process of draining and filling takes
about 30 to 40 minutes.
This is incorrect. PD is an uncommon process used at times as an alternative to
hemodialysis. CRRT is similar to hemodialysis and is a slower process used for
clients who are hemodynamically unstable and fluid overloaded.
5.
This is correct. The process of draining and filling in PD takes about 30 to 40 minutes.
PTS: 1
CON: Urinary Elimination
17. ANS: 1, 3, 5
Chapter: Chapter 22, Renal Disorders
PRIMEXAM.COM
Page: 487
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts of Renal Function
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Urinary Elimination
1.
2.
3.
4.
5.
Feedback
This is correct. A disease process that has decreased the client’s blood pressure can result in
a decreased glomerular filtration rate.
This is incorrect. A disease process that has increased the client’s blood pressure is not
likely to result in a decreased glomerular filtration rate.
This is correct. A disease process that has decreased the client’s renal perfusion can result
in a decreased glomerular filtration rate.
This is incorrect. A disease process that has increased the client’s renal perfusion is not
likely to result in a decreased glomerular filtration rate.
This is correct. Glomerular filtration rate can diminish with age.
PTS: 1
CON: Urinary Elimination
18. ANS: 2, 3
Chapter: Chapter 22, Renal Disorders
Page: 490, 491
Objective: N/A
Difficulty: Moderate
Heading: Risk Factors
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Urinary Elimination
1.
2.
3.
4.
5.
Feedback
This is incorrect. Excretion of protein of up to 150 mg/day in the urine is normal.
Therefore, a urine protein level of 130 mg/day does not indicate that the client has
proteinuria.
This is correct. Excretion of protein of up to 150 mg/day in the urine is normal. Therefore,
urine protein level of 200 mg/day indicates that the client is suffering from proteinuria.
This is correct. Proteinuria is a condition where excess protein is excreted in the urine.
High levels of protein in the urine give the urine a foamy appearance. Therefore, the
presence of foamy urine indicates that the client is suffering from proteinuria.
This is incorrect. Proteinuria is a condition where excess protein is excreted in the urine.
Tea-colored urine indicates the presence of bilirubin in the urine, but not the presence of
excess protein.
This is incorrect. Crystals are usually seen in the urine of clients with renal calculi. This is
unrelated to proteinuria.
PRIMEXAM.COM
PTS: 1
CON: Urinary Elimination
19. ANS: 1, 4
Chapter: Chapter 22, Renal Disorders
Page: 498
Objective: N/A
Difficulty: Difficult
Heading: Nephrolithiasis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Urinary Elimination
1.
2.
3.
4.
5.
Feedback
This is correct. A low-sodium diet is recommended to limit fluid overload for the treatment
of nephrotic syndrome. This is done to ensure adequate fluid intake, but to avoid
overhydration. Therefore, the statement that a low-sodium diet is recommended to limit
fluid overload in case of nephrolithiasis indicates the need for further learning.
Since nephrolithiasis is characterized by excruciating pain that interferes with activities of
daily living, pain management is a major part of treatment. Therefore, this statement does
not indicate the need for further learning in the student nurse.
Since most renal stones pass spontaneously with administration of large amounts of fluid,
clients are instructed to drink at least 3 liters of fluid a day to increase urine volume and to
strain all urine. Therefore, this statement does not indicate the need for further learning in
the student nurse.
Most renal stones will pass spontaneously with administration of large amounts of fluid.
Lithotripsy is used in situations where the client cannot pass the stone. Therefore, this
statement by the student nurse indicates the need for further learning.
Calcium phosphate, calcium carbonate, and magnesium phosphate stones develop in
alkaline urine. Drinking cranberry juice keeps the urine acidic, which prevents the
recurrence of this type of stones. Therefore, this statement by the student nurse does not
indicate the need for further learning.
PTS: 1
CON: Urinary Elimination
20. ANS: 1, 3, 5
Chapter: Chapter 22, Renal Disorders
Page: 496
Objective: N/A
Difficulty: Moderate
Heading: Nephrolithiasis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Urinary Elimination
1.
Feedback
This is correct. Excretion of excess uric acid in the urine, or hyperuricemia, is one of the
metabolic risk factors for nephrolithiasis. Therefore, the nurse would identify the excretion
PRIMEXAM.COM
2.
3.
4.
5.
of excess uric acid in the urine as a causal factor of nephrolithiasis.
This is incorrect. Low fluid content of the urine is one of the most common predisposing
factors that lead to nephrolithiasis. This can be caused by low fluid intake. Drinking over 3
liters of water every day is more than adequate for hydration and is not likely to cause low
fluid content of urine under normal circumstances.
This is correct. There is a genetic predisposition to nephrolithiasis, with more than 30
genetic variations associated with it. A client who has a family history of renal calculi has
double the risk of developing the condition.
This is incorrect. Taking excess calcium supplements is one of the most common
predisposing factors that lead to nephrolithiasis.
This is correct. Hyperparathyroidism is a metabolic risk factor for nephrolithiasis.
Therefore, the nurse would identify this as a possible cause for the disease in the client.
PTS: 1
CON: Urinary Elimination
21. ANS: 1, 2, 4
Chapter: Chapter 22, Renal Disorders
Page: 488
Objective: N/A
Difficulty: Easy
Heading: Secretory Functions
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Urinary Elimination
1.
2.
3.
4.
5.
Feedback
This is correct because the RAAS contributes to sodium reabsorption into the bloodstream
at the renal tubules.
This is correct because the RAAS contributes to water reabsorption into the bloodstream at
the renal tubules.
This is incorrect. The RAAS does not contribute to potassium reabsorption into the
bloodstream at the renal tubules.
This is correct because the RAAS contributes to potassium excretion into the bloodstream
at the renal tubules.
This is incorrect because the RAAS contributes to arterial vasoconstriction.
PTS: 1
CON: Urinary Elimination
22. ANS: 1, 2
Chapter: Chapter 22, Renal Disorders
Page: 497
Objective: N/A
Difficulty: Difficult
Heading: Nephrolithiasis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Urinary Elimination
PRIMEXAM.COM
1.
2.
3.
4.
5.
Feedback
This is correct. A colicky type of flank pain that radiates into the groin indicates that the
client is suffering from renal calculi, since the renal calculi cause an obstruction of urine
and thus create increased pressure within the kidney. Hydronephrosis occurs when edema
and distention of the renal pelvis interferes with renal blood flow and function.
Compression of the kidney tissue is caused by prolonged hydronephrosis.
This is correct. Ischemia is caused by prolonged hydronephrosis. The symptom of colicky
type of flank pain radiating into the groin indicates that the client is suffering from renal
calculi. Also, the edema and distention of the renal pelvis indicate that the stone has caused
obstruction of urine and put backpressure into the renal pelvis, leading to hydronephrosis.
This is incorrect. While hematuria can be seen in nephrolithiasis, which is the client’s
condition in this case, hematuria occurs when the stone scrapes against the ureter’s
membrane. Hematuria does not develop due to edema and distention of the renal pelvis for
a prolonged period of time.
This is incorrect. While crystalluria is a classic sign of nephrolithiasis, which is the client’s
condition in this case, prolonged edema and distention of the renal pelvis do not lead to
crystalluria.
This is incorrect. Pleural effusion can be seen in clients suffering from nephrotic syndrome
and who have severe albumin loss. The symptoms of nephrotic syndrome include
albuminuria and edema of the face. Nephrotic syndrome is not associated with colicky type
of flank pain that radiates into the groin.
PTS: 1
CON: Urinary Elimination
ORDERED RESPONSE
23. ANS:
CBEDA
Chapter: Chapter 22, Renal Disorders
Page: 497
Objective: N/A
Difficulty: Difficult
Heading: Nephrolithiasis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Urinary Elimination
Feedback: According to one of the theories of formation of renal calculi, calcium phosphate, a normal
compound from breakdown of bone, deposits onto an area of tubule cell membranes in the renal papilla,
which is an area of kidney that empties into the minor calyx. The calcium phosphate compound collects layers
of collagenous material and cellular debris. At this point, it is known as a Randall plaque. The Randall plaque
is located within the subepithelial membrane. The plaque collects layers of crystalline elements and becomes
a calculus. The calculus erodes through the urothelium of the renal pelvis to enter the ureter.
PTS: 1
CON: Urinary Elimination
PRIMEXAM.COM
24. ANS:
FCDBEA
Chapter: Chapter 22, Renal Disorders
Page: 493, 494
Objective: N/A
Difficulty: Difficult
Heading: Glomerulonephritis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Urinary Elimination
Feedback: Acute glomerulonephritis (AGN) begins with an antigen-antibody reaction. An antigen, such as
streptococcus, enters the body and stimulates antibody synthesis. The antigen-antibody complexes damage the
structure of the glomeruli and cause nephron dysfunction throughout the kidneys. Hyperpermeability of the
capillaries is caused by glomerular injury, which allows loss of albumin and red blood cells in the urine.
Because of the large loss of albumin from the bloodstream, diminished colloid oncotic pressure (COP) occurs
throughout the body. According to Starling’s Law of Capillary Forces, the decrease of COP causes an
imbalance in hydrostatic and oncotic pressure. The low COP is overcome by hydrostatic pressure, which
causes edema.
PTS: 1
CON: Urinary Elimination
25. ANS:
DBGCAEF
Chapter: Chapter 22, Renal Disorders
Page: 500
Objective: N/A
Difficulty: Difficult
Heading: Polycystic Kidney Disease
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Urinary Elimination
Feedback: Initially, the renal epithelial cell cycle becomes dysfunctional, leading to hyperplasia of renal
epithelial cells. The hyperplastic cells cause an outpocketing of the nephron tubule walls, with the formation
of cysts. Glomerular filtrate accumulates in these cysts, and the surrounding normal renal tissue is compressed
and damaged. With time, the cystic structures develop blood vessels. The blood vessels are extremely fragile
and susceptible to rupture, which causes leakage of blood into the cysts. With the entry of blood, the cystic
walls stretch, causing excruciating pain. Cysts often rupture into the renal calyces, causing gross hematuria.
PTS: 1
CON: Urinary Elimination
PRIMEXAM.COM
Chapter 23: Urological Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. How much urine can the urinary bladder usually hold?
1. 150 to 250 mL
2. 300 to 400 mL
3. 450 to 550 mL
4. 600 to 700 mL
2. Which is the most common cause of urinary obstruction in men older than 60 years of age?
1. Cancers of the pelvic organs
2. Kidney stones
3. Benign prostate hyperplasia
4. Genetic mutation
3. What is the rate of recurrence of urolithiasis within 5 years after it occurs in a client for the first time?
1. 35%
2. 45%
3. 52%
4. 62%
4. Which type of calculi in the ureter is found most often in clients with spinal cord injuries?
1. Calcium
2. Struvite
3. Uric acid
4. Cystine
5. How long does a typical wave of renal colic last?
1. 10 to 15 minutes
2. 20 to 60 minutes
3. 70 to 90 minutes
4. 5 to 7 minutes
6. A nurse is teaching student nurses about the epidemiology of lower urinary tract infections (UTIs). Which
statement made by a student nurse indicates a need for further learning?
1. “Young adult women are more likely to suffer a lower UTI than are young adult men.”
2. “Up to 40% of men in the United States, aged 20 to 40 years, have suffered a lower UTI.”
3. “Benign prostate hyperplasia is a common cause of UTI in men older than 60 years of
age.”
4. “Approximately 50% of all women are believed to have had a UTI at some point in their
lifetime.”
7. Which type of renal calculi is caused by a genetic disorder associated with the faulty metabolism of an amino
acid?
1. Calcium stones
2. Uric acid stones
3. Cystine stones
4. Struvite stones
PRIMEXAM.COM
8. Which statement about the pathophysiology of lower urinary tract infections is true?
1. The low osmolarity of urine diminishes bacterial viability in the bladder.
2. Any obstruction of urinary outflow decreases the bladder’s resistance to bacterial
infection.
3. Immunoglobulin A (IgA) facilitates adherence of bacteria to the bladder wall.
4. The presence of IgA in all women decreases their ability to combat bacterial invasion of
the bladder.
9. Which factor does the nurse identify to be responsible for potentially lower urinary tract infections (UTIs) in
young men?
1. Lack of circumcision
2. Anal intercourse
3. Benign prostate hyperplasia
4. Both A and B
10. Which is a risk factor for both bacterial and fungal urinary tract infections (UTIs)?
1. Chronic voluntary suppression of urination
2. Urinary catheters
3. Diabetes mellitus
4. Antibiotic use
5. Stagnation of urine flow
6. All of the above
11. Which observation is associated with the nonulcerative type of interstitial cystitis (IC)?
1. Thinning of bladder mucosa
2. Hemorrhages on the bladder wall when the bladder is distended
3. Erythema on the inner bladder surface
4. Inflammation on the inner bladder wall
5. Both A and B
12. Which type of stone in the case of urolithiasis is associated with indwelling catheters?
1. Calcium
2. Struvite
3. Uric acid
4. Cystine
13. Which situation makes an individual susceptible to developing a lower urinary tract infection (UTI)?
1. Urea in the urine
2. Immunoglobulin A (IgA) secretion
3. Vesicoureteral reflux
4. Urease-secreting bacterium
5. Both C and D
14. A nurse is caring for an older adult with a urinary tract infection (UTI). A spinal injury has necessitated the
long-term use of an indwelling urinary catheter in this client. Which is the most likely complication that the
nurse would anticipate in this client?
1. Benign prostate hyperplasia
2. Urosepsis
3. Vesicoureteral reflux
4. Bladder cancer
5. Both B and D
PRIMEXAM.COM
15. A nurse is teaching student nurses about the epidemiology of urolithiasis. Which statement made by a student
nurse indicates the need for further learning?
1. “Urolithiasis occurs in 1 to 3 per 1,000 in men.”
2. “The incidence of recurrence of calculi is 52% at 10 years after the initial incident.”
3. “The incidence of urolithiasis increases among men in their twenties.”
4. “The incidence of urolithiasis in women peaks in the late fifties.”
16. Which statement by the nurse to a client demonstrates an understanding of the factors responsible for the
formation of different types of ureter stones?
1. “Prolonged use of indwelling catheters has predisposed you to uric acid stones.”
2. “You are likely to have developed cystine stones because your diet is excessively rich in
animal proteins.”
3. “You are likely to have developed calcium stones because of a genetic predisposition.”
4. “Prolonged use of supplements has contributed to your developing calcium stones.”
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
17. A student nurse is comparing treatment methods for urolithiasis and urinary incontinence. Which statement
made by the student nurse indicates proper understanding of the treatment methods? Select all that apply.
1. “Local estrogen therapy is very effective in treating incontinence in women.”
2. “Kegel exercises are contraindicated in women with incontinence.”
3. “A transurethral catheter is recommended for long-term catheterization in the treatment of
incontinence.”
4. “Botulinum toxin injection is used as a last resort in the treatment of urolithiasis.”
5. “Hydrochlorothiazide is the drug of choice for treatment of calcium stones.”
18. Which factors will a nurse identify to be associated with the formation of struvite stones, after comparing
struvite stones with calcium stones? Select all that apply.
1. Hypoparathyroidism
2. Dietary factors
3. Anatomical abnormalities in the urinary tract
4. Presence of urease-producing organisms
5. Neurological disorders of the bladder
19. Which statements made by a student nurse demonstrate an understanding of the clinical presentation for lower
urinary tract infections (UTIs)? Select all that apply.
1. “Hematuria is a classic symptom of lower UTIs.”
2. “Suprapubic tenderness is commonly seen in lower UTIs.”
3. “Fever is commonly associated with lower UTIs.”
4. “Severe pain in the glans penis is common in case of lower UTIs.”
5. “Frequency is a common symptom of UTIs.”
20. Which diagnostic procedures are used for the detection of interstitial cystitis (IC) in females? Select all that
apply.
1. Positive leukocyte esterase
2. Laparoscopy
3. Intravenous pyelogram (IVP)
4. Urodynamic studies
PRIMEXAM.COM
5. Hysteroscopy
21. A nurse is taking the history of a female client who is suspected of having urolithiasis. Which are effective
questions that the nurse can ask the client in order to facilitate the diagnosis? Select all that apply.
1. “Do you have pain in the lower back?”
2. “Are you taking any over-the-counter herbal supplements?”
3. “Has anyone in your family ever had kidney stones?”
4. “Do you have gout?”
5. “Have you been diagnosed with endometriosis?”
6. “Do you use strongly scented bath products?”
22. Which statement is true regarding the bacteria that frequently cause lower urinary tract infections (UTIs)?
Select all that apply.
1. Proteus mirabilis causes 70% to 95% of upper and lower urinary tract infections (UTIs).
2. Uropathogenic bacteria thrive by resisting the alkaline nature of urine.
3. Escherichia coli changes the pH of urine by secreting urease.
4. Urease-producing bacteria enhance formation of struvite staghorn calculi in the kidney.
5. Both A and D
Other
23. Arrange in order the steps that depict how untreated urolithiasis can lead to kidney failure (A-G). (Enter the
letter of each step in the proper sequence; do not use commas or spaces.)
A. Bleeding occurs when ureteral mucosa is sheared off.
B. Urine flow pushes the stone down the ureter.
C. Backward accumulation of pressure occurs into the renal pelvis.
D. Urine gets supersaturated with stone-forming salts.
E. Toxicity occurs in nephrons.
F. Intense pain is caused by buildup of pressure and spasms within the ureter.
G. Swelling of the renal pelvis is seen.
24. Arrange in order the events associated with the micturition reflex, when voiding is not appropriate (A-G).
(Enter the letter of each step in the proper sequence; do not use commas or spaces.)
A. The cerebral cortex initiates impulses that travel back down the spinal cord to inhibit the reflex arc.
B. Contraction of the bladder wall takes place.
C. The parasympathetic nerves stimulate the detrusor muscle.
D. The individual then makes a conscious decision about whether it is appropriate to void.
E. The bladder wall stretches to accommodate the increasing volume of urine.
F. The external urinary sphincter stays contracted.
G. Simultaneously, the spinal cord sends nerve impulses up to the cerebral cortex.
25. Arrange in order the events associated with the obstruction of the urinary tract that eventually leads to renal
failure (A-G). (Enter the letter of each step in the proper sequence; do not use commas or spaces.)
A. Glomerular filtration rate (GFR) decreases.
B. Ischemia and incremental nephron loss take place.
C. Ureteral peristalsis is overcome by the pressure.
D. The intraluminal ureteral pressure becomes elevated.
E. Depressed GFR is maintained if complete obstruction is not relieved after 12 to 24 hours.
PRIMEXAM.COM
F. Renal blood flow progressively falls.
PRIMEXAM.COM
G. Increased hydrostatic pressures are transmitted directly to the nephron tubules.
Chapter 23: Urological Disorders
Answer Section
MULTIPLE CHOICE
1. ANS: 2
Chapter: Chapter 23, Urological Disorders
Page: 512
Objective: N/A
Difficulty: Easy
Heading: Neuromuscular Control of the Bladder
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Urinary Elimination
1
2
3
4
Feedback
The urinary bladder can usually hold more urine than 150 to 250 mL.
The urinary bladder can usually hold 300 to 400 mL of urine.
The urinary bladder can usually hold a less urine than 450 to 550 mL.
The urinary bladder can usually hold much less urine than 600 to 700 mL.
PTS: 1
CON: Urinary Elimination
2. ANS: 3
Chapter: Chapter 23, Urological Disorders
Page: 512
Objective: N/A
Difficulty: Easy
Heading: Basic Pathophysiological Concepts of Urological Function
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Urinary Elimination
1
2
3
4
Feedback
Cancers of the pelvic organs are important causes of urinary obstruction in young and
middle-aged women.
Kidney stones are the most common cause of urinary obstruction in young and middleaged men.
Benign prostate hyperplasia is the most common cause of urinary obstruction in men
older than 60 years of age.
Genetic mutation is not the most common cause of urinary obstruction in men older
than 60 years of age.
PTS: 1
CON: Urinary Elimination
PRIMEXAM.COM
3. ANS: 1
Chapter: Chapter 23, Urological Disorders
Page: 518
Objective: N/A
Difficulty: Easy
Heading: Urolithiasis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Urinary Elimination
1
2
3
4
Feedback
The rate of recurrence of urolithiasis at 5 years after the initial incident is 35%.
The rate of recurrence of urolithiasis at 5 years after the initial incident is less than
45%.
The rate of recurrence of urolithiasis at 10 years after the initial incident is 52%.
The rate of recurrence of urolithiasis at 10 years after the initial incident and at 5 years
after the incident is less than 62%.
PTS: 1
CON: Urinary Elimination
4. ANS: 2
Chapter: Chapter 23, Urological Disorders
Page: 518
Objective: N/A
Difficulty: Easy
Heading: Urolithiasis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Urinary Elimination
1
2
3
4
Feedback
While calcium is the most common component of urological stones, clients with spinal
cord injuries are not particularly vulnerable to calcium stones.
Clients with spinal cord injuries are particularly vulnerable to the formation of struvite
stones, since 8% of these clients form stones, 98% of which are struvite stones.
Clients with spinal cord injuries are not particularly vulnerable to uric acid stones.
Cystine stones are uncommon; clients with spinal cord injuries are not particularly
vulnerable to the formation of cystine stones.
PTS: 1
CON: Urinary Elimination
5. ANS: 2
Chapter: Chapter 23, Urological Disorders
Page: 519
Objective: N/A
Difficulty: Easy
Heading: Urolithiasis
PRIMEXAM.COM
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Urinary Elimination
1
2
3
4
Feedback
A typical wave of renal colic lasts longer than 10 to 15 minutes.
A typical wave of renal colic lasts 20 to 60 minutes.
A typical wave of renal colic does not last as long as 70 to 90 minutes.
A typical wave of renal colic lasts longer than 5 to 7 minutes.
PTS: 1
CON: Urinary Elimination
6. ANS: 2
Chapter: Chapter 23, Urological Disorders
Page: 511
Objective: N/A
Difficulty: Moderate
Heading: Epidemiology
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Infection
1
2
3
4
Feedback
A lower UTI is a frequent condition among women, but rare in men. Young adult
women are 30 times more likely to suffer a lower UTI than are young adult men.
Therefore, this statement made by the student nurse does not indicate a need for further
learning.
A lower UTI is a frequent condition among women, but rare in men. Up to 40% of
women in the United States, aged 20 to 40 years, have suffered a lower UTI. In
contrast, the incidence of UTI in males is approximately 5 to 8 per 10,000 people in the
United States. Therefore, the student nurse’s statement that up to 40% of men in the
United States, aged 20 to 40 years, have suffered a lower UTI indicates a need for
further learning.
While a lower UTI is rare in a young adult male and requires further investigation of
the urological system, benign prostate hyperplasia is a common cause of a UTI in men
after the age of 60 years. Therefore, this statement made by the student nurse does not
indicate a need for further learning.
A lower UTI is very common in females, and it is estimated that approximately 50% of
all women will have a UTI at some point in their lifetime. Therefore, this statement
made by the student nurse does not indicate a need for further learning.
PTS: 1
CON: Urinary Elimination
7. ANS: 3
Chapter: Chapter 23, Urological Disorders
Page: 519
Objective: N/A
PRIMEXAM.COM
Difficulty: Easy
Heading: Urolithiasis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Urinary Elimination
1
2
3
4
Feedback
Calcium stones are related to increased intestinal absorption of calcium, excess
resorption of calcium from bone, and an inability of the renal tubules to properly
reabsorb calcium in the glomerular filtrate. These stones are not caused by a genetic
disorder associated with the faulty metabolism of an amino acid.
Uric acid stones are formed by the consumption of food containing a high amount of
purines, which break down into uric acid. These stones are not caused by a genetic
disorder associated with the faulty metabolism of an amino acid.
Cystine stones formed in the ureter are caused by a genetic disorder associated with the
faulty metabolism of the amino acid, cystine.
Struvite stones occur when urea is split into ammonia, bicarbonate, and carbonate ions
by urease-producing organisms. These stones are not caused by a genetic disorder
associated with the faulty metabolism of an amino acid.
PTS: 1
CON: Urinary Elimination
8. ANS: 2
Chapter: Chapter 23, Urological Disorders
Page: 515
Objective: N/A
Difficulty: Easy
Heading: Lower Urinary Tract Infections
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Urinary Elimination
1
2
3
4
Feedback
The high osmolarity of urine, along with the presence of urea and organic acids,
diminishes bacterial viability in the bladder.
Stagnant urine is a good medium for bacterial growth, and continual free outflow of
urine clears bacteria from the body. Therefore, any obstruction of urinary outflow
decreases the bladder’s resistance to bacterial infection.
IgA, secreted by white blood cells in the urinary tract, prevents adherence of bacteria to
the bladder wall; this decreases the possibility of the occurrence of UTIs.
Not all women have IgA; many women are nonsecretors. The presence of IgA prevents
the occurrence of UTIs. The absence of IgA in nonsecreting women decreases their
ability to combat bacterial invasion of the bladder.
PTS: 1
9. ANS: 4
CON: Urinary Elimination
PRIMEXAM.COM
Chapter: Chapter 23, Urological Disorders
Page: 516
Objective: N/A
Difficulty: Moderate
Heading: Lower Urinary Tract Infections
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Infection
1
2
3
4
Feedback
Lack of circumcision is a risk factor for lower UTIs in young men.
Anal intercourse is a risk factor for causing lower UTIs in young men.
Benign prostate hyperplasia (BPH) causes obstruction of the urethra, which results in
stasis of urine. This is the most common reason for infection in older males, not young
men.
Lack of circumcision and anal intercourse are risk factors for lower UTIs in young men.
PTS: 1
CON: Urinary Elimination
10. ANS: 2
Chapter: Chapter 23, Urological Disorders
Page: 516
Objective: N/A
Difficulty: Moderate
Heading: Lower Urinary Tract Infections
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Infection
1
2
3
4
5
6
Feedback
Any obstruction of urinary outflow decreases the bladder’s resistance to bacterial
infection. Chronic voluntary suppression of urination causes interference with urinary
outflow and thus is a risk factor for bacterial UTIs. Fungal growth is not dependent on
obstruction of urinary outflow.
UTIs caused by Proteus mirabilis, a bacterium from the bowel, is most commonly
associated with urinary instrumentation or catheterization. Urinary catheters are also a
risk factor for UTIs caused by Candida albicans, a fungal pathogen that colonizes the
vaginal area. Therefore, catheter use is a risk factor for both bacterial and fungal UTIs.
Diabetes mellitus is a risk factor for Candida UTIs. It is not a risk factor for bacterial
UTIs.
Antibiotic use is a risk factor for Candida UTIs. It is not a risk factor for bacterial UTIs.
Any obstruction of urinary outflow decreases the bladder’s resistance to bacterial
infection. That makes stagnant urine a good medium for bacterial growth. However, it
is unrelated to fungal UTIs.
Options A and E are risk factors for only bacterial UTIs, while options C and D are risk
factors for only fungal UTIs, specifically Candida UTIs. Only option B is a risk factor
PRIMEXAM.COM
for both bacterial and fungal UTIs.
PTS: 1
CON: Urinary Elimination
11. ANS: 5
Chapter: Chapter 23, Urological Disorders
Page: 517
Objective: N/A
Difficulty: Difficult
Heading: Interstitial Cystitis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Urinary Elimination
1
2
3
4
5
Feedback
Thinning of bladder mucosa is observed in nonulcerative IC. This is not a feature of
ulcerative IC.
Small tears and hemorrhages are seen in nonulcerative IC when the bladder is
distended.
Erythema can be present on the inner bladder surface in ulcerative IC. This is not seen
in nonulcerative IC.
The inner bladder surface may contain one or more ulcerations surrounded by
inflammation in ulcerative IC. This is not seen in nonulcerative IC.
Thinning of bladder mucosa and small tears and hemorrhages on the bladder wall when
the bladder is distended are observed in nonulcerative IC.
PTS: 1
CON: Urinary Elimination
12. ANS: 2
Chapter: Chapter 23, Urological Disorders
Page: 518
Objective: N/A
Difficulty: Easy
Heading: Urolithiasis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Urinary Elimination
1
2
3
Feedback
Indwelling catheters are not responsible for predisposing clients to the formation of
calcium stones. Calcium stones are formed due to excess dietary calcium and excess
resorption of calcium from the bone.
Indwelling catheters are responsible for predisposing clients to the formation of struvite
stones.
Indwelling catheters are not responsible for predisposing clients to the formation of uric
acid stones. These stones are formed when excess purines in the bloodstream break
down into uric acid.
PRIMEXAM.COM
4
Indwelling catheters are not responsible for predisposing clients to the formation of
cystine stones. These stones are linked to a genetic disorder associated with the faulty
metabolism of the amino acid, cystine.
PTS: 1
CON: Urinary Elimination
13. ANS: 5
Chapter: Chapter 23, Urological Disorders
Page: 515, 516
Objective: N/A
Difficulty: Difficult
Heading: Lower Urinary Tract Infections
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Infection
1
2
3
4
5
Feedback
The presence of urea in the urine diminishes bacterial viability in the bladder.
Therefore, this will not make an individual susceptible to developing a lower UTI.
Immunoglobulin A (IgA), secreted by white blood cells in the urinary tract, prevents
adherence of bacteria to the bladder wall. Therefore, the secretion of IgA does make an
individual susceptible to developing a lower UTI.
Vesicoureteral reflux, commonly seen in young female children, allows urine to reflux
up toward the kidney because of an anatomical abnormality at the junction where the
ureter enters the bladder. This increases the risk of UTIs.
Urease-secreting bacteria such as Proteus mirabilis have an enhanced ability to invade
the bladder because urease decreases the acidity of urine.
Vesicoureteral reflux allows urine to reflux up toward the kidney, which increases the
risk of UTIs. Urease-secreting bacteria such as Proteus mirabilis have an enhanced
ability to invade the bladder because urease decreases the acidity of urine. Therefore,
these will make an individual susceptible to developing a lower UTI.
PTS: 1
CON: Urinary Elimination
14. ANS: 5
Chapter: Chapter 23, Urological Disorders
Page: 516, 520
Objective: N/A
Difficulty: Difficult
Heading: Lower Urinary Tract Infections
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Urinary Elimination
1
Feedback
Benign prostate hyperplasia causes stasis of urine by obstruction of the urethra. This is
the most common reason for urinary tract infections in older males; it is not a
PRIMEXAM.COM
2
3
4
5
complication that arises from the infection. Also, it is unrelated to long-term use of an
indwelling urinary catheter.
Urosepsis or bacterial invasion of the bloodstream can be a complication of UTIs in
older adults, particularly those with long-term indwelling urinary catheterization.
Vesicoureteral reflux is a cause of UTIs in young female children. It is caused by an
anatomical abnormality that allows urine to reflux up toward the kidney, increasing the
risk of UTIs. Therefore, it is not a complication that arises from the infection, and it is
unrelated to long-term use of an indwelling urinary catheter.
Clients with spinal cord injuries who require a long-term indwelling urinary catheter
have a 16 to 20 times greater risk of developing bladder cancer than the general
population.
Urosepsis, or bacterial invasion of the bloodstream, can be a complication of UTIs in
older adults, particularly those with long-term indwelling urinary catheterization. Also,
clients with spinal cord injuries who require a long-term indwelling urinary catheter
have a 16 to 20 times greater risk of developing bladder cancer than the general
population. Therefore, urosepsis and bladder cancer can be anticipated in the client.
PTS: 1
CON: Urinary Elimination
15. ANS: 4
Chapter: Chapter 23, Urological Disorders
Page: 518
Objective: N/A
Difficulty: Moderate
Heading: Urolithiasis
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Urinary Elimination
1
2
3
4
Feedback
Population estimates of the incidence of urolithiasis range from 1 to 3 per 1,000 in men.
So, this statement by the student nurse does not indicate the need for further learning.
Recurrence of calculi is common; it is 52% at 10 years after the initial incident.
Therefore, this statement by the student nurse does not indicate the need for further
learning.
Incidence of urolithiasis increases among men in their twenties and peaks in the late
fifties. Therefore, this statement by the student nurse does not indicate the need for
further learning.
Incidence of urolithiasis is less common in women than in men. Incidence increases
among men in their twenties and peaks in the late fifties; in women, the incidence rate
is approximately equal across all age groups. Therefore, this statement by the student
nurse indicates the need for further learning.
PTS: 1
CON: Urinary Elimination
16. ANS: 4
Chapter: Chapter 23, Urological Disorders
Page: 518
PRIMEXAM.COM
Objective: N/A
Difficulty: Difficult
Heading: Urolithiasis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Urinary Elimination
Feedback
1
2
3
4
Prolonged use of indwelling catheters is responsible for predisposing individuals to
struvite stones. Instead, a diet rich in animal proteins contains a high amount of purines,
which break down into uric acid. This increased uric acid in the bloodstream
precipitates out of solution in the kidney and forms uric acid stones. Therefore, this
statement made by the nurse is incorrect.
Cystine stones are linked to a genetic disorder associated with the faulty metabolism of
the amino acid, cystine. They are unrelated to having a diet rich in animal proteins.
Instead, a diet rich in animal proteins contains a high amount of purines, which break
down into uric acid. This increased uric acid in the bloodstream precipitates out of
solution in the kidney and forms uric acid stones. Therefore, this statement made by the
nurse is incorrect.
Factors that predispose individuals to calcium stone formation include excess dietary
calcium, overactive calcium absorption mechanisms, excess resorption of calcium from
bone, and inability of the renal tubules to properly reabsorb calcium in the glomerular
filtrate. Calcium stones do not develop due to a genetic predisposition. Instead, cystine
stones are linked to a genetic disorder associated with the faulty metabolism of the
amino acid, cystine. Therefore, this statement made by the nurse is incorrect.
Calcium stones are formed because of hypercalciuria, which is often related to
increased intestinal absorption of calcium. Taking excess calcium supplements can lead
to increased intestinal absorption of calcium; this facilitates the development of calcium
stones. Therefore, this statement made by the nurse is correct.
PTS: 1
CON: Urinary Elimination
MULTIPLE RESPONSE
17. ANS: 5
Chapter: Chapter 23, Urological Disorders
Page: 520, 521
Objective: N/A
Difficulty: Difficult
Heading: Urolithiasis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Urinary Elimination
Feedback
PRIMEXAM.COM
1.
2.
3.
4.
5.
This is incorrect. Although local estrogen therapy is sometimes used as a nonsurgical
treatment method of urinary incontinence, its effectiveness is inconclusive.
This is incorrect. Stress incontinence in women is the most common type of urinary
incontinence; it occurs because of a loss of muscle support in the pelvic floor. Kegel
exercises can improve pelvic muscle strength and are recommended for the treatment of
urinary incontinence.
This is incorrect. Long-term catheterization can be needed for the treatment of urinary
incontinence. In such a situation, a suprapubic catheter may be preferable to a transurethral
catheter. Catheterization is not required for the treatment of urolithiasis.
This is incorrect. Botulinum toxin injection is not used as a last resort in the treatment of
urolithiasis. Instead, intradetrusor muscle injection of botulinum toxin is used to treat
urinary incontinence when all pharmacological agents fail.
This is correct. Diuretics such as hydrochlorothiazide can limit calcium excretion into
urine. This prevents the formation of calcium stones in the case of urolithiasis. Therefore,
using hydrochlorothiazide to treat urolithiasis is an effective treatment method. Diuretics
are not used to treat urinary incontinence. Instead, treatment of urinary incontinence
requires drugs that would diminish bladder activity and allow retention of urine.
Anticholinergic drugs such as oxybutynin are used for this purpose.
PTS: 1
CON: Urinary Elimination
18. ANS: 3, 4, 5
Chapter: Chapter 23, Urological Disorders
Page: 518, 519
Objective: N/A
Difficulty: Moderate
Heading: Urolithiasis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Urinary Elimination
1.
2.
3.
4.
5.
Feedback
This is incorrect. Hypoparathyroidism is not associated with the formation of either
calcium stones or struvite stones. In fact, hyperparathyroidism involves excess resorption
of calcium from bone, which can cause calcium stones. Struvite stones are unrelated to
this.
This is incorrect. Dietary factors are unrelated to the formation of struvite stones. Instead,
calcium stones can be formed due to excess dietary calcium and overactive calcium
absorption mechanisms, which cause increased intestinal absorption of calcium.
This is correct. Anatomical abnormalities in the urinary tract predispose individuals to
struvite stone formation. Calcium stone formation is unrelated to the presence of
anatomical abnormalities in the urinary tract.
This is correct. Struvite stones occur when urea is split into ammonia, bicarbonate, and
carbonate ions by urease-producing organisms, especially Proteus mirabilis. These
organisms are not responsible for the formation of calcium stones.
This is correct. Neurological disorders of the bladder predispose individuals to struvite
stone formation. Calcium stone formation is unrelated to neurological disorders of the
PRIMEXAM.COM
bladder.
PTS: 1
CON: Urinary Elimination
19. ANS: 4, 5
Chapter: Chapter 23, Urological Disorders
Page: 516
Objective: N/A
Difficulty: Moderate
Heading: Lower Urinary Tract Infections
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Urinary Elimination
1.
2.
3.
4.
5.
Feedback
This is incorrect. Hematuria is occasionally present in UTIs. The classic symptoms are
dysuria, frequency, and urgency. Therefore, this statement by the student nurse does not
demonstrate correct understanding.
This is incorrect. Suprapubic tenderness is seen in clients suffering from UTIs in rare cases.
Therefore, this statement by the student nurse does not demonstrate correct understanding.
This is incorrect. A lower UTI does not cause fever. Fever can be an indication of
pyelonephritis. Therefore, this statement by the student nurse does not demonstrate correct
understanding.
This is correct. Severe infections can cause bladder spasms. In men, these spasms can
produce severe referred pain in the glans penis. Therefore, this statement by the student
nurse demonstrates correct understanding.
This is correct. Frequency, along with dysuria and urgency, is a classic symptom of lower
UTIs. Therefore, this statement by the student nurse demonstrates correct understanding.
PTS: 1
CON: Urinary Elimination
20. ANS: 2, 4, 5
Chapter: Chapter 23, Urological Disorders
Page: 517
Objective: N/A
Difficulty: Easy
Heading: Interstitial Cystitis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Urinary Elimination
1.
2.
Feedback
This is incorrect. Positive leukocyte esterase is used for the detection of white blood cells.
This test is used to detect lower urinary tract infections.
This is correct. Endometriosis has to be ruled out in order to properly diagnose IC in
females. Laparoscopy is one procedure for detecting endometriosis, so the client needs to
get this test done for the detection of IC.
PRIMEXAM.COM
3.
4.
5.
This is incorrect. IVP is used for the detection of urolithiasis. This test is more sensitive in
detecting urolithiasis than abdominal x-rays of the kidneys, ureters, and bladder, which
miss stones that are not opaque to x-ray.
This is correct. Urodynamic studies can be used to diagnose IC by evaluating bladder
sensation and neuromuscular function.
This is correct. Endometriosis has to be ruled for the diagnosis of IC in females.
Hysteroscopy is one procedure for detecting endometriosis, so the client needs this test for
the detection of IC.
PTS: 1
CON: Urinary Elimination
21. ANS: 1, 2, 3, 4
Chapter: Chapter 23, Urological Disorders
Page: 519
Objective: N/A
Difficulty: Difficult
Heading: Urolithiasis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Urinary Elimination
1.
2.
3.
4.
5.
6.
Feedback
This is correct. Diagnosis of urolithiasis is most often based on the client’s history because
there are distinct symptoms. It is characterized by severe colicky type pain beginning in the
flank or lower back and often radiating to the groin or genitals. Therefore, asking the client
whether she has pain in the lower back is an effective question.
This is correct. Current medications, including over-the-counter medications and herbal
supplements, can predispose individuals to stone formation. Therefore, asking the client
whether she has been taking over-the-counter herbal supplements is an effective question.
This is correct. There is a strong genetic predisposition to kidney stones. Therefore, asking
whether anyone in the client’s family has ever had kidney stones is an effective question.
This is correct. It is important to note any disorders that can increase the client’s
susceptibility to hyperuricemia because uric acid is a common component of stones. Since
individuals with gout have hyperuricemia, asking the client whether she has gout is an
effective question.
This is incorrect. Endometriosis should be ruled out in women for diagnosis of interstitial
cystitis. This is unrelated to urolithiasis.
This is incorrect. Using irritating bath products increases susceptibility to urinary tract
infections in women, but are not a risk factor for urolithiasis.
PTS: 1
CON: Urinary Elimination
22. ANS: 4
Chapter: Chapter 23, Urological Disorders
Page: 515, 516
Objective: N/A
Difficulty: Moderate
Heading: Lower Urinary Tract Infections
PRIMEXAM.COM
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Urinary Elimination
1.
2.
3.
4.
5.
Feedback
This is incorrect. Escherichia coli (E. coli), a bacterium found in the bowel, causes 70% to
95% of upper and lower UTIs. Proteus mirabilis is another bacterium from the bowel that
also causes UTIs, but not as often as E. coli.
This is incorrect. Uropathogenic bacteria have outer capsules that can resist the acidic
nature of urine. An alkaline pH facilitates bacterial growth.
This is incorrect. Proteus mirabilis secretes urease, which decreases the acidity of urine,
thus changing the pH of the urine. This enhances formation of struvite staghorn calculi in
the kidney. E. coli does not change the acidic nature of urine; the outer capsules can resist
the acid in the urine.
This is correct. Proteus mirabilis secretes urease, which decreases the acidity of urine. This
changes the pH of the urine, which enhances formation of struvite staghorn calculi in the
kidney.
This is incorrect. Option A is incorrect because E. coli causes 70% to 95% of upper and
lower UTIs. Option D is correct because urease-producing bacteria like Proteus mirabilis
enhance formation of struvite staghorn calculi in the kidney.
PTS: 1
CON: Urinary Elimination
ORDERED RESPONSE
23. ANS:
DBAFCGE
Chapter: Chapter 23, Urological Disorders
Page: 519
Objective: N/A
Difficulty: Difficult
Heading: Urolithiasis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Urinary Elimination
Feedback: Urolithiasis occurs because of supersaturation of the urine with stone-forming salts as a result of
chemical, metabolic, or genetic causes. The urine flow slowly pushes the stone down the ureter. Along the
way, it shears off some of the ureteral mucosa, which causes superficial bleeding of the membrane. The stone
causes a buildup of pressure and spasms proximally within the ureter, which results in intense pain. Lack of a
urine passage can cause backward accumulation of pressure into the renal pelvis. This leads to
hydronephrosis, which is swelling of the renal pelvis. Backward accumulation of urine is toxic to nephrons
and can result in kidney failure.
PTS: 1
CON: Urinary Elimination
PRIMEXAM.COM
24. ANS:
ECBGDAF
Chapter: Chapter 23, Urological Disorders
Page: 512
Objective: N/A
Difficulty: Difficult
Heading: Neuromuscular Control of the Bladder
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Urinary Elimination
Feedback: The micturition reflex, which is a reflex involving the spinal cord and cortex of the brain, controls
voiding. When the bladder wall stretches to accommodate the increasing volume of urine, the
parasympathetic nerves in the reflex arc respond by stimulating the detrusor muscle in the bladder wall to
contract. At the same time, the spinal cord sends nerve impulses up to the cerebral cortex. This allows the
individual to make a conscious decision about whether it is appropriate to void. If voiding is not appropriate,
the cerebral cortex initiates impulses that travel back down the spinal cord to inhibit the reflex arc. The
external urinary sphincter is kept contracted, and micturition is prevented.
PTS: 1
CON: Urinary Elimination
25. ANS:
DCGAEFB
Chapter: Chapter 23, Urological Disorders
Page: 512
Objective: N/A
Difficulty: Difficult
Heading: Obstructive Uropathy
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Urinary Elimination
Feedback: Elevation of intraluminal ureteral pressure eventually occurs with obstruction of the urinary tract at
any level. With prolonged obstruction, ureteral peristalsis is overcome, and increased hydrostatic pressures are
transmitted directly to the nephron tubules. As pressures in the proximal tubule and Bowman space increase,
GFR decreases. If complete obstruction is not relieved after 12 to 14 hours, a depressed GFR is maintained,
and there is a decrease in renal blood flow. With continued obstruction, renal blood flow progressively falls,
resulting in ischemia and incremental nephron loss. This can eventually lead to obstruction of urine at the
kidney, backup of urine into the kidney, and kidney failure.
PTS: 1
CON: Urinary Elimination
PRIMEXAM.COM
Chapter 24: Endocrine Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. Which disorder is caused by an increase in the hormones that are secreted from the adrenal gland?
1. Addison’s disease
2. Hypothyroidism
3. Diabetes mellitus
4. Cushing’s syndrome
2. A client tells the nurse, “I’ve been feeling excessively thirsty for the last 2 days.” On examination, the nurse
finds the client has poor skin turgor, low blood pressure, and dry skin. A computed tomography scan of the
client’s head shows a pituitary tumor. Which treatment does the nurse expect to be prescribed by the primary
health-care provider?
1. Bromocriptine
2. Growth hormone
3. Arginine vasopressin
4. Adrenocorticotropic hormone
3. A client who underwent laryngotomy presented with depression, increased sensitivity to cold, and
constipation. On assessment, the nurse finds a puffy face and periorbital edema. The blood report shows a
high TSH level. What does the nurse interpret from the findings?
1. The client has hypothyroidism.
2. The client has hyperthyroidism.
3. The client has hypoparathyroidism.
4. The client has hyperparathyroidism.
4. Which condition exhibits “moon facies” as a characteristic symptom?
1. Myxedema
2. Graves’s disease
3. Cushing’s syndrome
4. Adrenal insufficiency
5. Which diagnostic test is useful for detecting hyperactivity of the thyroid gland during an evaluation of a
thyroid disorder?
1. Sestamibi scan
2. Ultrasound
3. Radioactive iodine scan
4. CT scan of the anterior neck
6. The nurse is caring for a client with seizures, severely elevated blood pressure, and impaired mentation. The
primary health-care provider suspects the client’s condition is an endocrine disorder. A 24-hour urinalysis
report shows an excess amount of catecholamine metabolites. What might be the diagnosis of the client?
1. The client has a pineal tumor.
2. The client has pheochromocytoma.
3. The client has Cushing’s syndrome.
4. The client has multiple endocrine neoplasia.
PRIMEXAM.COM
7. Which endocrine disorder involves treatment using antithyroid hormone medication such as propylthiouracil
(PTU)?
1. Grave’s disease
2. Plummer disease
3. Cushing’s disease
4. Addison’s disease
8. Which congenital condition occurs due to thyroid hormone deficiency during embryonic development and
early neonatal life?
1. Cretinism
2. Pheochromocytoma
3. Sheehan’s syndrome
4. Fetal alcohol syndrome
9. The nurse is teaching a group of student nurses about treatment strategies that are beneficial to a client with
hyperparathyroidism. Which statement of the student nurse does the nurse correct?
1. “The client is prescribed calcitonin to inhibit bone breakdown.”
2. “The client is prescribed calcium and vitamins for bone building.”
3. “The client is advised to increase water intake to prevent kidney stones.”
4. “The client is prescribed bisphosphonates to stimulate osteoclast activity.”
10. Which chromosomal genetic mutations are associated with the cause of pituitary adenoma?
1. PIT1
2. LHX3
3. LHX4
4. 11q13
11. A client is diagnosed with multiple endocrine neoplasia. Which sign or symptom observed in the client
indicates the presence of pituitary tumors?
1. Bone pain
2. Galactorrhea
3. Gynecomastia
4. Visual disturbances
12. Which medication does the primary health-care provider prescribe for the treatment of prolactinoma in a
client with hyperpituitarism?
1. Conivaptan
2. Furosemide
3. Bromocriptine
4. Levothyroxine
13. Which diagnostic test would be beneficial to rule out ectopic ACTH-secreting tumors in the body?
1. Chest x-ray
2. Octreotide scintigraphy
3. Contrast-enhanced MRI
4. Abdominal CT scan
14. Which value of cortisol levels would the nurse expect to find in the laboratory report of a client with
Cushing’s disease?
1. 0.6 mcg/dL
2. 1.8 mcg/dL
PRIMEXAM.COM
3. 2.4 mcg/dL
4. 3.8 mcg/dL
15. The nurse finds that the symptoms of thyroid dysfunction in a client are due to abnormal pituitary activity.
The client’s laboratory report shows a low TSH level, which supports the nurse’s finding. What type of
endocrine disorder is likely present in the client?
1. Primary hypothyroidism
2. Tertiary hyperthyroidism
3. Primary hyperthyroidism
4. Secondary hypothyroidism
16. Which endocrine gland is called the master gland?
1. The pineal gland
2. The adrenal gland
3. The thyroid gland
4. The pituitary gland
17. Which disorder is described as the complete loss of all of the pituitary hormones?
1. Hypopituitarism
2. Panhypopituitarism
3. Sheehan’s syndrome
4. Empty sella syndrome
NARRBEGIN: Exhibit
Exhibit
NARREND
18. The nurse is caring for four clients in a health-care setting diagnosed with different endocrine disorders.
Client
Client 1
Client 2
Client 3
Client 4
Disorder
Pineal tumor
Diabetes insipidus
Pheochromocytoma
Cushing syndrome
Which client requires treatment by placement of a ventriculo-peritoneal shunt?
1. Client 1
2. Client 2
3. Client 3
4. Client 4
19. The nurse observes the final diagnosis of four clients in their case reports as given below.
Client
Client 1
Client 2
Client 3
Client 4
Disorder
Pineal tumor
Hypothyroidism
Pheochromocytoma
Hypoparathyroidism
In which client does the nurse notice the presence of Chvostek sign and Trousseau sign?
PRIMEXAM.COM
1.
2.
3.
4.
Client 1
Client 2
Client 3
Client 4
20. Four clients are diagnosed with different endocrine disorders as given below.
Client
Client 1
Client 2
Client 3
Client 4
Disorder
Pineal tumor
Hypothyroidism
Pheochromocytoma
Hypoparathyroidism
Which client would be prescribed a magnetic resonance imaging (MRI) scan of the abdomen to visualize the
adrenal gland?
1. Client 1
2. Client 2
3. Client 3
4. Client 4
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
21. The caregiver of a client tells the nurse, “The client has coarsening of facial features and enlarged bones in the
face.” On assessment of the client, the nurse finds that the client has a high blood pressure and visual
impairment. Which diagnostic tests does the primary health-care provider prescribe for further confirmation?
Select all that apply.
1. Ultrasonography
2. CT scan of whole head
3. MRI scans of whole head
4. Corticotropin stimulation test
5. Blood studies of tropic hormones
22. A client is admitted to the emergency room with complaints of impaired mentation, two episodes of seizures,
nausea, and vomiting. The blood studies reveal hyponatremia, a high ADH level, and low serum osmolality.
The urine study shows high urine osmolality. Which medications would be beneficial to the client in this
situation? Select all that apply.
1. Conivaptan
2. Furosemide
3. Tetracyclines
4. Bromocriptine
5. Levothyroxine
6. Arginine vasopressin
23. Which signs or symptoms does the nurse observe while assessing a client with diabetes insipidus? Select all
that apply.
1. Amenorrhea
2. Galactorrhea
3. Poor skin turgor
PRIMEXAM.COM
4. Orthostatic hypotension
5. Dry mucous membranes
24. While assessing a client with a pineal tumor, the nurse finds disturbed vision. Which other signs and
symptoms are associated with this disorder? Select all that apply.
1. Seizures
2. Bulging eyes
3. Conjunctivitis
4. Memory disturbances
5. Upper eyelid retraction
25. Which electrolyte disturbances occur due to low levels of aldosterone? Select all that apply.
1. Hyperkalemia
2. Hyponatremia
3. Hypercalcemia
4. Hypomagnesemia
5. Hypoglycemia
PRIMEXAM.COM
Chapter 24: Endocrine Disorders
Answer Section
MULTIPLE CHOICE
1. ANS: 4
Chapter: Chapter 24, Endocrine Disorders
Page: 529
Objective: N/A
Difficulty: Easy
Heading: Epidemiology
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Metabolism
1
2
3
4
Feedback
Addison’s disease is a disorder caused by hypofunction of the adrenal gland.
Hypothyroidism is a disorder caused by decreased levels of the thyroid hormone.
Diabetes mellitus is a metabolic disorder caused by decreased or impaired function of
the pancreas.
Cushing’s syndrome is a disorder caused by increased levels of the cortisol hormone,
which is secreted from the adrenal gland.
PTS: 1
CON: Metabolism
2. ANS: 3
Chapter: Chapter 24, Endocrine Disorders
Page: 548
Objective: N/A
Difficulty: Difficult
Heading: Diabetes Insipidus
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Medication
1
2
3
4
Feedback
Bromocriptine is used to reduce the secretion of pituitary hormones, when
prolactinemia is present.
Growth hormone replacement is beneficial in the clients with hypopituitarism.
Arginine vasopressin is also known as antidiuretic hormone (ADH). Administration of
ADH helps to relieve signs of dehydration such as poor skin turgor, low BP, and dry
skin.
Adrenocorticotropic hormone is used as a supplement when growth hormones and
tropic hormones are deficient.
PRIMEXAM.COM
PTS: 1
CON: Medication
3. ANS: 1
Chapter: Chapter 24, Endocrine Disorders
Page: 549
Objective: N/A
Difficulty: Moderate
Heading: Hypothyroidism
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Assessment: Metabolism
1
2
3
4
Feedback
Hypothyroidism is characterized by weight gain, increased sensitivity to cold,
constipation, puffy face, and periorbital edema. The blood report shows a high TSH
level, which further confirms the diagnosis of hypothyroidism.
Hyperthyroidism is characterized by weight loss, sensitivity to heat, palpitations, and an
enlarged thyroid.
Hypoparathyroidism is characterized by muscle spasms, tetany, and seizures.
Hyperparathyroidism is characterized by bone pain, muscle weakness, and
hypercalcemia.
PTS: 1
CON: Assessment: Metabolism
4. ANS: 3
Chapter: Chapter 24, Endocrine Disorders
Page: 537
Objective: N/A
Difficulty: Easy
Heading: Pituitary Gland Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Assessment: Metabolism
1
2
3
4
Feedback
Myxedema is characterized by a puffy face and periorbital edema.
Grave’s disease is characterized by an enlarged thyroid or nodule.
Moon facies are a characteristic feature of Cushing’s syndrome.
Adrenal insufficiency is characterized by orthostatic hypotension and a tanned
appearance.
PTS: 1
CON: Assessment: Metabolism
5. ANS: 3
Chapter: Chapter 24, Endocrine Disorders
Page: 550
Objective: N/A
Difficulty: Easy
PRIMEXAM.COM
Heading: Hyperthyroidism
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Comprehension [Understanding]
Concept: Assessment: Metabolism
1
2
3
4
Feedback
A Sestamibi scan shows masses or cysts of parathyroid gland.
Ultrasound is useful in detecting masses or cysts and gland enlargement.
Hyperactivity of the thyroid gland is seen in hyperthyroidism. A radioactive iodine scan
shows the hyperactive gland.
A CT scan of the anterior neck shows the presence of pituitary mass.
PTS: 1
CON: Assessment: Metabolism
6. ANS: 2
Chapter: Chapter 24, Endocrine Disorders
Page: 546
Objective: N/A
Difficulty: Difficult
Heading: Parathyroid Gland Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Critical Thinking: Metabolism
1
2
3
4
Feedback
A Pineal tumor is characterized by seizures, headache, memory disturbances, nausea,
and vomiting. The condition is confirmed by a computed tomography or magnetic
resonance imaging scan that shows a tumor.
Pheochromocytoma is characterized by hypertensive crises such as severely elevated
BP, seizures, and altered mental status due to excess secretion of catecholamines. A 24hour urine analysis is the most common method used for diagnosing the condition.
Presence of catecholamines indicates pheochromocytoma.
Cushing’s syndrome is a disorder caused by excessive secretion of cortisol. This is
characterized by weight gain, moon facies, antithyroid buffalo hump, and hirsutism.
Various diagnostic tests are required for confirmation.
Multiple endocrine neoplasia has various clinical features due to involvement of
multiple endocrine glands. This condition is diagnosed by using various blood tests that
detect the level of growth hormones.
PTS: 1
CON: Critical Thinking: Metabolism
7. ANS: 1
Chapter: Chapter 24, Endocrine Disorders
Page: 541
Objective: N/A
Difficulty: Easy
Heading: Thyroid Disorders
PRIMEXAM.COM
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapy
Cognitive Level: Comprehension [Understanding]
Concept: Medication
1
2
3
4
Feedback
Grave’s disease is the most common cause of hyperthyroidism, which is commonly
treated with propylthiouracil (PTU). This medication helps to suppress the function of the
thyroid gland.
Plummer disease, also called toxic multinodular goiter, requires surgery as a method of
treatment because of the extensive spread of nodules.
Cushing’s disease is most commonly treated with ADH antagonists, furosemide, and by
providing symptomatic treatment.
Addison’s disease is caused by adrenal insufficiency, which is most commonly treated
with replacement of ACTH or cortisol, depending on the cause.
PTS: 1
CON: Medication
8. ANS: 1
Chapter: Chapter 24, Endocrine Disorders
Page: 538
Objective: N/A
Difficulty: Easy
Heading: Thyroid Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Metabolism
1
2
3
4
Feedback
Cretinism is a congenital condition caused by hypothyroidism during embryonic
development and early neonatal life.
Pheochromocytoma is a rare tumor of the adrenal medulla; the cause is unknown.
Sheehan’s syndrome is an endocrine disorder that occurs after childbirth due to severe
hemorrhage.
Fetal alcohol syndrome is a congenital disorder caused by diminished parathyroid gland
function.
PTS: 1
CON: Metabolism
9. ANS: 4
Chapter: Chapter 24, Endocrine Disorders
Page: 551
Objective: N/A
Difficulty: Difficult
Heading: Hyperparathyroidism
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapy
Cognitive Level: Analysis [Analyzing]
PRIMEXAM.COM
Concept: Metabolism: Medication
1
2
3
4
Feedback
Calcitonin is a drug that inhibits bone breakdown and is used for the treatment of clients
with hyperparathyroidism.
Calcium and vitamin D are also supplemented to the client with hyperparathyroidism for
bone building.
An increase in water intake prevents the occurrence of kidney stones and helps avoid
complications during treatment.
Bisphosphonates are administered to the client with hyperparathyroidism to inhibit
osteoclast activity.
PTS: 1
CON: Metabolism: Medication
10. ANS: 4
Chapter: Chapter 24, Endocrine Disorders
Page: 536
Objective: N/A
Difficulty: Easy
Heading: Pituitary Gland Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Assessment; Critical Thinking
1
2
3
4
Feedback
A genetic mutation in the PIT1 is the cause of congenital hypopituitarism.
A genetic mutation in the LHX3 is the cause of congenital hypopituitarism.
A genetic mutation in the LHX4 is the cause of congenital hypopituitarism.
A genetic mutation on chromosome 11q13 is the cause of pituitary adenoma.
PTS: 1
CON: Assessment; Critical Thinking
11. ANS: 4
Chapter: Chapter 24, Endocrine Disorders
Page: 536
Objective: N/A
Difficulty: Easy
Heading: Pituitary Gland Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Assessment: Cellular Regulation
1
2
Feedback
Bone pain is a characteristic finding observed in clients with dysfunction of the
parathyroid gland.
Galactorrhea is a symptom observed in clients with prolactinemia due to excess secretion
of pituitary hormones.
PRIMEXAM.COM
3
4
Gynecomastia is a symptom observed in clients with prolactinemia due to excess
secretion of pituitary hormones.
Visual disturbances are the characteristic feature of large tumors due to their proximity to
the optic nerve chiasm.
PTS: 1
CON: Assessment: Cellular Regulation
12. ANS: 3
Chapter: Chapter 24, Endocrine Disorders
Page: 548
Objective: N/A
Difficulty: Moderate
Heading: Pituitary Gland Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Medication
1
2
3
4
Feedback
Conivaptan is an antidiuretic hormone antagonist used for the treatment of syndrome of
inappropriate antidiuretic hormone.
Furosemide is used to decrease the water content in the blood while treating a client with
Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH).
Bromocriptine is used to inhibit prolactin production for treating a client with
prolactinoma.
Levothyroxine is used to replace thyroid hormone in a client with hypothyroidism.
PTS: 1
CON: Medication
13. ANS: 2
Chapter: Chapter 24, Endocrine Disorders
Page: 546
Objective: N/A
Difficulty: Moderate
Heading: Cushing’s syndrome
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Assessment: Evidence-Based Practice; Metabolism
1
2
3
4
Feedback
A chest x-ray is used to rule out an ACTH-secreting pulmonary tumor in the body.
An octreotide scintigraphy is a diagnostic test used to rule out ectopic ACTH-secreting
tumors in the body.
An abdominal contrast-enhanced MRI is a test used to reveal the presence of tumor of the
adrenal glands.
An abdominal CT scan reveals the presence of tumor in the adrenal glands.
PTS: 1
CON: Assessment: Evidence-Based Practice
PRIMEXAM.COM
14. ANS: 4
Chapter: Chapter 24, Endocrine Disorders
Page: 546
Objective: N/A
Difficulty: Easy
Heading: Cushing’s Syndrome
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Assessment: Metabolism
1
2
3
4
Feedback
A serum cortisol level of 0.6 mcg/dL is present in healthy individuals.
After administration of dexamethasone, a serum cortisol level of 1.8 mcg/dL indicates the
absence of Cushing’s syndrome.
A serum cortisol level of 2.4 mcg/dL after administration of dexamethasone is present in
healthy individuals.
A serum cortisol level greater than 3 mcg/dL is present in individuals with Cushing’s
syndrome. Therefore, the nurse may find a serum cortisol level of 3.8 mcg/dL in the
laboratory report of the client with Cushing’s disease.
PTS: 1
CON: Assessment: Metabolism
15. ANS: 4
Chapter: Chapter 24, Endocrine Disorders
Page: 531
Objective: N/A
Difficulty: Moderate
Heading: Types of Endocrine Dysfunction
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Assessment: Metabolism: Critical Thinking
1
2
3
4
Feedback
Primary hypothyroidism is caused by the destruction of the endocrine gland itself.
Tertiary hyperthyroidism is caused by the dysfunction of a hypothalamus.
Primary hyperthyroidism is caused by the dysfunction of the endocrine gland itself.
Secondary hypothyroidism is caused by abnormal pituitary activity.
PTS: 1
CON: Assessment: Metabolism: Critical Thinking
16. ANS: 4
Chapter: Chapter 24, Endocrine Disorders
Page: 530
Objective: N/A
Difficulty: Easy
Heading: The Pituitary as Master Gland
Integrated Processes: Nursing Process
PRIMEXAM.COM
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Assessment: Metabolism
Feedback
The pineal gland is a neuroendocrine gland located in the brain, near the hypothalamus.
The adrenal gland is an endocrine gland found on the top of the kidneys.
The thyroid gland is the largest endocrine gland found in the neck region.
The pituitary gland is called the master gland because it regulates all of the body’s
endocrine glands. It is a pea-sized organ located in the center of the brain.
1
2
3
4
PTS: 1
CON: Assessment: Metabolism
17. ANS: 2
Chapter: Chapter 24, Endocrine Disorders
Page: 534
Objective: N/A
Difficulty: Easy
Heading: Pituitary Gland Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Assessment: Metabolism
Feedback
Hypopituitarism is the hyposecretion of one or more of the pituitary hormones.
Panhypopituitarism is the complete loss of all the pituitary hormones, which is a rare
disorder.
Sheehan’s syndrome is described as pituitary ischemia and infarction that develops after
childbirth due to severe hemorrhage.
Empty sella syndrome is a condition caused by compression of the pituitary gland by
brain tissue herniation.
1
2
3
4
PTS: 1
CON: Assessment: Metabolism
18. ANS: 1
Chapter: Chapter 24, Endocrine Disorders
Page: 546, 547
Objective: N/A
Difficulty: Moderate
Heading: Adrenal Gland Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Assessment; Metabolism
1
Feedback
A tumor in the pineal gland causes severe dysfunction and results in hydrocephalus,
memory disturbances, seizures, and visual disturbances. A ventriculo-peritoneal shunt is
PRIMEXAM.COM
2
3
4
used to decrease the CSF blockage.
Diabetes insipidus is a disease caused by lack of the posterior pituitary hormone that is
treated with replacement or supplement of arginine vasopressin.
Pheochromocytoma is a rare tumor of the adrenal medulla that requires adrenergic
blockers for treating hypertension. Surgery is also a method used to remove the tumor.
Cushing syndrome is a disease characterized by moon facies, buffalo hump, and
increased central weight gain. This condition is treated with the help of ADH
antagonists, furosemide, and symptomatic relief.
PTS: 1
CON: Assessment; Metabolism
19. ANS: 4
Chapter: Chapter 24, Endocrine Disorders
Page: 551
Objective: N/A
Difficulty: Moderate
Heading: Adrenal Gland Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Assessment
1
2
3
4
Feedback
Chvostek sign and Trousseau sign will not be noticed in client 1 because a pineal tumor
causes seizures, memory disturbances, and visual disturbances.
Depression, weight gain, constipation, and features of myxedema characterize
hypothyroidism; therefore, Chvostek sign and Trousseau sign will not be observed in
client 2.
Chvostek sign and Trousseau sign will not be seen in client 3 because
pheochromocytoma is a rare tumor of the endocrine gland. Severe hypertension and
neurological signs of stroke characterize this.
Chvostek sign and Trousseau sign may be seen in client 4 because hyperparathyroidism
is excessive secretion of parathyroid hormone. The presence of Chvostek sign and
Trousseau sign is due to muscle weakness and bone demineralization.
PTS: 1
CON: Assessment
20. ANS: 3
Chapter: Chapter 24, Endocrine Disorders
Page: 546
Objective: N/A
Difficulty: Difficult
Heading: Pheochromocytoma
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Assessment
Feedback
PRIMEXAM.COM
1
2
3
4
A pineal tumor is a tumor of the neuroendocrine gland in the brain near the
hypothalamus. Therefore, an MRI scan of the abdomen is not beneficial in client 1.
Hypothyroidism is an endocrine disorder caused by decreased secretion of thyroid
hormones. Therefore, client 2 requires radioactive iodine scan and thyroid ultrasound.
A pheochromocytoma is a rare tumor of the adrenal medulla. Therefore, client 3
requires an MRI scan of the abdomen to visualize the adrenal gland.
Hypoparathyroidism is a condition characterized by decreased secretion of the
parathyroid hormone. Therefore, client 4 needs ultrasound of the thyroid gland to detect
any masses or gland enlargement.
PTS: 1
CON: Assessment
MULTIPLE RESPONSE
21. ANS: 2, 3, 5
Chapter: Chapter 24, Endocrine Disorders
Page: 548
Objective: N/A
Difficulty: Difficult
Heading: Hyperpituitarism
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Assessment
1.
2.
3.
4.
5.
Feedback
Ultrasonography is used for medical imaging, detection of anatomical abnormalities, and
measurement of organs.
A CT scan of the whole head enables the primary health-care provider to look for pituitary
tumor. The client’s signs and symptoms indicate pituitary tumor.
MRI scans of whole head provide a detailed picture of tissues and organs. Therefore, the
primary health-care provider will prescribe MRI scans of the whole head to confirm the
diagnosis.
The corticotropin stimulation test is helpful to evaluate the hypothalamic-pituitary axis.
Blood studies are helpful for accurate measurement of tropic hormones in the body.
PTS: 1
CON: Assessment
22. ANS: 1, 2, 3
Chapter: Chapter 24, Endocrine Disorders
Page: 549
Objective: N/A
Difficulty: Difficult
Heading: Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Medication
PRIMEXAM.COM
1.
2.
3.
4.
5.
6.
Feedback
Conivaptan is an ADH antagonist; it removes excess water in the bloodstream. This drug
helps to correct dilutional hyponatremia. Therefore, it is beneficial for clients with SIADH.
Furosemide helps to reduce the water content of blood. Therefore, it is also called an
antidiuretic drug. Therefore, it is beneficial for clients with SIADH.
Tetracyclines comprise a group of antibiotics which help to decrease the ADH effect on the
kidney. Therefore, they are beneficial for clients with SIADH.
Bromocriptine is used to reduce the secretion of pituitary hormones when prolactinemia is
present. Therefore, it is not beneficial for clients with SIADH.
Levothyroxine is used to replace the function of thyroid hormone during deficiency.
Therefore, it is not beneficial for clients with SIADH.
Arginine vasopressin increases the absorption of water into the bloodstream. It is not
beneficial for clients with SIADH.
PTS: 1
CON: Medication
23. ANS: 3, 5
Chapter: Chapter 24, Endocrine Disorders
Page: 548
Objective: N/A
Difficulty: Easy
Heading: Pituitary Gland Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
1.
2.
3.
4.
5.
Feedback
Amenorrhea is a clinical finding observed in clients with increased secretion of pituitary
hormones or a tumor, such as prolactinoma.
Galactorrhea is a clinical finding observed in clients with increased secretion of pituitary
hormones or a tumor, such as prolactinoma.
Poor skin turgor is a sign that indicates dehydration in the client with diabetes insipidus.
Orthostatic hypotension is an assessment finding observed in clients with adrenal
insufficiency due to inadequate secretion of hormones.
Dry mucous membranes indicate dehydration in the client with diabetes insipidus.
PTS: 1
CON: Assessment
24. ANS: 1, 4
Chapter: Chapter 24, Endocrine Disorders
Page: 552
Objective: N/A
Difficulty: Easy
Heading: Adrenal Gland disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
PRIMEXAM.COM
Concept: Assessment
1.
2.
3.
4.
5.
Feedback
Seizure is a neurovascular sign observed in clients with a pineal tumor due to pressure
exerted by the enlarged adrenal gland on the adjacent brain tissue.
Bulging eyes are a sign observed in clients with multiple endocrine neoplasia due to
involvement of the pituitary gland.
Conjunctivitis is a characteristic sign that indicates exophthalmos, which is an autoimmune
disorder that causes hyperthyroidism.
Memory disturbances are characteristic signs and symptoms that occur due to a pineal gland
tumor caused by hyper or hypofunction of the endocrine gland.
Upper eyelid retraction is a characteristic sign that indicates exophthalmos, which is an
inflammatory disorder that causes hyperthyroidism.
PTS: 1
CON: Assessment
25. ANS: 1, 2
Chapter: Chapter 24, Endocrine Disorders
Page: 550
Objective: N/A
Difficulty: Easy
Heading: Adrenal Gland Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Assessment
1.
2.
3.
4.
5.
Feedback
Hyperkalemia is caused by decreased or insufficient levels of aldosterone, which plays a
central role in the regulation of blood pressure.
Hyponatremia is caused by decreased levels of aldosterone, which plays an important role in
sodium and water excretion.
Hypercalcemia is caused by increased levels of parathyroid hormones, which results in
constipation.
Hypomagnesemia is the decreased levels of magnesium in the blood caused by various
potential complications.
Hypoglycemia is the decreased blood sugar level, which commonly occurs during adrenal
crisis. It is a potential life-threatening condition.
PTS: 1
CON: Assessment
PRIMEXAM.COM
Chapter 25: Diabetes Mellitus and the Metabolic Syndrome
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. The nurse reviews the laboratory reports of a diabetic client and concludes that the client has diabetic
nephropathy. Which finding supports the nurse’s conclusion?
1. Ketones in urine
2. Glucose in urine
3. Albumin in urine
4. All of the above
2. Which diagnostic test helps in detecting the natural insulin secretion from the pancreas?
1. Urinalysis
2. C-peptide test
3. Islet cell autoantibodies
4. Both B and C
3. While preparing a client for the oral glucose tolerance test (OGTT), the nurse asks the client to ingest soda
which contains 80 g of carbohydrates. After 2 hours, the nurse measures the postprandial blood glucose level
and concludes that the client has diabetes. Which blood glucose finding supports the nurse’s conclusion?
1. 160 mg/dL
2. 190 mg/dL
3. 250 mg/dL
4. None of the above
4. Which is the most common complication expected in clients with type 1diabetes?
1. Diabetic ketoacidosis
2. Hyperosmolar hyperglycemic syndrome
3. Metabolic syndrome
4. None of the above
5. The nurse is caring for a client with immune mediated type 1 diabetes. What would the nurse expect to be the
cause for this condition in the client?
1. The client has hyperinsulinism.
2. The client has destruction of beta cells.
3. The client has insulin resistance.
4. Both A and B
6. The laboratory report of a client shows arterial blood pH of 7.6, blood glucose level of 650 mg/dL, and serum
bicarbonate level of 17 mEq/L. What does the nurse infer from these laboratory findings?
1. The client has diabetic ketoacidosis.
2. The client has hyperosmolar hyperglycemic syndrome.
3. The client has prediabetes.
4. None of the above
7. Which symptom is associated with hyperosmolar hyperglycemic syndrome?
1. Severe dehydration
2. Stupor
3. Confusion
PRIMEXAM.COM
4. All of the above
8. The nurse reviews the laboratory reports of a client and concludes that the client has diabetes. Which finding
helped the nurse to reach this conclusion?
1. A fasting plasma glucose level of 100 mg/dL
2. A glycated hemoglobin (HbA1c) value of 7
3. A postprandial blood glucose level of 170 mg/dL
4. All of the above
9. The nurse observes sweating, dizziness, and disorientation in the client and consults the primary health-care
provider while caring for a diabetic client. Which treatment option would be most beneficial to the client?
1. Administering 25 g of glucose intravenously
2. Administering 1 mg of glucagon subcutaneously
3. Administering 50 mL of 50% dextrose intravenously
4. Both A and B
10. The nurse is assessing the blood glucose levels of a client at regular intervals. The nurse finds 55 mg/dL of
blood glucose at 2 am and150 mg/dL at 7 am. Which mechanism does the nurse suspect behind the change in
the glucose levels in the client?
1. Somogyi effect
2. Dawn phenomenon
3. Prediabetes
4. None of the above
11. The registered nurse is teaching a group of student nurses about managing hyperosmolar hyperglycemic
syndrome (HHS) in clients. Which response of a student nurse indicates effective learning?
1. “Fluids should be administered before administering intravenous (IV) insulin to the
client.”
2. “IV insulin should be administered until blood glucose is 150 mg/dL.”
3. “IV insulin administration should be followed by subcutaneous insulin.”
4. “Fluid administration should be followed by IV fluid administration.”
12. The nurse observes hyperpigmented, velvety macular lesions on the neck during the assessment of a diabetic
client. What does the nurse infer from this observation?
1. The client has lipoatrophy.
2. The client has lipohypertrophy.
3. The client has acanthosis nigricans.
4. The client has pigmented pretibial papules.
13. Which complication is suspected in a client whose blood sugar is less than 30 mg/dL?
1. Bradycardia
2. Anhidrosis
3. Anorexia
4. Seizure
14. Which antidiabetic medication is a sulfonylurea?
1. Glipizide (Glucotrol)
2. Pioglitazone (Actos)
3. Repaglinide (Prandin)
4. Metformin (Glucophage)
15. Why does the nurse use the C-peptide test for a type 1 diabetic client?
PRIMEXAM.COM
1.
2.
3.
4.
To evaluate residual pancreatic function
To monitor the status of pancreatic beta cells
To monitor the red blood cell count
None of the above
16. The nurse observes a diabetic client who has a wound that has not healed for a long time. Which condition
does the nurse suspect in the client?
1. Immunosuppression
2. Peripheral neuropathy
3. Transient ischemic attack
4. Accelerated atherosclerosis
17. The mother of an adolescent diabetic client tells the nurse, “My daughter is skipping insulin doses frequently
because she is concerned about weight gain.” Which condition does the nurse document for this client?
1. Insulin purging
2. Autonomic neuropathy
3. Peripheral neuropathy
4. Psychological insulin resistance
18. After reviewing the medical records of a 35-year-old female client, the nurse concludes that the client has
metabolic syndrome. Which findings helped the nurse to reach this conclusion?
1. Triglyceride level of 140 mg/dL, waist circumference of 32 inches, and fasting blood
glucose level 80 mg/dL
2. High-density lipoprotein (HDL) cholesterol of 40 mg/dL, blood pressure of 138/90 mm
Hg, and fasting blood glucose level of 130 mg/dL
3. Fasting blood glucose of 90 mg/dL, triglyceride level of 120 mg/dL, and waist
circumference of 30 inches.
4. Blood pressure of 120/80 mm Hg, waist circumference of 34 inches, and triglyceride level
of 130 mg/dL
NARRBEGIN: Exhibit
Exhibit
NARREND
19. The nurse is reviewing the medical records of different clients.
Client
Gender
Waist
circumference
Triglyceride levels
Client 1
Male
38 inches
Client 2
Female
37 inches
Client 3
Male
32 inches
Client 4
Female
30 inches
100 mg/dL
160 mg/dL
130 mg/dL
120 mg/dL
Which client does the nurse expect to have metabolic syndrome?
1. Client 1
2. Client 2
3. Client 3
4. Client 4
20. The nurse is assessing the medical records of different clients with diabetes.
PRIMEXAM.COM
Client
Blood pressure
(BP)
Low-density lipid
(LDL) levels
High-density lipid
(HDL) levels
Triglycerides
Client 1
130/90 mm Hg
Client 2
128/90 mm Hg
Client 3
115/75 mm Hg
Client 4
140/90 mm Hg
140 mg/dL
120 mg/dL
100 mg/dL
130 mg/dL
40 mg/dL
50 mg/dL
70 mg/dL
45 mg/dL
170 mg/dL
160 mg/dL
140 mg/dL
175 mg/dL
Which client has a reduced risk of cardiovascular disease?
1. Client 1
2. Client 2
3. Client 3
4. Client 4
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
21. After reviewing the laboratory reports of a client with diabetes, the nurse finds that the client has diabetic
ketoacidosis. Which findings support the nurse’s conclusion? Select all that apply.
1. Client’s arterial blood pH of 6
2. Trace elements of ketones in urine
3. Serum bicarbonate level of 12 mEq/L
4. Blood glucose level of 300 mg/dL
5. None of the above
22. The nurse suspects nocturnal hypoglycemia in a diabetic client. Which symptoms can the nurse expect to
observe in this client? Select all that apply.
1. Sleep disturbance
2. Vivid nightmares
3. Severe dehydration
4. Morning headache
5. All of the above
23. Which symptoms are associated with autonomic neuropathy? Select all that apply.
1. Anhidrosis
2. Gastroparesis
3. Microalbuminuria
4. Paresthesias in feet
5. Postural hypotension
24. Which symptoms does the nurse observe in a client with hyperosmolar hyperglycemic syndrome (HHS)?
Select all that apply.
1. Polyuria
2. Confusion
3. Polydipsia
4. Hypertension
5. Anorexia
PRIMEXAM.COM
25. A client with diabetes is prescribed exenatide (Byetta). What are the immediate effects of the drug that could
be observed in the client? Select all that apply.
1. Weight loss
2. Delay in gastric emptying
3. Glucose-dependent insulin secretion
4. Improved beta cell mass and function
5. Suppression of postprandial glucagon
PRIMEXAM.COM
Chapter 25: Diabetes Mellitus and the Metabolic Syndrome
Answer Section
MULTIPLE CHOICE
1. ANS: 3
Chapter: Chapter 25, Diabetes Mellitus and the Metabolic Syndrome
Page: 575
Objective: N/A
Difficulty: Moderate
Heading: Diabetic Nephropathy as a Cause of Renal Failure
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Metabolism
1
2
3
4
Feedback
The presence of ketones in the urine is called ketonuria, which is seen in clients with
uncontrolled diabetes or prolonged fasting.
The presence of glucose in the urine is called glucosuria, which is suggestive of
uncontrolled diabetes in clients.
High blood glucose levels damage the glomerular capillaries and make them
hyperpermeable, allowing albumin to leak into the urine. Microalbuminuria is a sign of
nephropathy. Therefore, presence of albumin in the urine suggests the risk of diabetic
nephropathy in the client.
The presence of ketones, glucose, and albumin in the urine does not indicate that the
client has developed diabetic nephropathy.
PTS: 1
CON: Metabolism
2. ANS: 2
Chapter: Chapter 25, Diabetes Mellitus and the Metabolic Syndrome
Page: 562
Objective: N/A
Difficulty: Easy
Heading: Diagnosis of Diabetes Mellitus
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Knowledge [Remembering]
Concept: Metabolism
1
2
3
4
Feedback
Urinalysis helps detect the presence of ketones, urea, and glucose in urine.
The pancreas releases C-peptide when it secretes insulin. Therefore, the C-peptide test
helps to detect if there is natural insulin secretion from the pancreas.
The islet cell autoantibody helps monitor treatment effectiveness in clients.
The islet cell autoantibody test does not help in detecting the insulin secretion from the
PRIMEXAM.COM
pancreas.
PTS: 1
CON: Metabolism
3. ANS: 3
Chapter: Chapter 25, Diabetes Mellitus and the Metabolic Syndrome
Page: 561
Objective: N/A
Difficulty: Difficult
Heading: Diagnosis of Diabetes Mellitus
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Metabolism
1
2
3
4
Feedback
A postprandial blood glucose level of 149 to 199 mg/dL indicates prediabetes.
Therefore, if the client has 160 mg/dL of blood glucose, then the nurse suspects
prediabetes in this client.
Postprandial blood glucose level of 190 mg/dL after ingesting carbohydrates suggests
that the client is prediabetic.
Postprandial blood glucose level equal to or greater than 200 mg/dL is indicative of
diabetes. Therefore, the postprandial blood glucose level of 250 mg/dL supports the
nurse’s conclusion.
Postprandial blood glucose level of 250 mg/dL suggests that the client has diabetes.
PTS: 1
CON: Metabolism
4. ANS: 1
Chapter: Chapter 25, Diabetes Mellitus and the Metabolic Syndrome
Page: 562
Objective: N/A
Difficulty: Easy
Heading: Complications of Diabetes Mellitus
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: pH Regulation
1
2
3
4
Feedback
Clients with type 1 diabetes have a risk of ketone formation from lipolysis due to the
absence of endogenous insulin. This results in diabetic ketoacidosis. Therefore, diabetic
ketoacidosis is the most expected complication in clients with type 1 diabetes.
Hyperosmolar hyperglycemic syndrome is most commonly seen in clients with type 2
diabetes.
Metabolic syndrome is most commonly seen in clients with type 2 diabetes.
Diabetic ketoacidosis is expected in clients with type 1 diabetes mellitus.
PTS: 1
CON: pH Regulation
PRIMEXAM.COM
5. ANS: 2
Chapter: Chapter 25, Diabetes Mellitus and the Metabolic Syndrome
Page: 559
Objective: N/A
Difficulty: Easy
Heading: Etiology and Classification of Diabetes
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Metabolism
1
2
3
4
Feedback
Clients with immune-mediated type 1diabetes have hypoinsulinism.
Immunological destruction of beta cells of the pancreas results in a condition called
immune- mediated type 1 diabetes.
Clients with type 2 diabetes will have resistance to insulin.
Clients with immune-mediated type 1 diabetes will have destruction of pancreatic beta
cells.
PTS: 1
CON: Metabolism
6. ANS: 2
Chapter: Chapter 25, Diabetes Mellitus and the Metabolic Syndrome
Page: 567, 568
Objective: N/A
Difficulty: Moderate
Heading: Complications of Diabetes Mellitus
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Metabolism
1
2
3
4
Feedback
Clients who have diabetic ketoacidosis will have arterial blood pH less than 7.3, blood
glucose level above 250 mg/dL, and serum bicarbonate level less than 15 mEq/L.
Clients who develop hyperosmolar hyperglycemic syndrome will have an arterial blood
pH of more than 7.3, blood glucose level above 600 mg/dL, and serum bicarbonate
level more than 15mEq/L. Therefore, from the laboratory findings the nurse infers that
the client has hyperosmolar hyperglycemic syndrome.
Clients with prediabetes have slightly higher than normal elevated blood glucose levels
but do not have a blood glucose level of 650 mg/dL.
Clients with hyperosmolar hyperglycemic syndrome will have blood glucose levels
above 600 mg/dL and serum bicarbonate levels above 15 mEq/L.
PTS: 1
CON: Metabolism
7. ANS: 4
Chapter: Chapter 25, Diabetes Mellitus and the Metabolic Syndrome
Page: 560
PRIMEXAM.COM
Objective: N/A
Difficulty: Easy
Heading: Short-Term Acute Complications of Type 2 Diabetes
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Metabolism
1
2
3
4
Feedback
Severe dehydration is associated with hyperosmolar hyperglycemic syndrome.
Stupor can be caused by hyperosmolar hyperglycemic syndrome.
Hyperosmolar hyperglycemic syndrome can cause confusion.
Hyperosmolar hyperglycemic syndrome causes severe dehydration, stupor, and
confusion.
PTS: 1
CON: Metabolism
8. ANS: 2
Chapter: Chapter 25, Diabetes Mellitus and the Metabolic Syndrome
Page: 561
Objective: N/A
Difficulty: Moderate
Heading: Diagnosis of Diabetes Mellitus
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Metabolism
1
2
3
4
Feedback
A fasting plasma glucose level above 126 mg/dL suggests diabetes. However, the
client’s report shows fasting plasma glucose level of 100 mg/dL, which indicates that
the client has a normal blood glucose level.
Glycated hemoglobin (HbA1C) gives the average blood glucose value for the past 3
months. An HbA1C value above 6.5 indicates diabetes mellitus. The laboratory report
of this client shows an HbA1C value of 7, which suggests that the client has diabetes.
A postprandial blood glucose level equal to or above 200 mg/dL suggests diabetes.
However, the client’s report shows a postprandial blood glucose level of 170 mg/dL.
A fasting plasma glucose level of 100 mg/dL and a postprandial blood glucose level of
200 mg/dL do not indicate diabetes.
PTS: 1
CON: Metabolism
9. ANS: 3
Chapter: Chapter 25, Diabetes Mellitus and the Metabolic Syndrome
Page: 563
Objective: N/A
Difficulty: Difficult
Heading: Complications of Diabetes Mellitus
Integrated Processes: Nursing Process
PRIMEXAM.COM
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Critical Thinking
1
2
3
4
Feedback
Clients who have hypoglycemia will experience sweating, dizziness, headache,
nervousness, and disorientation. Administering 25 g of intravenous glucose will help
manage hypoglycemia in the client. However, the primary health-care provider will
order intravenous glucose only when the client cannot take oral carbohydrates.
Administering 1 mg of glucagon injection subcutaneously can help manage symptoms
in client with hypoglycemia. However, this treatment is not preferred to a 50% dextrose
injection.
Administering 50 mL of 50% dextrose intravenous injection provides relief from
hypoglycemic symptoms immediately due to its rapid action. It is the most preferred
remedy to manage hypoglycemia in the client. Therefore, the primary health-care
provider will suggest the nurse administer 50 mL of 50% dextrose intravenously.
Although the administration of IV glucose and subcutaneous glucagon can alleviate the
symptoms of hypoglycemia, administration of 50% IV dextrose is the most preferred
option because of its rapid action.
PTS: 1
CON: Critical Thinking
10. ANS: 1
Chapter: Chapter 25, Diabetes Mellitus and the Metabolic Syndrome
Page: 564
Objective: N/A
Difficulty: Difficult
Heading: Complications of Diabetes Mellitus
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Metabolism
1
2
3
4
Feedback
Blood glucose levels of 55 mg/dL at 2 pm and 150 mg/dL at 7 pm indicate nocturnal
hypoglycemia and morning hyperglycemia in the client. When the blood glucose levels
drop too low during the night, the body counters by releasing hormones to raise it. This
mechanism is known as the Somogyi effect.
Dawn phenomenon is suspected when the blood glucose level is normal or higher when
measured between 2 and 4 am.
A client with prediabetes does not have nocturnal hypoglycemia and morning
hyperglycemia.
The Somogyi effect refers to when the client experiences nocturnal hypoglycemia at
night, causing a rise in blood glucose levels by activating glucagon, cortisol, and
epinephrine hormones.
PTS: 1
11. ANS: 1
CON: Metabolism
PRIMEXAM.COM
Chapter: Chapter 25, Diabetes Mellitus and the Metabolic Syndrome
Page: 569
Objective: N/A
Difficulty: Difficult
Heading: Complications of Diabetes Mellitus
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Evaluation [Evaluating]
Concept: Nursing Roles
1
2
3
4
Feedback
Clients with HHS will have severe dehydration. To avoid further complications such as
hypovolemia, the client should be administered adequate fluids before IV insulin.
Therefore, this statement from a student nurse indicates effective learning.
Clients with HHS will have a glucose level above 600 mg/dL. IV insulin should be
administered until the blood glucose level is 300 mg/dL. Therefore, this statement from
a student nurse indicates the need for additional teaching.
Subcutaneous insulin should be followed by IV insulin administration.
Administering IV insulin before rehydration worsens hypotension and hypovolemic
shock in clients.
PTS: 1
CON: Nursing Roles
12. ANS: 3
Chapter: Chapter 25, Diabetes Mellitus and the Metabolic Syndrome
Page: 575
Objective: N/A
Difficulty: Moderate
Heading: Complications of Diabetes Mellitus
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Skin Integrity
1
2
3
4
Feedback
Lipoatrophy is the localized loss of fat tissue, which occurs due to the repetitive use of
insulin injections in diabetic clients. It is not associated with hyperpigmentation and
velvety macular lesions on the neck.
Lipohypertrophy is due to the accumulation of fat under the skin. It occurs at the sites
of insulin injection. Clients with lipohypertrophy will not have velvety macular lesions
on the neck.
Acanthosis nigricans is associated with velvety macular lesions on the neck and axilla.
This occurs due to insulin resistance.
Pigmented pretibial papules are associated with minor trauma in the tibial region. The
clients will have hyperpigmentation in lower extremities.
PTS: 1
13. ANS: 4
CON: Skin Integrity
PRIMEXAM.COM
Chapter: Chapter 25, Diabetes Mellitus and the Metabolic Syndrome
Page: 577
Objective: N/A
Difficulty: Easy
Heading: Treatment of Diabetes Mellitus
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Assessment
1
2
3
4
Feedback
Tachycardia is suspected in clients with a blood glucose level lower than 30 mg/dL but
bradycardia is not.
Clients with severe hypoglycemia can have diaphoresis but not anhidrosis.
Clients with severe hypoglycemia may have increased appetite but not anorexia.
A blood glucose level of 30 mg/dL indicates severe hypoglycemia in clients. Clients
with severe hypoglycemia may have seizures and coma.
PTS: 1
CON: Assessment
14. ANS: 1
Chapter: Chapter 25, Diabetes Mellitus and the Metabolic Syndrome
Page: 582
Objective: N/A
Difficulty: Easy
Heading: Treatment of Diabetes mellitus
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Knowledge [Remembering]
Concept: Medication
1
2
3
4
Feedback
Glipizide (Glucotrol) is an antidiabetic medication which falls under the category of
sulfonylureas.
Pioglitazone (Actos) is an antidiabetic medication which belongs to thiazolidinediones.
Repaglinide (Prandin) is an antidiabetic medication that falls under meglitinides.
Metformin (Glucophage) is the only biguanide antidiabetic medication that is approved
by the U.S. FDA.
PTS: 1
CON: Medication
15. ANS: 1
Chapter: Chapter 25, Diabetes Mellitus and the Metabolic Syndrome
Page: 562
Objective: N/A
Difficulty: Easy
Heading: Diagnosis of Diabetes Mellitus
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
PRIMEXAM.COM
Cognitive Level: Comprehension [Understanding]
Concept: Metabolism
1
2
3
4
Feedback
The C-peptide test is a diagnostic test to detect the natural insulin secreted by the
pancreas. The client with type 1 diabetes will have low or absent natural insulin.
Therefore, the nurse evaluates residual pancreatic function through this test.
The nurse monitors the status of the pancreatic beta cells with the C-peptide test in the
client with type 2 diabetes.
The C-peptide test does not detect the red blood cell count. Therefore, the nurse does
not assess for red blood cell count by performing the C-peptide test in the client.
The client with type 1 diabetes may have trace insulin, which is detected through this
test.
PTS: 1
CON: Metabolism
16. ANS: 1
Chapter: Chapter 25, Diabetes Mellitus and the Metabolic Syndrome
Page: 570
Objective: N/A
Difficulty: Moderate
Heading: Systemic Long-Term Complications of Diabetes
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Immunity
1
2
3
4
Feedback
Immunosuppression delays the wound healing capacity and increases the risk of
infections in the diabetic clients.
Clients with peripheral neuropathy will have impaired circulation, which may result in
loss of sensation in the feet and hands. However, it is not associated with delayed
wound healing.
Transient ischemic attack is a condition resulting from decreased blood flow to the
brain. Therefore, the client will have dizziness and disorientation.
Clients with accelerated atherosclerosis will have narrowing of arteries. This may result
in decreased arterial circulation and hypertension. However, it is not associated with
delayed wound healing.
PTS: 1
CON: Immunity
17. ANS: 1
Chapter: Chapter 25, Diabetes Mellitus and the Metabolic Syndrome
Page: 570
Objective: N/A
Difficulty: Moderate
Heading: Systemic Long-Term Complications of Diabetes
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity: Physiological Adaptation
PRIMEXAM.COM
Cognitive Level: Application [Applying]
Concept: Metabolism
1
2
3
4
Feedback
The adolescent skips insulin medication to avoid weight gain. This tendency to skip
medication is called insulin purging.
An adolescent with autonomic neuropathy does not have a tendency to skip insulin
medication.
An adolescent with diabetes may develop neuropathy due to poor diabetic control. This
may lead to nerve damage in the clients.
An adolescent with psychological insulin resistance performs vigorous exercises but
does not have a tendency to skip insulin medication.
PTS: 1
CON: Metabolism
18. ANS: 2
Chapter: Chapter 25, Diabetes Mellitus and the Metabolic Syndrome
Page: 560
Objective: N/A
Difficulty: Difficult
Heading: What is Metabolic Syndrome?
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Metabolism
1
2
3
4
Feedback
A woman with a waist circumference more than or equal to 35 inches, fasting blood
glucose levels of less than 100 mg/dL, and a triglyceride level greater than or equal to
150 mg/dL will have a risk for metabolic syndrome. However, this client has a waist
circumference of 32 inches, a triglyceride level of 140 mg/dL, and a fasting blood
glucose level of 80 mg/dL, which indicate that the client does not have metabolic
syndrome.
A woman who has HDL less than 50 mg/dL, blood pressure more than 20/80 mm Hg,
and a fasting blood glucose level less than 100 mg/dL will have a risk for metabolic
syndrome. The client has HDL of 40 mg/dL, a fasting blood glucose level of 130
mg/dL, and a blood pressure of 138/90 mm Hg, indicating that the client has metabolic
syndrome.
A woman with metabolic syndrome will have a fasting blood glucose level of more than
100 mg/dL, triglycerides more than or equal to 150 mg/dL, and a waist circumference
of less than 34 in. However, the client has a fasting blood glucose level of 90 mg/dL, a
triglyceride level of 120 mg/dl, and a waist circumference of 30 inches, indicating that
the client does not have metabolic syndrome.
A blood pressure 120/80 mm Hg, which is normal, a triglyceride level of 130 mg/dL,
and a waist circumference of 34 inches indicates that the client does not have metabolic
syndrome.
PTS: 1
CON: Metabolism
PRIMEXAM.COM
19. ANS: 2
Chapter: Chapter 25, Diabetes Mellitus and the Metabolic Syndrome
Page: 560
Objective: N/A
Difficulty: Difficult
Heading: What is Metabolic Syndrome?
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Metabolism
1
2
3
4
Feedback
A male who has a waist circumference of more than 40 inches and triglyceride levels of
more than 150 mg/dL will have a risk of metabolic syndrome. However, Client 1 is a
male with a waist circumference of 38 inches and triglycerides of 100 mg/dL,
indicating that the client does not have metabolic syndrome.
A female who has a waist circumference of more than 35 inches and triglycerides of
more than 150 mg/dL will have a risk of metabolic syndrome. Client 2 has a waist
circumference of 37 inches and a triglyceride level of 160 mg/dL, indicating that the
client has metabolic syndrome.
Client 3 is a male with a waist circumference of 32 inches, which is less than 40 inches,
and a triglyceride level of 130 mg/dL, which is less than 150 mg/dL. Therefore, it
indicates that the client does not have metabolic syndrome.
Client 4 is a female with a waist circumference of 30 inches, which is less than 35
inches, and a triglyceride level of 120 mg/dL, which is less than 150 mg/dL. Therefore,
it indicates that the client does not have metabolic syndrome.
PTS: 1
CON: Metabolism
20. ANS: 3
Chapter: Chapter 25, Diabetes Mellitus and the Metabolic Syndrome
Page: 579
Objective: N/A
Difficulty: Difficult
Heading: Treatment of Diabetes
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analyzing [Analysis]
Concept: Metabolism
1
2
Feedback
A client with diabetes should have BP less than or equal to 120/80 mm Hg, LDL less
than or equal to 100 mg/dL, HDL greater than or equal to 60 mg/dL, and triglycerides
less than or equal to 60 mg/dL. However, Client 1 has BP 130/90 mm Hg, LDL 140 mg/
dL, HDL 40 mg/dL, and triglycerides 170 mg/dL, indicating that the client has a high
risk of cardiovascular disease.
Client 2 has BP 128/90 mm Hg, LDL 120 mg/dL, HDL 50 mg/dL, and triglycerides 140
mg/dL, indicating that the client has high BP, high LDL, low HDL, and high
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3
4
triglycerides. Therefore, Client 2 has a risk of cardiovascular disease.
Client 3 has BP 115/75 mm Hg, LDL 100 mg/dL, HDL 70 mg/dL, and triglycerides 140
mg/dL, indicating that the client has BP less than 120/80 mm Hg, LDL normal, a
slightly high HDL, and normal triglycerides. Therefore, Client 3 does not have a risk of
cardiovascular disease.
Client 4 has BP 140/90 mm Hg, LDL 130 mg/dL, HDL 45 mg/dL, and triglycerides 175
mg/dL, indicating that the client has high BP, high LDL, low HDL, and high
triglycerides. Therefore, Client 4 has a high risk of cardiovascular disease.
PTS: 1
MULTIPLE RESPONSE
21. ANS: 1, 3, 4
Chapter: Chapter 25, Diabetes Mellitus and the Metabolic Syndrome
Page: 566
Objective: N/A
Difficulty: Difficult
Heading: Short-Term Acute Complications of Type 1 Diabetes
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Metabolism
1.
2.
3.
4.
5.
Feedback
This is correct. Clients with diabetic ketoacidosis will have an arterial blood pH of less
than 7.3. The client’s arterial pH is 6. This indicates that the client has developed diabetic
ketoacidosis.
This is incorrect. Clients with diabetic ketoacidosis will have large amounts of ketones in
urine. However, trace elements of ketones have no risk of diabetic ketoacidosis.
This is correct. Clients with diabetic ketoacidosis will have serum bicarbonate levels less
than 15 mEq/L. The client has a serum bicarbonate level of 12 mEq/L, indicating diabetic
ketoacidosis.
This is correct. Clients with diabetic ketoacidosis will have a blood glucose level greater
than 250 mg/dL. The client has a glucose level of 300 mg/dL, indicating that the client has
diabetic ketoacidosis.
This is incorrect. Clients with diabetic ketoacidosis will have an arterial blood pH less than
7.3, a serum bicarbonate level less than 15 mEq/L and a blood glucose level greater than
250 mg/dL.
PTS: 1
CON: Metabolism
22. ANS: 1, 2, 4
Chapter: Chapter 25, Diabetes Mellitus and the Metabolic Syndrome
Page: 563
Objective: N/A
Difficulty: Difficult
Heading: Complications of Diabetes Mellitus
PRIMEXAM.COM
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Metabolism
1.
2.
3.
4.
5.
Feedback
This is correct. Nocturnal hypoglycemia is low nighttime blood glucose levels. This leads
to sleep disruption in the clients. Therefore, the client will experience sleeplessness.
This is correct. Vivid nightmares can be seen in the clients who have nocturnal
hypoglycemia.
This is incorrect. Severe dehydration is seen in the clients with hyperosmolar
hyperglycemic syndrome.
This is correct. The client with nocturnal hypoglycemia complains of a morning headache.
This is incorrect. Severe dehydration is not seen in the clients with nocturnal
hypoglycemia.
PTS: 1
CON: Metabolism
23. ANS: 1, 2, 5
Chapter: Chapter 25, Diabetes Mellitus and the Metabolic Syndrome
Page: 570
Objective: N/A
Difficulty: Easy
Heading: Systemic Long-Term Complications of Diabetes
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Neurologic Regulation
1.
2.
3.
4.
5.
Feedback
This is correct. Autonomic neuropathy is the damage of nerves, which may result in
anhidrosis, or sweat gland dysfunction.
This is correct. Autonomic neuropathy is associated with damage of the nervous system.
So, the nerves in the gastrointestinal system may be damaged. Therefore, the client will
have gastroparesis or partial paralysis of the stomach.
This is incorrect. The increase in albumin levels of urine, or microalbuminuria, is
associated with renal dysfunction. However, it is not a finding in the client with autonomic
neuropathy.
This is incorrect. Paresthesias of feet, or loss of sensation in the feet, is a common finding
in a client who has peripheral neuropathy. However, it is not a finding of autonomic
neuropathy.
This is correct. The client with autonomic neuropathy will have low blood flow. Therefore,
the client will have postural hypotension.
PTS: 1
CON: Neurologic Regulation
24. ANS: 1, 2, 3
Chapter: Chapter 25, Diabetes Mellitus and the Metabolic Syndrome
Page: 569
PRIMEXAM.COM
Objective: N/A
Difficulty: Moderate
Heading: Symptoms of Hyperglycemic Hyperosmolar Syndrome in Type 2 Diabetes
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Metabolism
1.
2.
3.
4.
5.
Feedback
This is correct. The client with HHS will have dehydration due to an increase in
osmolarity. Therefore, the client may have polyuria.
This is correct. The client with HHS will have extreme levels of high sugar, which induce
sleep. Therefore, the client will have disorientation or confusion.
This is correct. The client with HHS will have very high blood glucose levels, which may
result in dehydration. Therefore, the client will have a risk of polydipsia.
This is incorrect. The client with HHS will have hypovolemia or low blood volume due to
dehydration. This may result in hypotension but not hypertension.
This is incorrect. The client with HHS will have polyphagia but not anorexia.
PTS: 1
CON: Metabolism
25. ANS: 2, 3, 5
Chapter: Chapter 25, Diabetes Mellitus and the Metabolic Syndrome
Page: 583
Objective: N/A
Difficulty: Moderate
Heading: Treatment of Diabetes
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapy
Cognitive Level: Application [Applying]
Concept: Metabolism
1.
2.
3.
4.
5.
Feedback
This is incorrect. Exenatide (Byetta) is an incretin mimetic drug, which helps to control
glycemia by stimulating insulin secretion. The client who is on exenatide (Byetta) will
have a feeling of satiety, which decreases appetite and may lead to weight loss. However,
this drug effect is delayed in the client.
This is correct. The immediate effect of exenatide (Byetta) is that it delays emptying of the
stomach by reducing secretion of postprandial glucagon.
This is correct. Exenatide (Byetta) is an incretin mimetic drug, which helps to control
glycemia by secreting glucose-dependent insulin. This drug effect is seen immediately.
This is incorrect. Exenatide (Byetta) promotes growth and development of pancreatic cells
so the client will have improved beta cell mass and function. However, this drug effect is
delayed in the client.
This is correct. Exenatide (Byetta) suppresses the secretion of postprandial glucagon,
which helps provide antidiabetic effects. This drug effect is seen immediately in the client.
PTS: 1
CON: Metabolism
PRIMEXAM.COM
Chapter 26: Disorders of the Female Reproductive System
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. A female client tells a nurse, “I have excessive bleeding that lasts for more than 7 days every time I
menstruate.” Which menstrual disorder does the nurse suspect in the client?
1. Menorrhagia
2. Metrorrhagia
3. Oligomenorrhea
4. Secondary amenorrhea
2. Which physiological changes occur in a female during the perimenopausal stage?
1. Decreased estrogen secretion
2. Increased follicle-stimulating hormone (FSH) level
3. Both A and B
4. None of the above
3. While assessing a 7-year-old female client, the primary health-care provider finds that the client has
enlargement of the breasts, erection of the nipples, and development of pubic hair. Which hormonal levels can
be found high in the client?
1. Estrogen
2. Gonadotropin
3. Both A and B
4. None of the above
4. A 14-year-old female client with constitutional growth delay tells a nurse, “I am not getting any taller! I am
the same height I was last year!” How should the nurse respond?
1. “I will refer you to an endocrinologist.”
2. “You should start taking growth supplements.”
3. “You will reach full height by adulthood.”
4. “I am afraid you will not grow any taller.”
5. A female client is diagnosed to be infertile due to the production of antibodies against the ovarian tissue.
Which treatment will the nurse expect for the client?
1. Estrogen replacement therapy
2. Oral contraceptive therapy
3. Clomiphene citrate
4. Dilatation and curettage surgery
6. A nurse is caring for a 19-year-old female client who has never had a menstrual cycle and has a webbed neck,
short stature, and a broad shield-like chest. What is the most probable cause of the client’s condition?
1. Turner syndrome
2. Sheehan’s syndrome
3. Asherman’s syndrome
4. Mayer-Rokitansky-Hauser syndrome
7. A female client reports missed menstrual periods after discontinuing hormonal contraceptives. What could be
the reason behind the missed menstrual periods?
1. Obstruction in the cervix
PRIMEXAM.COM
2. Damage to the fallopian tube
3. Hypothalamic-pituitary-ovarian dysfunction
4. Extra growth of uterine tissue
8. A client diagnosed with dysmenorrhea is prescribed ibuprofen and hormonal contraceptives. Which outcome
in the client indicates the effectiveness of the therapy?
1. No painful experience during the first 2 days of her menstrual period
2. No behavioral change during the luteal phase of the menstrual cycle
3. No formation of multiple regions of unreleased egg on the ovarian surface
4. All of the above
9. A woman who has tested positive on a serum beta-human chorionic gonadotropin (b-HCG) test had her last
menstrual period on April 18, 2015. What would be the estimated date of childbirth, according to Naegele’s
rule?
1. January 15, 2016
2. January 20, 2016
3. January 25, 2016
4. January 30, 2016
10. A night-shift nurse documents “primigravida” for a client. Which client is being referred to by the nurse?
1. The client who hasn’t had a pregnancy.
2. The client who had multiple pregnancies.
3. The client who is carrying her first pregnancy.
4. The client who has delivered a baby after her first pregnancy.
11. While reviewing a client’s medical record, a nurse finds the client to be described as gravida 2, para 2, or G2
P2. What will the nurse interpret from this description?
1. The client had two deliveries and two abortions.
2. The client had two pregnancies and both of them were aborted.
3. The client had one delivery after 24 weeks and two pregnancies.
4. The client had two pregnancies and two deliveries after 24 weeks.
12. Which laboratory test can assess a client’s blood to rule out the possibility of ovarian cancer?
1. Estrogen
2. Urine calcium oxalate
3. Carcinoembryonic antigen 125 (CA-125)
4. Follicle-stimulating hormone (FSH)
13. A client who is scheduled for a hysteroscopy asks a nurse about the procedure involved in this technique.
Which statement made by the client indicates effective understanding?
1. “A radiopaque dye is used during a hysteroscopy.”
2. “A scope is inserted into the uterus to take a small amount of tissue.”
3. “A scope is inserted through a small surgical incision in the abdomen.”
4. “A thin telescopic type device is inserted via the vagina into the uterus.”
14. Which medical condition needs careful use of hormone replacement?
1. Breast cancer
2. Cardiac disease
3. Venous thrombus
4. All of the above
PRIMEXAM.COM
15. While assessing a young female client for reproductive disorders, a nurse understands that the client has
amenorrhea. Which specific question should the nurse ask the client?
1. “Do you have frequent vaginal infections?”
2. “Do you have any thyroid gland disorders?”
3. “Do you have diabetes mellitus?”
4. “Do you have continuous or intermittent pelvic pain?”
16. A client with premenstrual syndrome (PMS) is prescribed selective serotonin receptor inhibitors (SSRIs) and
nutritional supplements. Which symptom in the client indicates the effectiveness of the therapy?
1. The client has decreased irritability and mood swings.
2. The client no longer experiences painful menstruation.
3. The client’s blood report shows no serum beta-human chorionic gonadotropin (b-HCG).
4. The client has elevated levels of progesterone.
17. While assessing a female client for anomalies of the genital tract, the primary health-care professional
observes that the uterus is absent in the client and the vagina is foreshortened. However, the client’s breast is
normal in shape and contour. Which menstrual disorder would the nurse suspect in the client?
1. Dysmenorrhea
2. Mayer-Rokitansky-Hauser syndrome
3. Premenstrual syndrome
4. Menorrhea
18. A nurse observes that the endometrial lining is absent is a client who underwent a dilation and curettage
(D&C) abortion. Which syndrome will the nurse suspect in the client?
1. Turner syndrome
2. Sheehan’s syndrome
3. Asherman’s syndrome
4. Mayer-Rokitansky-Hauser syndrome
19. A registered nurse is teaching a client with dysmenorrhea about her treatment plan. Which statement made by
the client indicates the need for further teaching?
1. “I should avoid the use of oral contraceptives.”
2. “I should take ibuprofen as prescribed.”
3. “I should consume a low-fat diet.”
4. “I should perform regular exercise.”
20. Which medication is associated with the growth of endometrial polyps?
1. Tamoxifen
2. Ibuprofen
3. Haloperidol
4. Metoclopramide
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
21. In a client with a uterine disorder, a nurse observes that the endometrial tissue grows inside the muscular layer
of the uterus. Which complications will the nurse observe in the client? Select all that apply.
1. Menorrhagia
2. Infertility
3. Pelvic pain
PRIMEXAM.COM
4. Dysmenorrhea
5. Dyspareunia
22. The transabdominal ultrasound examination of a female client shows the presence of fibroid tumors. Which
treatment options should the nurse anticipate from the primary health-care provider to suppress the growth of
the tumors? Select all that apply.
1. Myomectomy
2. Hysterectomy
3. Ablation of the endometrium
4. Uterine artery embolization
5. Injection of hypothalamic gonadotropic-releasing hormone (GnRH)
23. Which complications should a nurse expect in a female client caused by atrophic vaginitis during the
perimenopausal stage? Select all that apply.
1. Hot flashes
2. Night sweats
3. Irregular menses
4. Painful sexual intercourse
5. Vaginal yeast infection
24. Which drugs are used to treat hyperprolactinemia? Select all that apply.
1. Clozapine
2. Cabergoline
3. Risperidone
4. Bromocriptine
5. Metoclopramide
Other
25. Prioritize the steps involved in menstrual cycle (A–F). (Enter the letter of each step in the proper sequence;
do not use commas or spaces.)
A. Ovulation
B. Production of progesterone
C. Formation of the corpus luteum
D. Release of luteinizing hormone
E. Increased follicle-stimulating hormone (FSH)
PRIMEXAM.COM
F. Inhibition of FSH and luteinizing hormone
Chapter 26: Disorders of the Female Reproductive System
Answer Section
MULTIPLE CHOICE
1. ANS: 1
Chapter: Chapter 26, Disorders of the Female Reproductive System
Page: 600
Objective: N/A
Difficulty: Moderate
Heading: Pathophysiology of Selected Female Reproductive Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Female Reproduction
1
2
3
4
Feedback
Menorrhagia is a menstrual disorder in which a client will experience excessive uterine
bleeding and the menstrual cycle usually lasts for more than 7 days. Therefore, the
nurse suspects menorrhagia in the client.
Metrorrhagia is a menstrual disorder in which a client experiences excessive bleeding
from the uterine region at frequent intervals. In this case, the client didn’t report that she
has excessive bleeding at frequent intervals.
Oligomenorrhea is an irregular menstrual cycle with longtime intervals between two
consecutive cycles.
Secondary amenorrhea is the lack of menses for 3 to 6 months. In this case, the client
does not report any such condition.
PTS: 1
CON: Female Reproduction
2. ANS: 3
Chapter: Chapter 26, Disorders of the Female Reproductive System
Page: 592
Objective: N/A
Difficulty: Easy
Heading: Menopause
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Female Reproduction
1
2
Feedback
During the perimenopausal stage, the ovaries start degenerating in a female. This results
in the decreased secretion of estrogen hormones.
The pituitary gland secretes a high amount of FSH in an attempt to increase estrogen
secretion. Therefore, an increased FSH level occurs in a client who is in the
PRIMEXAM.COM
3
4
perimenopausal stage.
During the perimenopausal stage, the ovaries start degenerating and thus estrogen
secretion is decreased. The pituitary gland secretes high amount of FSH in an attempt to
increase estrogen secretion leading to increased FSH level. Therefore, both A and B are
correct answers.
Decreased estrogen secretion and increased follicle-stimulating hormone level occur in
a client who is in the perimenopausal stage. Therefore, this option is incorrect.
PTS: 1
CON: Female Reproduction
3. ANS: 3
Chapter: Chapter 26, Disorders of the Female Reproductive System
Page: 592
Objective: N/A
Difficulty: Moderate
Heading: Precocious Puberty
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Female Reproduction
1
2
3
4
Feedback
Enlargement of the breasts, erection of the nipples, and development of pubic hair are
secondary sex characteristics. These are developed due to excess circulating estrogen in
precocious pseudopuberty. Therefore, elevated estrogen levels can be found in the
client.
Secondary sexual characteristics can develop due to the secretion of gonadotropin from
the pituitary gland. Therefore, elevated levels of gonadotropin can be found in the
client.
Secondary sexual characteristics must have developed in the client due to elevated
levels of estrogen or gonadotropins. Therefore, both A and B are correct.
Secondary sexual characteristics must have developed in the client due to elevated
levels of estrogen or gonadotropin. Therefore, both A and B are correct.
PTS: 1
CON: Female Reproduction
4. ANS: 3
Chapter: Chapter 26, Disorders of the Female Reproductive System
Page: 593
Objective: N/A
Difficulty: Moderate
Heading: Delayed Puberty
Integrated Processes: Communication and Documentation
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Nursing Roles
1
Feedback
The client with constitutional growth delay will attain normal height by adulthood.
PRIMEXAM.COM
2
3
4
Referring this client to an endocrinologist would not be the most appropriate nursing
response.
Because the client has constitutional growth delay where the normal height is attained
by adulthood, the client does not require growth supplements.
Constitutional growth delay is also called delayed puberty. Normal stature and sexual
maturity is reached by adulthood. Therefore, this statement made by the nurse is the
most appropriate response to the client.
A client with constitutional growth delay may attain normal height by adulthood.
Telling the client that she will not grow more is incorrect.
PTS: 1
CON: Nursing Roles
5. ANS: 1
Chapter: Chapter 26, Disorders of the Female Reproductive System
Page: 599
Objective: N/A
Difficulty: Moderate
Heading: Infertility
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Medication
1
2
3
4
Feedback
Infertility caused due to the production of antibodies against the ovarian tissue is known
as premature ovarian failure (POF). This leads to loss of ova and decreased estrogen
production. Therefore, the nurse expects estrogen replacement therapy for the client.
Oral contraceptives will further decrease the level of estrogen in the client, leading to
further complications. Therefore, they should be avoided in the client.
Clomiphene citrate is used to treat infertility caused due to an abnormal secretion of
luteinizing hormone and follicle-stimulating hormone. In this case, infertility is caused
due to the production of antibodies against the ovarian tissue.
Dilatation and curettage surgery is a common surgical procedure that refers to the
dilation of the cervix and surgical removal of the lining of the uterus. It is used to treat
reproductive disorders. However, it is not beneficial in the client because infertility is
due to the secretion of antibodies against the ovarian tissue.
PTS: 1
CON: Medication
6. ANS: 1
Chapter: Chapter 26, Disorders of the Female Reproductive System
Page: 595
Objective: N/A
Difficulty: Moderate
Heading: Menstrual Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Female Reproduction
PRIMEXAM.COM
1
2
3
4
Feedback
If a 19-year-old female has never had a menstrual cycle, the client would have primary
amenorrhea. The most probable cause of primary amenorrhea is Turner syndrome,
which is characterized by a webbed neck, short stature, and a broad shield-like chest.
Sheehan’s syndrome is pituitary necrosis due to hemorrhage in a postpartum woman.
Because the client is 19 years old, this could not be the cause for absence of menstrual
bleeding.
Asherman’s syndrome is the lack of lining of the uterine endometrium. It is a cause of
secondary amenorrhea.
Mayer-Rokitansky-Hauser syndrome is the second-most common cause for primary
amenorrhea. However, it is not characterized by a webbed neck, short stature, and a
broad shield-like chest.
PTS: 1
CON: Female Reproduction
7. ANS: 3
Chapter: Chapter 26, Disorders of the Female Reproductive System
Page: 595
Objective: N/A
Difficulty: Moderate
Heading: Menstrual Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Medication
1
2
3
4
Feedback
Obstruction in the cervix prevents the sperm from reaching the egg. This will not result
in missed menstrual periods.
Damage to the fallopian tube prevents the sperm from reaching the egg. It does not
cause missed menstrual periods.
Discontinuation of hormonal contraceptives may lead to a dysfunction of the
hypothalamic-pituitary-ovarian axis, preventing the release of the egg by the ovaries.
This results in missed menstrual periods.
Extra growth of uterine tissue is called endometriosis. Endometriosis may cause
infertility but not missed menstrual periods.
PTS: 1
CON: Medication
8. ANS: 1
Chapter: Chapter 26, Disorders of the Female Reproductive System
Page: 596
Objective: N/A
Difficulty: Difficult
Heading: Menstrual Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
PRIMEXAM.COM
Concept: Nursing Roles
1
2
3
4
Feedback
Painful menstruation is called dysmenorrhea. Nonsteroidal anti-inflammatory drugs like
ibuprofen, in addition to hormonal contraceptives, are recommended to reduce the pain
in clients with dysmenorrhea. Therefore, if the client experiences no pain during the
first 2 days of her menstrual period, it indicates an effective outcome.
Premenstrual syndrome is the behavioral, physical, and emotional changes during the
luteal phase of the menstrual cycle. Therefore, experiencing no behavioral changes
during the luteal phase of the menstrual cycle would be an effective outcome after
treatment for premenstrual syndrome.
Polycystic ovarian disease is the formation of multiple regions on the ovarian surface of
an unreleased egg. If there are no such formations, it would indicate an effective
outcome after treatment for polycystic ovarian disease.
Dysmenorrhea is painful menstrual periods. There are no marked behavioral changes or
formation of multiple regions of unreleased egg on the ovarian surface with
dysmenorrhea.
PTS: 1
CON: Nursing Roles
9. ANS: 3
Chapter: Chapter 26, Disorders of the Female Reproductive System
Page: 597
Objective: N/A
Difficulty: Difficult
Heading: Menstrual Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Assessment
1
2
3
4
Feedback
The estimated date of childbirth using Naegele’s rule to calculate for a client whose last
menstrual period is April 18, 2015 would be January 25, 2016, not January 15, 2016.
A pregnant woman whose last menstrual period is April 18, 2015 would be estimated to
deliver the baby on January 25, 2016, not January 20, 2016, based on the calculations
using Naegele’s rule.
Naegele’s rule calculates the childbirth by adding 1 year to the last menstrual period,
subtracting 3 months from it, and then adding 7 days to it. Therefore, if the last
menstrual period is April 18, 2015, then adding 1 year to it would be April 18, 2016.
Subtracting 3 months from April 18, 2016 is January 18, 2016. Adding 7 days to that
would be January 25, 2016. Therefore, January 25, 2016 is the estimated date of
childbirth.
The woman with April 18, 2015 as the last menstrual period would have an estimated
delivery date of January 25, 2016, not January 30, 2016, based on the calculations using
Naegele’s rule.
PTS: 1
CON: Assessment
PRIMEXAM.COM
10. ANS: 3
Chapter: Chapter 26, Disorders of the Female Reproductive System
Page: 597
Objective: N/A
Difficulty: Difficult
Heading: Assessment
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity: Basic Care and Comfort
Cognitive Level: Analysis [Analyzing]
Concept: Communication
1
2
3
4
Feedback
A client who has not had a pregnancy is called a nulliparous.
A client who has had multiple pregnancies is called a multiparous.
A client who is carrying her first pregnancy is called primigravida. Therefore, this is the
client that the nurse is discussing.
A client who has delivered a baby after the first pregnancy is called primiparous.
PTS: 1
CON: Communication
11. ANS: 4
Chapter: Chapter 26, Disorders of the Female Reproductive System
Page: 597
Objective: N/A
Difficulty: Difficult
Heading: Assessment
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Basic Care and Comfort
Cognitive Level: Analysis [Analyzing]
Concept: Assessment
1
2
3
4
Feedback
A client who had two deliveries and two abortions would be described as G4 P2.
A client who had two pregnancies and if both of them were aborted would be described
as G2 P0.
A client who had one delivery after 24 weeks and two pregnancies would be described
as P1 G2.
A client who had two pregnancies and two deliveries after 24 weeks would be described
as G2 P2.
PTS: 1
CON: Assessment
12. ANS: 3
Chapter: Chapter 26, Disorders of the Female Reproductive System
Page: 598
Objective: N/A
Difficulty: Easy
Heading: Assessment
Integrated Processes: Nursing Process
PRIMEXAM.COM
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
1
2
3
4
Feedback
Estrogen levels may help in diagnosing vaginitis.
Urine calcium oxalate levels may help in diagnosing vulvodynia.
CA-125 is a biomarker that is released into the bloodstream of clients with ovarian
cancer. Therefore, it helps in ruling out the possibility of ovarian cancer.
FSH helps in diagnosing premature ovarian failure.
PTS: 1
CON: Assessment
13. ANS: 4
Chapter: Chapter 26, Disorders of the Female Reproductive System
Page: 598
Objective: N/A
Difficulty: Difficult
Heading: Diagnosis
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Evaluation [Evaluating]
Concept: Nursing Roles
1
2
3
4
Feedback
Radiopaque dye is used in hysterosalpingography, not in hysteroscopy.
Proctoscopy involves inserting an instrument into the uterus to take a small amount of
tissue.
Laparoscopy is the insertion through a small surgical incision in the abdomen.
This statement of the client indicates effective understanding because in hysteroscopy, a
thin telescopic-type device is inserted via the vagina into the uterus to visualize the
interior of the uterus.
PTS: 1
CON: Nursing Roles
14. ANS: 4
Chapter: Chapter 26, Disorders of the Female Reproductive System
Page: 598
Objective: N/A
Difficulty: Easy
Heading: Treatment
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Knowledge [Remembering]
Concept: Medication
1
Feedback
Hormone replacement therapy may increase the risk of developing breast cancer. This
therapy should be used with extreme caution after weighing the risks and benefits. In a
PRIMEXAM.COM
2
3
4
client with breast cancer, it may worsen the client’s condition.
Development of cardiac disease is also a risk involved in using hormone replacement
therapy. Thus, this therapy should be used with extreme caution in a client who already
has cardiac disease.
Venous thrombus is a risk factor for hormone replacement therapy. Therefore, a client
with venous thrombus should be given this therapy with high precaution only if the
benefits outweigh the risks.
This option is correct because breast cancer, cardiac disease, and venous thrombus are
major risks involved in hormone replacement therapy. Therefore, clients with these
medical problems should be given hormone replacement therapy with extreme caution.
PTS: 1
CON: Medication
15. ANS: 2
Chapter: Chapter 26, Disorders of the Female Reproductive System
Page: 594
Objective: N/A
Difficulty: Difficult
Heading: Menstrual Disorders
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Assessment
1
2
3
4
Feedback
Frequent vaginal infections are observed in a client with diabetes mellitus.
A female client with a thyroid gland disorder may experience the absence of a
menstrual cycle, which is known as amenorrhea.
A client with diabetes mellitus may experience frequent vaginal infections.
Asking the client about the duration of pelvic pain is a general question that should be
asked while assessing a client with menstrual disorders. This is not a specific question
related to amenorrhea.
PTS: 1
CON: Assessment
16. ANS: 1
Chapter: Chapter 26, Disorders of the Female Reproductive System
Page: 596
Objective: N/A
Difficulty: Difficult
Heading: Menstrual Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Medication
1
Feedback
PMS is characterized by irritability and mood swings. Therapy with SSRIs and
nutritional supplements will provide relief from symptoms of PMS.
PRIMEXAM.COM
2
3
4
Painful menstruation is experienced in clients with dysmenorrhea. A client with PMS
will not experience painful menstruation. Therefore, if the client no longer experiences
painful menstruation, it does not indicate an effective outcome of the treatment.
b-HCG is observed in the serum of a pregnant client. Absence of b-HCG in a client
with PMS does not indicate the effectiveness of SSRIs and nutritional supplements.
The level of progesterone is not elevated due to SSRIs and nutritional supplements.
Therefore, this is not an effective outcome in clients with PMS.
PTS: 1
CON: Medication
17. ANS: 2
Chapter: Chapter 26, Disorders of the Female Reproductive System
Page: 594
Objective: N/A
Difficulty: Moderate
Heading: Menstrual Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Female Reproduction
1
2
3
4
Feedback
Painful menstruation is known as dysmenorrhea, which is not caused by MayerRokitansky-Hauser syndrome.
Absence of the uterus and a foreshortened vagina are the signs of Mayer-RokitanskyHauser syndrome. This syndrome can be responsible for amenorrhea, which is the
absence of a menstrual cycle.
Behavioral changes during menstruation are due to premenstrual syndrome. MayerRokitansky-Hauser syndrome does not result in premenstrual syndrome.
Excessive bleeding during menstruation is called menorrhea. It is not caused by MayerRokitansky-Hauser syndrome.
PTS: 1
CON: Female Reproduction
18. ANS: 3
Chapter: Chapter 26, Disorders of the Female Reproductive System
Page: 595
Objective: N/A
Difficulty: Moderate
Heading: Menstrual Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Female Reproduction
1
Feedback
Turner syndrome is a genetic disorder in which a female client partly or completely
misses an X chromosome. Clinical signs like a webbed neck, short stature, and a broad
shield-like chest are observed in the client.
PRIMEXAM.COM
2
3
4
Sheehan’s syndrome is a disorder observed in the postpartum period where the
hemorrhage during menses causes pituitary necrosis.
Asherman’s syndrome is characterized by the lack of uterine endometrial lining. It is
mostly observed after D&C surgery and can be a cause of secondary amenorrhea.
Mayer-Rokitansky-Hauser syndrome is an anomaly of the genital tract where the uterus
is absent and the vagina is foreshortened.
PTS: 1
CON: Female Reproduction
19. ANS: 1
Chapter: Chapter 26, Disorders of the Female Reproductive System
Page: 596
Objective: N/A
Difficulty: Difficult
Heading: Menstrual Disorders
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive Level: Evaluation [Evaluating]
Concept: Nursing Roles
1
2
3
4
Feedback
Oral contraceptives stop ovulation and decrease prostaglandin synthesis and
myometrial contractility. This helps in relieving the symptoms of dysmenorrhea. They
should not be avoided in clients with dysmenorrhea.
Ibuprofen is a nonsteroidal anti-inflammatory drug that decreases prostaglandin
synthesis. It is recommended for relief from the symptoms of dysmenorrhea.
A low-fat diet will reduce the hormonal imbalance in the body and give relief from the
symptoms of dysmenorrhea.
Regular exercise is recommended to maintain hormonal levels in the body, which gives
relief from the symptoms of dysmenorrhea.
PTS: 1
CON: Nursing Roles
20. ANS: 1
Chapter: Chapter 26, Disorders of the Female Reproductive System
Page: 600
Objective: N/A
Difficulty: Easy
Heading: Disorders of the Uterus
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Knowledge [Remembering]
Concept: Medication
1
2
Feedback
Tamoxifen is used in the treatment of breast cancer. It stimulates the growth of
endometrial tissue resulting in the growth of endometrial polyps.
Ibuprofen is a nonsteroidal anti-inflammatory drug that is recommended for clients with
dysmenorrhea.
PRIMEXAM.COM
3
4
Haloperidol is a psychoactive medication that results in hyperprolactinemia.
Metoclopramide is also a psychoactive medication that results in hyperprolactinemia. It
will not result in the growth of endometrial polyps.
PTS: 1
CON: Medication
MULTIPLE RESPONSE
21. ANS: 1, 3, 4, 5
Chapter: Chapter 26, Disorders of the Female Reproductive System
Page: 600
Objective: N/A
Difficulty: Difficult
Heading: Disorders of the Uterus
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Female Reproduction
1.
2.
3.
4.
5.
Feedback
This is correct. Menorrhagia is heavy menstrual bleeding that is observed in clients with
adenomyosis, where the endometrial tissue grows inside the muscular layer of the uterus.
This is incorrect. Infertility results when the process of placental implantation after
fertilization is hindered in the uterus. A client with menorrhagia will not have the problem
of infertility.
This is correct. Pelvic pain may be observed in the client due to the abnormal growth of the
endometrial tissue.
This is correct. Dysmenorrhea is an irregular menstrual cycle that is observed in clients
with adenomyosis due to abnormal growth of the endometrial tissue.
This is correct. Dyspareunia is painful sexual intercourse experienced by clients with
adenomyosis due to abnormal growth of endometrial tissue.
PTS: 1
CON: Female Reproduction
22. ANS: 4, 5
Chapter: Chapter 26, Disorders of the Female Reproductive System
Page: 601
Objective: N/A
Difficulty: Difficult
Heading: Disorders of the Uterus
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Female Reproduction
1.
Feedback
This is incorrect. A myomectomy is a surgical procedure used for the removal of fibroid
PRIMEXAM.COM
2.
3.
4.
5.
tumors. It will not suppress the growth of tumors.
This is incorrect. A hysterectomy is the surgical removal of the uterus. It is recommended
for clients with dysfunctional uterine bleeding (DUB).
This is incorrect. An ablation of the endometrium is the treatment recommended for clients
with DUB.
This is correct. Uterine artery embolization is a surgical technique that blocks the blood
flow to the tumor and suppresses its growth.
This is correct. Hypothalamic GnRH will stimulate the release of follicle-stimulating
hormone (FSH). FSH controls the movement of the endometrium and thus suppresses the
growth of fibroid tumors.
PTS: 1
CON: Female Reproduction
23. ANS: 4, 5
Chapter: Chapter 26, Disorders of the Female Reproductive System
Page: 592
Objective: N/A
Difficulty: Easy
Heading: Menopause
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Female Reproduction
1.
2.
3.
4.
5.
Feedback
This is incorrect. Hot flashes are caused by vasomotor instability during the
perimenopausal phase.
This is incorrect. Night sweats are caused by vasomotor instability during the
perimenopausal phase.
This is incorrect. Irregular menses are observed during the perimenopausal phase due to
hormonal imbalances. They are not caused by atrophic vaginitis.
This is correct. Painful sexual intercourse, called dysmenorrheal, is experienced due to
decreased vaginal secretions caused by atrophic vaginitis.
This is correct. Vaginal yeast infections are observed in females during the perimenopausal
stage due to decreased secretions caused by atrophic vaginitis.
PTS: 1
CON: Female Reproduction
24. ANS: 2, 4
Chapter: Chapter 26, Disorders of the Female Reproductive System
Page: 598
Objective: N/A
Difficulty: Easy
Heading: Treatment
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Knowledge [Remembering]
Concept: Medication
PRIMEXAM.COM
1.
2.
3.
4.
5.
Feedback
This is incorrect. Clozapine is an antipsychotic drug that may aggravate the symptoms of
hyperprolactinemia in clients.
This is correct. Cabergoline is a dopamine agonist. It is used to treat the symptoms of
hyperprolactinemia.
This is incorrect. The client’s symptoms of hyperprolactinemia may be worsened upon
administration of risperidone, which is an antipsychotic drug.
This is correct. Bromocriptine is a dopamine agonist used to treat symptoms of
hyperprolactinemia.
This is incorrect. Metoclopramide is a dopamine D2 receptor antagonist that should be
avoided in clients with hyperprolactinemia due to its antagonist effect.
PTS: 1
CON: Medication
ORDERED RESPONSE
25. ANS:
EDACBF
Chapter: Chapter 26, Disorders of the Female Reproductive System
Page: 589
Objective: N/A
Difficulty: Easy
Heading: The Menstrual Cycle
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Female Reproduction
Feedback: The first part of the menstrual cycle is the follicular phase where the pituitary gland produces FSH.
When the level of the FSH is at its peak, the pituitary gland releases luteinizing hormone, which results in
ovulation. The remnants of the Graafian follicle after ovulation form the corpus luteum. The corpus luteum
produces progesterone, which inhibits the synthesis of FSH and luteinizing hormone.
PTS: 1
CON: Female Reproduction
PRIMEXAM.COM
Chapter 27: Disorders of Male Reproductive System
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. While performing the genital assessment of a male client, a nurse observes that the client has curvature of the
penis. Which condition does the nurse suspect in the client?
1. Orchitis
2. Phimosis
3. Hypospadias
4. Peyronie’s disease
2. A client tells a nurse, “My erections lasts for several hours and are painful. “Which medication found in the
client’s prescription is responsible?
1. Sildenafil
2. Finasteride
3. Tamsulosin
4. Pyridoxine
3. A nurse observes that a newborn has an abnormally positioned urethral orifice of the penis. Which disorder
will the nurse suspect in the newborn?
1. Orchitis
2. Hypospadias
3. Cryptorchidism
4. Testicular torsion
4. Which physical finding in a client will lead a nurse to suspect paraphimosis?
1. Inflammation of the testes
2. Enlargement of the prostate glands
3. Abnormal prolonged erection of the penis
4. Permanent retracted position of the foreskin behind the penis
5. A registered nurse is teaching about the medications for benign prostatic hyperplasia (BPH) to a group of
student nurses. Which statement of a student nurse indicates the need for further teaching?
1. “Alpha-blockers improve urine flow.”
2. “Alpha-blockers reduce the size of the prostate.”
3. “Tamsulosin is a typical example of an alpha-blocker.”
4. “Alpha-blockers relax the smooth muscles in the prostate.”
6. Which hormone stimulates Sertoli cells to synthesize spermatozoa?
1. Inhibin
2. Testosterone
3. Luteinizing hormone (LH)
4. Follicle-stimulating hormone (FSH)
7. While assessing a male client for reproductive disorders, the primary health-care provider wants to understand
whether the client has prostate cancer or benign prostatic hyperplasia (BPH). Which diagnostic test will the
nurse expect in this case?
1. Ultrasound
2. Urine flow studies
PRIMEXAM.COM
3. Digital rectal examination (DRE)
4. Both A and B
8. While assessing a male client, a nurse finds erythema, swelling, and tenderness of the scrotum. The client also
reports pain in the scrotum. Which disorder does the nurse suspect in the client?
1. Epispadias
2. Cryptorchidism
3. Testicular torsion
4. Benign prostatic hyperplasia
9. A digital rectal examination (DRE) in a client reveals the enlargement of the prostate gland that is firm,
painless, and generalized. Which medications will the nurse anticipate from the primary health-care provider
to treat the client?
1. Alpha-blockers
2. 5-alpha-reductase inhibitors
3. Phosphodiesterase inhibitors
4. Both A and B
10. While assessing a male client, a nurse observes swelling in the scrotum due to the collection of serous fluid.
Which condition does the nurse suspect in the client?
1. Hydrocele
2. Epispadias
3. Hematocele
4. Hypospadias
11. Which disorder can occur due to HIV?
1. Varicocele
2. Hypospadias
3. Cryptorchidism
4. Testicular cancer
12. Which artery provides engorgement of the glans during erection?
1. Dorsal
2. Cavernous
3. Bulbourethral
4. Both A and C
13. After examining an elderly client’s penis, a nurse finds the presence of scar tissue in the corpora cavernosum.
On further assessment, the nurse confirms Peyronie’s disease in the client. Which finding supports the nurse’s
confirmation?
1. Small intrascrotal testes
2. Presence of a curved penis
3. Dilatation of the veins within the scrotum
4. Excessive growth of the prostate gland
14. A nurse teaches intervention to a client for healthy spermatogenesis. During a follow-up visit, the nurse finds
that the client has risk for diminished sperm production. Which statement of the client supports the nurse’s
conclusion?
1. “I should not limit fluid intake.”
2. “I should take a hot bath regularly.”
3. “I should refrain from cigarette smoking.”
PRIMEXAM.COM
4. “I should not wear tight undergarments.”
15. During an assessment, a nurse observes the signs of diminished secondary sexual characteristics in an adult
male client. What should be the appropriate nursing action?
1. Perform a digital rectal examination.
2. Check the prostate surface antigen levels.
3. Measure the morning serum testosterone levels.
4. Perform a computerized tomography (CT) scan.
16. Which hormone stimulates the Leydig cells of the testes to secrete testosterone?
1. Prolactin
2. Thyroid hormone
3. Luteinizing hormone
4. Follicle-stimulating hormone
17. Which cells secrete inhibin hormone?
1. Sperm cells
2. Leydig cells
3. Sertoli cells
4. White blood cells
18. Which condition can cause ischemia of the testicle?
1. Priapism
2. Hematocele
3. Testicular torsion
4. Cryptorchidism
19. While assessing a male client, a nurse observes that the client has a small penis, long legs, short trunk,
enlarged breast tissues, small testicles, and sexual dysfunction. What reason does the nurse suspect from these
findings?
1. Mumps infection
2. Presence of an extra X chromosome
3. Prolonged consumption of antihypertensive agents
4. Increased cellular growth and size of the prostate gland
20. Which gland secretes a lubricating fluid that coats the urethra during sexual arousal?
1. Pituitary gland
2. Prostate gland
3. Bulbourethral gland
4. Thyroid gland
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
21. What are signs of delayed puberty? Select all that apply.
1. Larger testes
2. Gynecomastia
3. Long arms and legs
4. Absence of pubic hair
5. Persistent high-pitched voice
PRIMEXAM.COM
22. Which signs will a nurse observe in a client who is diagnosed with precocious puberty? Select all that apply.
1. Gynecomastia
2. Long arms and legs
3. Reduced adult height
4. Small penis and testes
5. Presence of axillary and pubic hair
23. What are the risk factors of erectile dysfunction? Select all that apply.
1. Atherosclerosis
2. Cryptorchidism
3. Peyronie’s disease
4. Hypotension
5. Wearing tight undergarments
24. While teaching health promotion measures to a group of football players, a registered nurse instructs the
players to wear protective gear while on the field. Which complications is the nurse trying to avoid in the
players? Select all that apply.
1. Orchitis
2. Priapism
3. Prostatitis
4. Hydrocele
5. Testicular torsion
25. Which clients have a higher risk of delayed puberty? Select all that apply.
1. A client who has sickle cell anemia.
2. A client who has chronic renal failure.
3. A client who has inflammatory bowel disease.
4. A client who has exposure to diethylstilbestrol.
5. A client who is taking antidepressants for a longtime.
PRIMEXAM.COM
Chapter 27: Disorders of Male Reproductive System
Answer Section
MULTIPLE CHOICE
1. ANS: 4
Chapter: Chapter 27, Disorders of the Male Reproductive System
Page: 618
Objective: N/A
Difficulty: Moderate
Heading: Anatomical Abnormalities
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Male Reproduction
1
2
3
4
Feedback
Inflammation of the testes in response to a bacterial infection or the mumps virus is
known as orchitis.
Phimosis is an anatomical disorder in which the foreskin is constricted and does not
easily retract from the penis.
Abnormal position of the urethral opening on the head of the penis is known as
hypospadias.
Peyronie’s disease is a disorder in which the penis has an abnormal curvature due to
inflammation vasculitis. Therefore, the nurse suspects Peyronie’s disease in the client.
PTS: 1
CON: Male Reproduction
2. ANS: 1
Chapter: Chapter 27, Disorders of the Male Reproductive System
Page: 619
Objective: N/A
Difficulty: Difficult
Heading: Anatomical Abnormalities
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Medication
1
2
3
Feedback
Sildenafil is a phosphodiesterase inhibitor agent that causes persistent erection of the
penis as a side effect. This condition is known as priapism. The nurse finds sildenafil in
the client’s medical record.
Finasteride is a 5-alpha-reductase inhibitor used in the treatment of benign prostatic
hyperplasia. It blocks the conversion of testosterone to dihydrotestosterone, but does
not cause priapism.
Tamsulosin is an alpha-blocker that is used in the treatment of benign prostatic
PRIMEXAM.COM
4
hyperplasia. It works by relaxing the smooth muscles of the prostate.
Pyridoxine is a vitamin B6 supplement and it does not act as a
phosphodiesterase inhibitor agent. Therefore, it does not cause persistent erection of the
penis as a side effect.
PTS: 1
CON: Medication
3. ANS: 2
Chapter: Chapter 27, Disorders of the Male Reproductive System
Page: 616
Objective: N/A
Difficulty: Moderate
Heading: Epidemiology
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Male Reproduction
1
2
3
4
Feedback
Orchitis is inflammation of the penis that occurs due to the mumps virus or a bacterial
infection.
Hypospadias is most common congenital disorder that occurs in newborns. In this
condition, the position of the urethral surface of the penis is abnormal.
Cryptorchidism is characterized by undescended testicles in which the testicles remain
within the abdomen.
Testicular torsion is a congenital disorder in which the spermatic cord twists and cuts
the circulation to the testicles.
PTS: 1
CON: Male Reproduction
4. ANS: 4
Chapter: Chapter 27, Disorders of the Male Reproductive System
Page: 618
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts of Male Reproductive Dysfunction
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Male Reproduction
1
2
3
4
Feedback
Inflammation of the testes is known as orchitis.
Benign prostatic hyperplasia is characterized by the enlargement of the prostate glands.
Abnormally prolonged penis in the absence of stimulation is known as priapism.
Paraphimosis is an anatomical disorder in which the foreskin is in a permanently
retracted position behind the tip of the penis. Therefore, this physical finding in the
client will lead the nurse suspect paraphimosis.
PRIMEXAM.COM
PTS: 1
CON: Male Reproduction
5. ANS: 2
Chapter: Chapter 27, Disorders of the Male Reproductive System
Page: 621
Objective: N/A
Difficulty: Difficult
Heading: Disorders of the Male Reproductive System
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Male Reproduction
1
2
3
4
Feedback
Alpha-blockers used in the treatment of BPH relax the muscles in the neck of the
bladder, which in turn improves urine flow. Therefore, this statement of the student
nurse does not indicate the need for further teaching.
Alpha-blockers help to relax the smooth muscles of the prostate but do not aid in
reducing the size of the prostate. Therefore, this statement of the student nurse indicates
the need for further teaching.
A typical example of an alpha-blocker is tamsulosin. This statement of the student nurse
is correct and does not indicate the need for further teaching.
The smooth muscles of the prostate are relaxed by alpha-blockers. This statement of the
student nurse is correct and does not indicate the need for further teaching.
PTS: 1
CON: Male Reproduction
6. ANS: 4
Chapter: Chapter 27, Disorders of the Male Reproductive System
Page: 617
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts of Male Reproductive Function
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Male Reproduction
1
2
3
4
Feedback
Inhibin is a hormone secreted by Sertoli cells, which send feedback to the pituitary
glands to decrease or increase FSH.
Testosterone is the hormone used in the production of sperm.
LH promotes testosterone secretion by the Leydig cells of the testes.
The anterior pituitary secretes FSH. FSH stimulates the Sertoli cells of the seminiferous
tubules to synthesize spermatozoa.
PTS: 1
7. ANS: 4
CON: Male Reproduction
PRIMEXAM.COM
Chapter: Chapter 27, Disorders of the Male Reproductive System
Page: 621
Objective: N/A
Difficulty: Moderate
Heading: Assessment of Male Reproductive Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk potential
Cognitive Level: Application [Applying]
Concept: Male Reproduction
1
2
3
4
Feedback
An ultrasound examination involves the use of ultrasound waves to visualize the
structure of the internal organs. It is useful in differentiating prostate cancer from BPH.
Urine flow studies are used to differentiate prostate cancer from benign prostatic
hyperplasia.
A DRE is used to diagnose prostate enlargement. It cannot differentiate between
prostate cancer and BPH.
Ultrasound and urine flow studies are the two diagnostic tests used to differentiate
between prostate cancer and BPH.
PTS: 1
CON: Male Reproduction
8. ANS: 3
Chapter: Chapter 27, Disorders of the Male Reproductive System
Page: 624
Objective: N/A
Difficulty: Moderate
Heading: Disorders of the Male Reproductive System
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Male Reproduction
1
2
3
4
Feedback
Misplacement of the urethral orifice on the penis is seen in epispadias.
In cryptorchidism there is a lack of palpable testes in the scrotum.
In testicular torsion the tunica vaginalis is twisted because it obstructs the flow to the
testes. As a result, the scrotum shows erythema, swelling, tenderness, and acute pain.
Therefore, the nurse suspects testicular torsion in the client.
Benign prostatic hyperplasia is characterized by the enlargement of the scrotum.
PTS: 1
CON: Male Reproduction
9. ANS: 4
Chapter: Chapter 27, Disorders of the Male Reproductive System
Page: 622
Objective: N/A
Difficulty: Moderate
Heading: Disorders of the Male Reproductive System
PRIMEXAM.COM
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Medication
1
2
3
4
Feedback
Alpha-blockers are the first choice of medication used for the treatment of BPH. The
prostate gland appears to be enlarged, which is firm, painless, and generalized in clients
with BPH.
5-alpha-reductase inhibitors are the drugs that block the prostate-stimulating hormone
and are used for BPH.
Phosphodiesterase inhibitors are beneficial in cases of erectile dysfunction.
Both alpha-blockers and 5-alpha-reductase inhibitors are beneficial in clients with BPH.
Therefore, both A and B are correct answers.
PTS: 1
CON: Medication
10. ANS: 1
Chapter: Chapter 27, Disorders of the Male Reproductive System
Page: 621
Objective: N/A
Difficulty: Moderate
Heading: Disorders of the Male Reproductive System
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Male Reproduction
1
2
3
4
Feedback
Hydrocele is the collection of serous fluid in the scrotum that causes swelling and a
feeling of heaviness. It is caused due to a traumatic injury or infection in the testis.
The presence of the urethral orifice on the anterior side of the penis is known as
epispadias.
The collection of blood in the scrotum is known as hematocele. It causes the same
symptoms as hydrocele.
The presence of a urethral opening in the underside of the penis indicates hypospadias
in a client.
PTS: 1
CON: Male Reproduction
11. ANS: 4
Chapter: Chapter 27, Disorders of the Male Reproductive System
Page: 620
Objective: N/A
Difficulty: Easy
Heading: Assessment of Male Reproductive Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
PRIMEXAM.COM
Concept: Male Reproduction
1
2
3
4
Feedback
Varicocele occurs due to trauma.
Hypospadias is a congenital disorder of male newborns that occurs due to an
abnormally placed urethral orifice of the penis.
Cryptorchidism occurs due to undescended testes in male newborns.
Testicular cancer is a male reproductive cancer that may occur due to HIV.
PTS: 1
CON: Male Reproduction
12. ANS: 1
Chapter: Chapter 27, Disorders of the Male Reproductive System
Page: 617
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts of Male Reproductive Function
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Male Reproduction
1
2
3
4
Feedback
The dorsal artery is a branch of the penile artery that provides for engorgement of the
glans during an erection.
The cavernous artery causes swelling of the corpus cavernosum and is responsible for
penile erection.
The bulbourethral artery supplies oxygenated blood to the bulb and corpus spongiosum.
The dorsal and bulbourethral arteries do not result in engorgement of the glans during
erection.
PTS: 1
CON: Male Reproduction
13. ANS: 2
Chapter: Chapter 27, Disorders of the Male Reproductive System
Page: 618
Objective: N/A
Difficulty: Difficult
Heading: Basic Concepts of Male Reproductive Dysfunction
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Male Reproduction
1
2
Feedback
The presence of small intrascrotal testes on clinical examination represents testicular
atrophy.
Peyronie’s disease is an inflammatory disorder in which the penis curves. In this
disease, clients develop scar tissue in the corpora cavernosum that prevents blood flow.
PRIMEXAM.COM
3
4
Due to these findings, the nurse suspects that the client has Peyronie’s disease.
Varicocele is the dilatation of the veins within the scrotum.
Excessive growth of the prostate glands indicates benign prostatic hyperplasia.
PTS: 1
CON: Male Reproduction
14. ANS: 2
Chapter: Chapter 27, Disorders of the Male Reproductive System
Page: 620
Objective: N/A
Difficulty: Difficult
Heading: Assessment of Male Reproductive Disorders
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Basic Care and Comfort
Cognitive Level: Evaluation [Evaluating]
Concept: Promoting Health
1
2
3
4
Feedback
Adequate fluid intake helps to keep the body hydrated and does not affect sperm
production. Therefore, the client should not limit fluid intake.
Overheating of the testes affects spermatogenesis. Therefore, the client should not take
a hot bath frequently, because it reduces sperm production.
Cigarette smoking reduces sperm count. Therefore, the client should avoid cigarette
smoking.
Wearing tight undergarments increases the risk of overheating the testes. Therefore,
avoiding tight undergarments does not reduce the sperm count in the client.
PTS: 1
CON: Promoting Health
15. ANS: 3
Chapter: Chapter 27, Disorders of the Male Reproductive System
Page: 624
Objective: N/A
Difficulty: Moderate
Heading: Erectile Dysfunction
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Male Reproduction
1
2
3
4
Feedback
A digital rectal examination is used to assess the prostate gland, which helps to
diagnose benign prostatic hyperplasia.
Prostate surface antigen levels are measured to diagnose benign prostatic hyperplasia.
An endocrine evaluation is performed on a client if the secondary sexual characteristics
are diminished. The serum testosterone levels show a circadian variation. Serum
testosterone levels are the highest in the morning and the lowest in the late afternoon.
Therefore, the nurse should measure the morning serum testosterone levels in the client.
A CT scan is used to diagnose cryptorchidism.
PRIMEXAM.COM
PTS: 1
CON: Male Reproduction
16. ANS: 3
Chapter: Chapter 27, Disorders of the Male Reproductive System
Page: 616
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts of Male Reproductive Function
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Male Reproduction
1
2
3
4
Feedback
Prolactin stimulates the mammary glands to produce milk.
Thyroid hormone is helpful for metabolism, growth, and development.
Luteinizing hormone stimulates the Leydig cells of the testes to secrete testosterone.
Follicle-stimulating hormone stimulates spermatozoa production by the testes.
PTS: 1
CON: Male Reproduction
17. ANS: 3
Chapter: Chapter 27, Disorders of the Male Reproductive System
Page: 617
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts of Male Reproductive Function
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Knowledge [Remembering]
Concept: Male Reproduction
1
2
3
4
Feedback
Maturation of spermatids occurs in the sperm cells.
Leydig cells of the testes secrete testosterone.
Inhibin hormone sends feedback to the pituitary to turn off spermatogenesis. Sertoli
cells secrete inhibin hormone.
White blood cells improve immunity and protect the body against infection.
PTS: 1
CON: Male Reproduction
18. ANS: 3
Chapter: Chapter 27, Disorders of the Male Reproductive System
Page: 624
Objective: N/A
Difficulty: Easy
Heading: Testicular Torsion
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
PRIMEXAM.COM
Cognitive Level: Knowledge [Remembering]
Concept: Male Reproduction
1
2
3
4
Feedback
Priapism causes an abnormal prolonged erection of the penis in the absence of
stimulation.
Hematocele causes an accumulation of blood in the scrotal sac.
Testicular torsion causes twisting of the spermatic cord. It causes the obstruction of
blood flow to the testicle and can result in ischemia of the testicle.
Cryptorchidism is a condition in which the testes remain high in the inguinal canal or
abdominal cavity.
PTS: 1
CON: Male Reproduction
19. ANS: 2
Chapter: Chapter 27, Disorders of the Male Reproductive System
Page: 620
Objective: N/A
Difficulty: Difficult
Heading: Assessment of Male Reproductive Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Male Reproduction
1
2
3
4
Feedback
A mumps virus infection causes orchitis, which may lead to infertility. Inflammation of
one or both testicles is a sign of orchitis.
A small penis, long legs and short trunk, enlarged breast tissues, small testicles, and
sexual dysfunction are the symptoms of Klinefelter syndrome. It is a genetic disorder
that occurs due to the presence of an extra X chromosome.
Prolonged consumption of antihypertensive agents causes erectile dysfunction. Inability
of the penis to achieve erection is a sign of erectile dysfunction.
Increased cellular growth and size of the prostate gland causes benign prostatic
hyperplasia. Frequent urination, weak stream, and nocturia are the symptoms of benign
prostatic hyperplasia.
PTS: 1
CON: Male Reproduction
20. ANS: 3
Chapter: Chapter 27, Disorders of the Male Reproductive System
Page: 617
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts of Male Reproductive Function
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Knowledge [Remembering]
Concept: Male Reproduction
PRIMEXAM.COM
1
2
3
4
Feedback
The pituitary gland secretes luteinizing hormone and follicle-stimulating hormone.
The prostate gland secretes an alkaline fluid that produces lubrication and nutrition for
sperm.
The bulbourethral glands are two pea-sized glands located below the prostate. These
glands secrete a lubricating fluid that coats the urethra during sexual arousal.
The thyroid gland secretes thyroxin hormone in the body but does not secrete the
lubricating fluid that coats the urethra during sexual arousal.
PTS: 1
CON: Male Reproduction
MULTIPLE RESPONSE
21. ANS: 2, 3, 5
Chapter: Chapter 27, Disorders of the Male Reproductive System
Page: 619
Objective: N/A
Difficulty: Easy
Heading: Delayed Puberty
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Male Reproduction
1.
2.
3.
4.
5.
Feedback
This is incorrect. Small testes are observed in cases of delayed puberty.
This is correct. Delayed puberty causes hormone imbalance and results in the enlargement
of breast tissues. This condition is called gynecomastia.
This is correct. Delayed puberty delays the bone growth plate closure and causes long arms
and legs.
This is incorrect. Scant pubic hairs are observed in delayed puberty.
This is correct. Delayed puberty decreases the tension of the vocal cord and causes a
persistent high-pitched voice.
PTS: 1
CON: Male Reproduction
22. ANS: 3, 5
Chapter: Chapter 27, Disorders of the Male Reproductive System
Page: 619
Objective: N/A
Difficulty: Moderate
Heading: Basic Concepts of Male Reproductive Dysfunction
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Male Reproduction
PRIMEXAM.COM
1.
2.
3.
4.
5.
Feedback
This is incorrect. Precocious puberty occurs in males before the age of 9 years.
Gynecomastia is a symptom of delayed puberty.
This is incorrect. Long arms and legs is a symptom of delayed puberty.
This is correct. In the clients with precocious puberty, adult height is reduced because the
bone growth plates fuse before adult height is reached.
This is incorrect. Small penis and testes is a symptom of delayed puberty.
This is correct. In precocious puberty, axillary and pubic hairs are present.
PTS: 1
CON: Male Reproduction
23. ANS: 1, 2, 3
Chapter: Chapter 27, Disorders of the Male Reproductive System
Page: 620
Objective: N/A
Difficulty: Easy
Heading: Assessment of Male Reproductive Disorders
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Male Reproduction
1.
2.
3.
4.
5.
Feedback
This is correct. One of the causes of erectile dysfunction is atherosclerosis.
This is correct. Cryptorchidism is the risk factor of testicular cancer in men.
This is correct. The presence of Peyronie’s disease can cause erectile dysfunction.
This is incorrect. Hypertension can cause erectile dysfunction.
This is incorrect. Wearing tight undergarments reduces sperm production, but may not
cause erectile dysfunction.
PTS: 1
CON: Male Reproduction
24. ANS: 4, 5
Chapter: Chapter 27, Disorders of the Male Reproductive System
Page: 620
Objective: N/A
Difficulty: Difficult
Heading: Assessment of Male Reproductive Disorders
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Male Reproduction
1.
2.
3.
Feedback
This is incorrect. Orchitis is the inflammation of the testes, which is caused by the mumps
virus. Protective gear will not prevent orchitis.
This is incorrect. Abnormal prolonged erection of the penis is known as priapism. It occurs
as a side effect of the drug sildenafil and as a vasoocclusive crisis of sickle cell anemia.
This is incorrect. Prostatitis is the inflammation of the prostate. It occurs due to sexually
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5.
transmitted infections.
This is correct. Hydrocele is the collection of serous fluid in the scrotum that occurs due to
trauma in athletes while playing. Therefore, athletes should wear protective gear while
playing to prevent hydrocele.
This is correct. Testicular torsion is a condition in which the tunica vaginalis is twisted and
obstructs the blood flow to the penis. It occurs in athletes due to an injury while playing.
Therefore, athletes should wear protective gear while playing to prevent testicular torsion.
PTS: 1
CON: Male Reproduction
25. ANS: 2, 3
Chapter: Chapter 27, Disorders of the Male Reproductive System
Page: 619
Objective: N/A
Difficulty: Difficult
Heading: Delayed Puberty
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Development
1.
2.
3.
4.
5.
Feedback
This is incorrect. Sickle cell anemia affects the function of the penis and increases the risk
of priapism.
This is correct. Chronic renal failure imbalances the hormonal levels and impairs
development. Therefore, it results in delayed puberty.
This is correct. Inflammatory bowel disease causes growth impairment and results in
delayed puberty.
This is incorrect. Exposure to diethylstilbestrol increases the risk of urethral abnormalities,
epididymal cysts, and cryptorchidism.
This is incorrect. Prolonged consumption of antidepressants causes erectile dysfunction.
PTS: 1
CON: Development
PRIMEXAM.COM
Chapter 28: Sexually Transmitted Diseases
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. A registered nurse is teaching a group of nursing student about sexually transmitted diseases and makes the
following statement, “This disease spreads through close skin contact and cannot be prevented by using
condoms.” Which sexually transmitted disease is the nurse referring to in the teaching?
1. Herpes simplex virus (HSV)
2. Human immunodeficiency virus (HIV)
3. Hepatitis B
4. None of the above
2. A nurse is reviewing the medical records of a client who is pregnant and finds that the client has a Clamydia
infection. Which complication should the nurse expect in the newborn?
1. Meningitis
2. Conjunctivitis
3. Hearing disorders
4. Aortic valve deformity
3. Which infection is caused by the spirochete bacterium Treponema pallidum?
1. Syphilis
2. Chancroid
3. Granuloma inguinale
4. Lymphogranuloma venereum
4. A nurse is reviewing the medical records of a client and finds that the client has multiple clusters of fleshy
growths on the vagina. What should the nurse interpret from these findings?
1. The client has chancroid.
2. The client has granuloma inguinale.
3. The client has condyloma acuminata.
4. None of the above
5. A nurse is assessing a female client who has pelvic inflammatory disorder. Which condition in the client
indicates that the client requires immediate hospitalization?
1. The client is pregnant.
2. The client has a pelvic abscess.
3. The client has nausea and fever.
4. All of the above
6. Which infection would be detected by testing the swab samples of lesions on a Tzanck smear?
1. Neisseria gonorrhoeae
2. Treponema pallidum
3. Human papillomavirus (HPV)
4. None of the above
7. Which microorganism causes inclusion conjunctivitis?
1. Treponema pallidum
2. Neisseria gonorrhoeae
3. Chlamydia trachomatis
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4. None of the above
8. While caring for a neonate immediately following a vaginal birth, a nurse finds that the mother has gonorrhea.
Which prescription should the nurse anticipate to be most beneficial to the neonate?
1. Vitamin K1 (Mephyton, Aquamephyton)
2. Vitamin D and iron supplements
3. Tetracycline ophthalmic ointment (Ocudox)
4. Hepatitis B (RECOMBIVAX HB) vaccine
9. After reviewing the laboratory reports of a client, a nurse finds that the client has chronic pelvic inflammatory
disorder (PID). Which condition should the nurse anticipate in the client?
1. Meningitis
2. Condyloma acuminata
3. Mild salpingitis
4. Inflammation of the fallopian tubes
10. Where does the herpes simplex virus (HSV) remain during its dormant stage?
1. Epithelium layer
2. Sacral spinal nerves
3. Dorsal ganglion of sensory nerves
4. All of the above
11. A nurse is assessing a client who has condyloma acuminata. Which medication should the nurse find in the
client’s prescription?
1. Benzathine penicillin
2. Topical podophyllin
3. Trichloroacetic acid
4. Both B and C
12. A client is diagnosed with condyloma acuminata. Which test should the nurse expect will be beneficial to
detect the viral genome?
1. Biopsy
2. Papanicolaou (Pap) smear
3. Colposcopy
4. None of the above
13. A nurse is reviewing the Papanicolaou (Pap) smear test results of a client. What should the nurse assess in
review of the test results?
1. Dysplasia
2. Viral genome composition
3. Gummas
4. None of the above
14. After reviewing the medical records of a client, a nurse finds that the client was earlier diagnosed with mild
salpingitis and later had tubal dysfunction. The nurse also finds strains of Chlamydia in the client’s blood
specimen. What should the nurse interpret from this finding?
1. The client is infected with syphilis.
2. The client has condyloma acuminata.
3. The client is infected with the human papillomavirus (HPV).
4. The client has silent pelvic inflammatory disease.
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15. After assessing a client, a nurse finds that the client who has Chlamydia trachomatis infection has fibrotic
adhesions around the liver and a tender abdomen. Which condition does the nurse find in the client?
1. Salpingitis
2. Condyloma acuminata
3. Fitz-Hugh-Curtis syndrome
4. None of the above
16. The medical records of a client indicate that the client has Reiter’s syndrome. Which microorganism is most
likely to cause this infection?
1. Treponema pallidum
2. Neisseria gonorrhoeae
3. Human papillomavirus
4. Chlamydia trachomatis
17. A client has exposure to the Neisseria gonorrhoeae organism and becomes infected. Which symptom would
be noted in the client immediately after the infection?
1. Dysuria
2. Abdominal pain
3. Copious discharge
4. None of the above
18. Which sexually transmitted disease is known as the great imposter?
1. Syphilis
2. Chlamydia
3. Gonorrhea
4. All of the above
19. A nurse is caring for a neonate who is born to a mother who has the herpes simplex viral infection. Which
action by the nurse would be most beneficial to the neonate?
1. Encourage the mother to breastfeed the neonate continuously
2. Obtain the electrocardiogram results of the neonate
3. Obtain magnetic resonance imaging studies in the neonate
4. Educate the mother in preventing hypothermia in the neonate
20. A nurse is caring for a client who was newly diagnosed with the herpes simplex viral infection and who has
been prescribed acyclovir (Zovirax). Which would be the accurate nursing intervention for the client?
1. Administering the medication once a day before dinner
2. Administering the medication with some water once a day
3. Administering the medication three times daily for 7 to 10 days
4. Administering the medication three times daily for 15 to 20 days
21. A nursing student is caring for a neonate immediately following birth. The mother has genital warts. Which
action by the student nurse would be most beneficial to the neonate?
1. Examine the pharynx of the neonate.
2. Instruct the mother to breastfeed the neonate.
3. Encourage the mother to give kangaroo care to the neonate.
4. Administer vitamin D and iron supplements to the neonate.
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22. Upon reviewing a female client’s laboratory reports, a nurse finds that the client tested positive for a sexually
transmitted infection. Following assessment, the nurse determines the client has a low probability of infertility
problems because of an infection. Which infection in the client would not increase risk for infertility
problems?
1. Human papillomavirus infection
2. Chlamydia infection
3. Gonorrheal infection
4. Pelvic inflammatory disease
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
23. A client who is infected with the Neisseria gonorrhoeae infection has developed sepsis. Which symptoms
would the nurse observe in the client? Select all that apply.
1. Rhinitis
2. Meningitis
3. Polyuria
4. Hypertension
5. Respiratory acidosis
24. Which symptoms should a nurse observe for in a client who has pelvic inflammatory disease (PID)? Select all
that apply.
1. Oral temperature of 101°F
2. Increase in the C-reactive protein levels
3. Decrease in the erythrocyte sedimentation rate (ESR)
4. Presence of white blood cells in the vaginal secretions
5. Decrease in the sodium concentration of the blood
25. Which neurological disorders are associated with syphilis? Select all that apply.
1. Paresis
2. Dementia
3. Meningitis
4. Aortic aneurysm
5. Aortic valve deformity
PRIMEXAM.COM
Chapter 28: Sexually Transmitted Diseases
Answer Section
MULTIPLE CHOICE
1. ANS: 1
Chapter: Chapter 28, Sexually Transmitted Diseases
Page: 630
Objective: N/A
Difficulty: Moderate
Heading: Basic Concepts of Sexual Disease and Dysfunction
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Safety and Infection Control
Cognitive Level: Application [Applying]
Concept: Infection
1
2
3
4
Feedback
HSV is a sexually transmitted disease that infects through close skin-to-skin contact. It
cannot always be prevented by the use of condoms.
The HIV is a viral infection, which spreads through blood-to-blood transmission, sexual
contact, or breastfeeding; however, it does not spread through close skin contact, and
can be prevented by using condoms.
Hepatitis B is a viral infection that spreads through blood-to-blood transmission, sexual
contact, or breastfeeding; however, it does not spread through close skin contact and
can be prevented by using condoms.
The HSV cannot be prevented by using condoms; therefore, the option “None of the
above” is incorrect.
PTS: 1
CON: Infection
2. ANS: 2
Chapter: Chapter 28, Sexually Transmitted Diseases
Page: 631
Objective: N/A
Difficulty: Moderate
Heading: Bacterial Infections
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Safety and Infection Control
Cognitive Level: Application [Applying]
Concept: Infection
1
2
Feedback
Meningitis is the inflammation of the membranes of the brain and spinal cord. The
newborn of the client who is pregnant and has a Neisseria gonorrhoeae infection will
be at risk for meningitis.
Conjunctivitis is the inflammation of the conjunctiva. The client who is pregnant and
has a Chlamydia infection may transfer the infection to the newborn during a vaginal
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birth; therefore, the newborn would have direct exposure to the bacteria, which may
cause conjunctivitis in the newborn.
Hearing disorders are common in newborns who have Neisseria gonorrhoeae infection.
Newborns who are infected with the syphilis infection will be at high risk for
developing aortic valve deformity.
PTS: 1
CON: Infection
3. ANS: 1
Chapter: Chapter 28, Sexually Transmitted Diseases
Page: 633
Objective: N/A
Difficulty: Easy
Heading: Bacterial Infections
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Infection
1
2
3
4
Feedback
Treponema pallidum is a spirochete bacterium that easily spreads through sexual
contact and causes the syphilis infection.
Chancroid is a sexually transmitted disease that spreads through streptobacillary rod
bacteria Haemophilus ducreyi.
Granuloma inguinale is a sexually transmitted disease that manifests as ulcerative
lesions on the genital area. It is transmitted through the Klebsiella granulomatis
infection.
Lymphogranuloma venereum is a bacterial infection that affects the lymphatic system.
This infection is a result of the Chlamydia trachomatis infection.
PTS: 1
CON: Infection
4. ANS: 3
Chapter: Chapter 28, Sexually Transmitted Diseases
Page: 637
Objective: N/A
Difficulty: Moderate
Heading: Viral Infections
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Infection
1
2
Feedback
Chancroid is a sexually transmitted disease that is caused by the Klebsiella
granulomatis infection; however, it is not associated with multiple clusters of fleshy
growths in the genital area.
Granuloma inguinale is a sexually transmitted disease that is caused by the Klebsiella
granulomatis infection. This condition is characterized by ulcerative lesions over the
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genital area, but multiple clusters of fleshy growths are not a finding in this condition.
Condyloma acuminata is a clinical finding in clients who are infected with the human
papillomavirus (HPV). This condition is manifested as multiple clusters of fleshy
growths in the genital area.
Condyloma acuminata is associated with multiple clusters of fleshy growths in the
genital area.
PTS: 1
CON: Infection
5. ANS: 4
Chapter: Chapter 28, Sexually Transmitted Diseases
Page: 640
Objective: N/A
Difficulty: Moderate
Heading: Bacterial Infections
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Safety and Infection Control
Cognitive Level: Application [Applying]
Concept: Infection
1
2
3
4
Feedback
A client who is pregnant and has pelvic inflammatory disorder will have severe
complications because of severe pain and tenderness in the pelvic region; therefore, the
client needs immediate hospitalization.
The presence of swelling in the pelvis will increase complications in a client who has
pelvic inflammatory disorder; therefore, the client will need immediate hospitalization.
The presence of nausea and fever will increase the risk for infection in a client who has
pelvic inflammatory disorder; therefore, the client will require immediate
hospitalization.
The presence of pregnancy, pelvic abscess, nausea, and fever will increase the
complications of pelvic inflammatory disorder; therefore, the client will require
immediate hospitalization.
PTS: 1
CON: Infection
6. ANS: 3
Chapter: Chapter 28, Sexually Transmitted Diseases
Page: 638
Objective: N/A
Difficulty: Easy
Heading: Viral Infections
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Knowledge [Remembering]
Concept: Infection
1
Feedback
Neisseria gonorrhoeae causes several infections, which include pelvic inflammatory
disease and conjunctivitis. It is detected through a Papanicolaou (Pap) smear or
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4
immunoassay.
Treponema pallidum causes syphilis infection and is detected through a blood
immunoassay.
Tzanck smear involves the scraping of the ulcer base, which collects specialized cells
and helps detect the human papillomavirus (HPV).
Neisseria gonorrhoeae and Treponema pallidum are not detected through a Tzanck
smear, but human papillomavirus (HPV) is detected.
PTS: 1
CON: Infection
7. ANS: 3
Chapter: Chapter 28, Sexually Transmitted Diseases
Page: 631
Objective: N/A
Difficulty: Easy
Heading: Bacterial Infections
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Knowledge [Remembering]
Concept: Infection
1
2
3
4
Feedback
Treponema pallidum is a spirochete bacterium that causes syphilis. It is not associated
with inclusion conjunctivitis.
Neisseria gonorrhoeae is a gram-negative gonococcal bacterium that may cause
conjunctivitis, but is not associated with inclusion conjunctivitis.
Inclusion conjunctivitis is the inflammation of the conjunctiva. The Chlamydia
trachomatis gram-negative bacteria cause pelvic inflammatory disease and inclusion
conjunctivitis.
Treponema pallidum and Neisseria gonorrhoeae do not cause inclusion conjunctivitis.
Chlamydia trachomatis causes inclusion conjunctivitis.
PTS: 1
CON: Infection
8. ANS: 3
Chapter: Chapter 28, Sexually Transmitted Diseases
Page: 633
Objective: N/A
Difficulty: Difficult
Heading: Pathophysiology of Sexually Transmitted Diseases
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Infection
1
2
Feedback
Vitamin K1 (Mephyton, Aquamephyton) prevents the neonate from excessive blood
loss, but does not cause ophthalmia neonatorum in the neonate.
Vitamin D and iron supplements protect the neonate from rickets and anemia.
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Tetracycline ophthalmic ointment (Ocudox) protects the neonate against eye infections,
such as ophthalmia neonatorum, that are caused by gonorrheal infection; therefore, the
nurse should anticipate that tetracycline ophthalmic ointment (Ocudox) would be most
beneficial to the neonate.
The hepatitis B (RECOMBIVAX HB) vaccine does not protect the neonate from
neonatal conjunctivitis caused by chlamydial infections.
PTS: 1
CON: Infection
9. ANS: 4
Chapter: Chapter 28, Sexually Transmitted Diseases
Page: 639
Objective: N/A
Difficulty: Difficult
Heading: Viral Infections
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Infection
1
2
3
4
Feedback
Meningitis is the acute inflammation in the membranes of the brain and spinal cord.
However, it may occur in the infant whose mother who has Chlamydia infection. It is
not associated with chronic pelvic inflammatory disorder.
Condyloma acuminata is the clinical manifestation of human papilloma virus infection,
which is associated with a fleshy growth of multiple clusters on the genital area.
The client who has silent PID will have mild salpingitis and will not require any
immediate serious treatment.
The client who has chronic PID will have inflammation of the fallopian tubes, which
causes scars on the fallopian tube. Therefore, the client may have problems during
transportation of the egg.
PTS: 1
CON: Infection
10. ANS: 2
Chapter: Chapter 28, Sexually Transmitted Diseases
Page: 638
Objective: N/A
Difficulty: Easy
Heading: Viral Infections
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Safety and Infection Control
Cognitive Level: Comprehension [Understanding]
Concept: Infection
1
2
Feedback
The HSV affects the epithelium layer during the initial stage of the infection.
The HSV affects the skin and dorsal ganglion where it replicates. Thereafter, the
ganglion enters the sacral spinal nerves and remains dormant for a long time.
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The HSV enters the dorsal ganglion of the sensory nerves from the skin where it
replicates, but it does not remain dormant.
The epithelium layer and dorsal ganglion of the sensory nerves will help the virus
replicate and proliferate. The virus remains dormant only in the sacral spinal nerves.
PTS: 1
CON: Infection
11. ANS: 4
Chapter: Chapter 28, Sexually Transmitted Diseases
Page: 637
Objective: N/A
Difficulty: Moderate
Heading: Viral Infections
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Infection
1
2
3
4
Feedback
Benzathine penicillin is the medication of choice to treat the syphilis infection, but not
to treat condyloma acuminata.
Condyloma acuminata are the multiple clusters of fleshy growths that are caused by
human papillomavirus (HPV). Topical podophyllin is powder made of acidified water
that treats genital warts effectively.
Trichloroacetic acid is composed of salt and esters that helps in the treatment of genital
warts.
Both topical podophyllin and trichloroacetic acid will help medicate the warts and
provide effective treatment for the client.
PTS: 1
CON: Infection
12. ANS: 1
Chapter: Chapter 28, Sexually Transmitted Diseases
Page: 637
Objective: N/A
Difficulty: Moderate
Heading: Viral Infections
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Comprehension [Understanding]
Concept: Infection
1
2
Feedback
Condyloma acuminata is a sexually transmitted disease that results from the infection of
the human papillomavirus (HPV). The viral genome of HPV is detected through a
biopsy.
A Papanicolaou (Pap) smear test helps detect cervical cancer through the analysis of the
cervical cell growth; however, it does not detect the viral genome of the human
papillomavirus (HPV).
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Colposcopy helps determine the presence of cancerous cell in the cervix. However, it
does not determine the viral genome.
The biopsy test helps determine the viral genome.
PTS: 1
CON: Infection
13. ANS: 1
Chapter: Chapter 28, Sexually Transmitted Diseases
Page: 637
Objective: N/A
Difficulty: Easy
Heading: Viral Infections
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Knowledge [Remembering]
Concept: Infection
1
2
3
4
Feedback
A Papanicolaou (Pap) smear test helps examine cervical cells and detect cervical
cancer. The Pap smear test helps determine the presence of precancerous cells or
dysplasia.
The nurse would perform a DNA analysis or biopsy to determine a viral genome
composition.
A Pap smear test does not help identify gummas that are formed in syphilis; serological
tests are used to diagnose syphilis.
The presence of dysplasia or precancerous cells is determined by a Pap smear.
PTS: 1
CON: Infection
14. ANS: 4
Chapter: Chapter 28, Sexually Transmitted Diseases
Page: 639
Objective: N/A
Difficulty: Difficult
Heading: Viral Infections
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Infection
1
2
3
Feedback
A client who is infected with syphilis will have gummas or granulo cells with
macrophages, plasma cells, and T cells; however, these symptoms are not associated in
mild salpingitis or tubal dysfunction.
Condyloma acuminata is a clinical finding that is associated with fleshy growth of
multiple fibers in the genital region; however, it is not associated with mild salpingitis
or tubal dysfunction.
A client who is infected with human papillomavirus (HPV) will have condyloma
acuminata or genital warts.
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A client who has the Chlamydia trachomatis infection will have pelvic inflammatory
disease. The silent type of pelvic inflammatory disease is manifested by mild
salpingitis, which may result in tubal dysfunction that is caused by a delay in the
treatment.
PTS: 1
CON: Infection
15. ANS: 3
Chapter: Chapter 28, Sexually Transmitted Diseases
Page: 632
Objective: N/A
Difficulty: Difficult
Heading: Bacterial Infections
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Infection
1
2
3
4
Feedback
The client who has salpingitis will have scars on the fallopian tubes, which results in
infertility or ectopic pregnancy.
The client who has condyloma acuminata will have genital warts associated with the
human papillomavirus (HPV) infection.
The client who has the Chlamydia trachomatis infection has fibrotic adhesions around
the liver and a tender abdomen, indicating that the client has peritonitis or perihepatitis.
These symptoms are suggestive of Fitz-Hugh-Curtis syndrome.
Fibrotic adhesions around the liver and tender abdomen are findings that would be
present in clients who have Fitz-Hugh-Curtis syndrome.
PTS: 1
CON: Infection
16. ANS: 2
Chapter: Chapter 28, Sexually Transmitted Diseases
Page: 633
Objective: N/A
Difficulty: Easy
Heading: Bacterial Infections
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Safety and Infection Control
Cognitive Level: Comprehension [Understanding]
Concept: Infection
1
2
3
Feedback
Treponema pallidum is a spirochete bacterium that causes the syphilis infection;
however, it is not associated with Reiter’s syndrome.
Reiter’s syndrome, or Reiter’s arthritis, is an autoimmune disorder that is associated
with the gonococcal or Neisseria gonorrhoeae infection.
The Human papilloma virus (HPV) causes the sexually transmitted disease condyloma
acuminata, which manifests as genital warts.
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Chlamydia trachomatis is a gram-negative bacterium that causes pelvic inflammatory
disease, urethritis, or conjunctivitis; however, it is not associated with Reiter’s
syndrome.
PTS: 1
CON: Infection
17. ANS: 1
Chapter: Chapter 28, Sexually Transmitted Diseases
Page: 633
Objective: N/A
Difficulty: Difficult
Heading: Bacterial Infections
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Safety and Infection Control
Cognitive Level: Analysis [Analyzing]
Concept: Infection
1
2
3
4
Feedback
Clients who have Neisseria gonorrhoeae will have dysuria, or loss of urination,
immediately after the infection.
Clients who have Neisseria gonorrhoeae may develop pelvic inflammatory disease,
which is associated with abdominal pain; however, this infection develops in the later
stages.
Clients who have Neisseria gonorrhoeae will have purulent, copious discharge;
however, the discharge would not be the first symptom observed in the client after
infection. It follows dysuria.
Dysuria is the first symptom that would be observed after 2 to 5 days of infection with
the Neisseria gonorrhoeae organism.
PTS: 1
CON: Infection
18. ANS: 1
Chapter: Chapter 28, Sexually Transmitted Diseases
Page: 633
Objective: N/A
Difficulty: Easy
Heading: Bacterial Infections
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Safety and Infection Control
Cognitive Level: Knowledge [Remembering]
Concept: Infection
1
2
3
Feedback
Syphilis is a bacterial infection that is caused by the Treponema pallidum organism. The
syphilis infection has different presentations and can affect all parts of the body;
therefore, it is known as the great imposter.
Chlamydia is a silent infection, as it does not show any evident symptoms; however, it
is not known as the great imposter.
Gonorrhea is caused by the Neisseria gonorrhoeae organism. Its symptoms are evident
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and can result in infertility; therefore, it is not known as the great imposter.
Chlamydia and gonorrhea do not immediately affect all body parts and are, therefore,
not known as the great imposters.
PTS: 1
CON: Infection
19. ANS: 3
Chapter: Chapter 28, Sexually Transmitted Diseases
Page: 638
Objective: N/A
Difficulty: Difficult
Heading: Viral Infections
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Infection
Feedback
1
2
3
4
The herpes simplex viral infection can be transferred through breastmilk from the
mother to the neonate; therefore, the mother should not breastfeed the neonate.
The herpes simplex viral infection may not primarily cause cardiac disorders; therefore,
the nurse can obtain electrocardiogram reports in the neonate after testing for meningitis
in the neonate.
The neonate who is born to a mother who has the herpes simplex viral infection is at an
increased risk of meningitis; therefore, the nurse should assess the magnetic resonance
imaging studies in the neonate immediately to ensure safety.
The nurse can educate the mother about measures to prevent hypothermia in the neonate
after ensuring safety in the neonate.
PTS: 1
CON: Infection
20. ANS: 3
Chapter: Chapter 28, Sexually Transmitted Diseases
Page: 638
Objective: N/A
Difficulty: Moderate
Heading: Viral Infections
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Infection
1
2
3
Feedback
Administering the medication once a day either before or after dinner can cause drug
insufficiency in clients.
Administering the medication with some water once a day can cause drug insufficiency
in clients.
Antiviral medications, such as acyclovir (Zovirax), should be administered three times
a day for 7 to 10 days to reduce the symptoms of the herpes simplex viral infection
PRIMEXAM.COM
4
effectively in the client.
Administering the antiviral medication three times a day for 15 to 20 days can cause an
overdose toxicity of the medication in clients.
PTS: 1
CON: Infection
21. ANS: 1
Chapter: Chapter 28, Sexually Transmitted Diseases
Page: 637
Objective: N/A
Difficulty: Moderate
Heading: Viral Infections
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Infection
1
2
3
4
Feedback
The neonate who is born to the mother with extensive genital warts is at an increased
risk of the human papillomavirus (HPV) infection in the pharynx; therefore, the nurse
should examine the neonate’s pharynx to assess the risk of infection in the neonate.
HPV can be found in breast milk; therefore, the nurse should not instruct the mother to
breastfeed the neonate.
Kangaroo care can maintain thermoregulation in the neonate, but it does not reduce the
risk of HPV infection in the neonate.
Administering vitamin D and iron supplements can prevent rickets and anemia in the
neonate.
PTS: 1
CON: Infection
22. ANS: 1
Chapter: Chapter 28, Sexually Transmitted Diseases
Page: 639
Objective: N/A
Difficulty: Difficult
Heading: Viral Infections
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Infection
1
2
3
Feedback
HPV infection does not present in the fallopian tubes; therefore, this infection does not
pose a risk to infertility problems in the client.
The Chlamydia infection progresses in a silent and unrecognized manner; therefore, it
results in delayed treatment, which leads to fallopian tubular dysfunction and infertility
in the client.
Gonorrheal infections can cause cervicitis, proctitis, urethritis, and infertility in the
client.
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4
Pelvic inflammatory disease is mostly caused by Neisseria gonorrhoeae and
Chlamydia trachomatis organisms. These organisms ascend upward from the vagina
into the reproductive parts, such as the uterus, fallopian tubes, and ovaries; therefore,
and can cause infertility in the client.
PTS: 1
CON: Infection
MULTIPLE RESPONSE
23. ANS: 1, 2
Chapter: Chapter 28, Sexually Transmitted Diseases
Page: 633
Objective: N/A
Difficulty: Easy
Heading: Bacterial Infections
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Safety and Infection Control
Cognitive Level: Knowledge [Remembering]
Concept: Infection
1.
2.
3.
4.
5.
Feedback
This is correct. Sepsis is an inflammation that is associated with infection. The client who
has sepsis may develop rhinitis, which is the inflammation of the mucous membrane
around the nose.
This is correct. Meningitis is the inflammation of the membranes surrounding the brain and
the spinal cord. The client who has sepsis may develop meningitis.
This is incorrect. The client who has sepsis will have poor organ function, which may
result in a low urine output, or dysuria, but not polyuria.
This is incorrect. The client who has sepsis will have low blood flow, which results in
hypotension, but not hypertension.
This is incorrect. Sepsis can result in multiple organ dysfunction syndrome (MODSq) and
respiratory acidosis, which can cause respiratory failure.
PTS: 1
CON: Infection
24. ANS: 1, 2, 4
Chapter: Chapter 28, Sexually Transmitted Diseases
Page: 640
Objective: N/A
Difficulty: Easy
Heading: Box 28-3, Diagnosing Pelvic Inflammatory Disease
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Comprehension [Understanding]
Concept: Infection
Feedback
PRIMEXAM.COM
1.
2.
3.
4.
5.
This is correct. Pelvic inflammatory disease (PID) is a sexually transmitted disease that
results from the Neisseria gonorrhoeae organism. The client who has this disease will have
increased body temperature, resulting in a high oral temperature of 101oF.
This is correct. The client who is infected with Neisseria gonorrhoeae will have increased
C-reactive protein levels in response to the increased inflammation in the body.
This is incorrect. The client who has PID will have a high erythrocyte sedimentation rate
(ESR), as the blood cells proliferate during the infection.
This is correct. The client who is infected with Neisseria gonorrhoeae will have increased
white blood cells in response to the inflammation of the cells; therefore, white blood cells
would be present in the vaginal secretions.
This is incorrect. Hyponatremia, or low sodium levels, are not a finding in PID.
PTS: 1
CON: Infection
25. ANS: 1, 2, 3
Chapter: Chapter 28, Sexually Transmitted Diseases
Page: 634
Objective: N/A
Difficulty: Easy
Heading: Pathophysiology of Sexually Transmitted Diseases
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Infection
1.
2.
3.
4.
5.
Feedback
This is correct. Paresis is the partial loss of involuntary movements in the body caused by
the progression of the syphilis infection to the brain and spinal cord.
This is correct. Extension of the syphilis infection to the nervous system leads to dementia
in the client.
This is correct. Meningitis is the inflammation of the meningeal layers of the brain and is
caused by neurosyphilis.
This is incorrect. An aortic aneurysm is associated with cardiac disorders, not neurological
disorders.
This is incorrect. Aortic valve deformity is associated with cardiac disorders, not
neurological disorders.
PTS: 1
CON: Infection
PRIMEXAM.COM
Chapter 29: Disorders of the Esophagus, Stomach, and Small Intestine
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. The nurse is caring for a client who is due for a laparoscopic fundoplication. On reviewing the medical
history, the nurse notes the client complains of dysphagia, substernal burning, and belching. The endoscopy
and barium test reports are yet to be received. Which condition can the nurse expect in the client?
1. Hiatal hernia
2. Gastritis
3. Stomach cancer
4. Schatzki ring
2. The nurse concludes that an obese client is suffering from a rare type of hernia. Which finding confirmed the
condition?
1. Belching
2. Acute chest pain
3. Substernal burning
4. Epigastric discomfort
3. The nurse is assessing a client with complaints of nausea, vomiting, abdominal pain, and discomfort. The
nurse finds that the abdomen is firm and peristalsis is visible. The laboratory reports show electrolyte
imbalances. Which condition does the nurse anticipate in the client?
1. Hiatal hernia
2. Acute gastritis
3. Pyloric stenosis
4. Peptic ulcer disease
4. Which part of the stomach most commonly harbors Helicobacter pylori (H. pylori)?
1. Body
2. Fundus
3. Pylorus
4. Duodenum
5. The nurse finds a note stating “Reduction in 15% to 20% from the original stomach size” while reviewing the
medical record of an obese client. Which surgical procedure can the nurse expect for this client?
1. Gastric bypass
2. Gastric banding
3. Sleeve gastrectomy
4. Biliopancreatic diversion with duodenal switch
6. A client with sudden, excruciating abdominal pain, pale skin, and hematemesis is admitted to the emergency
room. On assessment, the client states that he had an overdose of NSAIDs and has a history of substance
abuse. The primary health-care provider instructs the nurse to prepare the client for a gastrojejunostomy
procedure. Which condition can the nurse expect in the client?
1. Hiatal hernia
2. Acute gastritis
3. Pyloric stenosis
4. Peptic ulcer disease
PRIMEXAM.COM
7. Which diagnostic test screens H. pylori in a client with peptic ulcer disease?
1. Urea breath test
2. Stool antigen test
3. Blood test for antibodies
4. All of the above
8. The primary health-care provider instructs the client with symptoms of peptic ulcer to take a fasting serum
gastrin level test and have an MRI scan done. On reviewing the laboratory reports, the nurse finds
hypergastrinemia and a tumor. The PHP instructs the nurse to administer proton pump inhibitors. Which
condition can the nurse expect?
1. Dumping syndrome
2. Mallory-Weiss syndrome
3. Zollinger-Ellison syndrome
4. Plummer-Vinson syndrome
9. Which gastrointestinal disorder occurs due to removal of part of the stomach?
1. Dumping syndrome
2. Mallory-Weiss syndrome
3. Zollinger-Ellison syndrome
4. Plummer-Vinson syndrome
10. Which is the most common etiologic agent of gastroenteritis in adults?
1. Norovirus
2. Escherichia coli (E.coli)
3. Candida albicans
4. Helicobacter pylori (H. pylori)
11. Which statement correctly describes the mechanism of inflammatory diarrhea?
1. It occurs as a result of intestinal neuromuscular disorders.
2. It occurs if the pathogen stimulates the intestine to secrete fluid and mucus.
3. It occurs if the mucosal lining of the intestine is injured.
4. It occurs because of an increase in the osmotic load.
12. A client tells the nurse, “I have had abdominal pain, bloating, visual disturbances, and bone pain for the last 3
to 6 months.” On assessment, the nurse finds excessive weight loss and suspects an autoimmune
hypersensitivity disorder. Which diagnostic test does the primary health-care provider recommend for further
confirmation?
1. Abdominal CT scan
2. Ultrasound abdomen
3. Serology celiac panel
4. Barium contrast x-ray series
13. Which therapeutic procedure treats peritonitis?
1. Upper endoscopy
2. Laparotomy
3. Paracentesis
4. Peritoneal lavage
14. Which is the characteristic feature of dumping syndrome?
1. Steatorrhea
2. Diaphoresis
PRIMEXAM.COM
3. Colicky cramping
4. Hematemesis
15. A client is admitted into the emergency room with vomiting blood, dark urine, and black, tarry feces. On
examination, the nurse finds that the client has weight loss and a distended abdomen. Which condition does
the nurse expect in the client?
1. Hiatal hernia
2. Acute gastritis
3. Pyloric stenosis
4. Esophageal varices
16. A client tells the nurse, “I have intense stomach pain for 3 hours after eating.” On assessment the nurse finds
abdominal pain and tenderness of the abdomen. The nurse suspects duodenal ulcers in the client. Which
diagnostic procedure does the primary health-care provider recommend?
1. Ultrasound
2. Urea breath test
3. Fecal occult blood test
4. Computed tomography (CT) scan
17. On assessing a client with a gastrointestinal disorder, the nurse finds steatorrhea, abdominal distension, and
muscle wasting. The primary health-care provider prescribes corticosteroid therapy for the client. Which
instructions does the nurse provide to effectively manage the condition?
1. Reduce alcohol ingestion
2. Reduce coffee consumption
3. Avoid fiber-containing foods
4. Avoid gluten-containing foods
NARRBEGIN: Exhibit
Exhibit
NARREND
18. The nurse is caring for four clients in the health-care setting suspected with different gastrointestinal
disorders.
Client
Client 1
Client 2
Client 3
Client 4
Condition
Peritonitis
Celiac disease
Gastroenteritis
Zollinger-Ellison syndrome
Which client should be ordered a tissue biopsy test for further confirmation of the disease?
1. Client 1
2. Client 2
3. Client 3
4. Client 4
19. The nurse is providing care for four clients diagnosed with different gastrointestinal disorders.
Client
Condition
PRIMEXAM.COM
Client 1
Client 2
Client 3
Client 4
Esophagitis
Esophageal cancer
Dumping syndrome
Upper gastrointestinal bleed (UGIB)
Which client does the nurse instruct to avoid eating or drinking food items that are hot or spicy?
1. Client 1
2. Client 2
3. Client 3
4. Client 4
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
20. Which pathophysiological changes are responsible for pain in a client with acute gastritis? Select all that
apply.
1. Atrophy of the gastric wall
2. Eradication of prostaglandins by medications
3. Increased blood supply at the inflammatory area
4. Increased pressure within the layers of the stomach
5. Accumulation of white blood cells at the inflammatory area
21. The laboratory reports of a client with gastritis reveal H. pylori is the causative organism. Which
pathophysiological changes can result from this infection? Select all that apply.
1. Decreased production of pepsin
2. Increased production of gastrin
3. Increased production of intrinsic factor
4. Increased production of prostaglandins
5. Decreased production of HCl acid
22. The client complains of nausea, vomiting, abdominal cramping, and diarrhea. On assessment, the nurse finds
high-pitched bowel sounds. Which nursing interventions will help the client improve her condition? Select all
that apply.
1. Administer antibiotics
2. Administer intravenous fluids
3. Administer frequent, small tube feedings
4. Administer antiemetic medications
5. Administer nonsteroidal anti-inflammatory drugs
23. The primary health-care provider suspects esophageal variceal bleeding in a client and orders an ultrasound
test. The client’s condition is further confirmed by endoscopy and via insertion of a Sengstaken-Blakemore
tube. Which medications would benefit the client to control bleeding? Select all that apply.
1. Octreotide
2. Propranolol
3. Vasopressin
4. Somatostatin
5. Isosorbide mononitrate
PRIMEXAM.COM
24. The caregiver of a client tells the nurse, “My child complains of a burning sensation in the throat and refuses
to eat foods.” On assessment, the nurse finds that the client also has a dry cough. Which interventions does
the nurse implement while caring for the client? Select all that apply.
1. Elevates the client’s head at an angle of 70°
2. Provides small, frequent meals to the client
3. Administers proton pump inhibitors to the client
4. Prepares the client for fluid electrolyte replacement
5. Provides fluids to the client after adding thickening powder
25. The nurse finds that a client coughs frequently while eating and makes repeated attempts to swallow. Based
on these findings, the health care team suspects dysphagia in the client. Which other findings indicate that the
client is also at risk for aspiration pneumonia? Select all that apply.
1. Elevated temperature
2. Hyperactive bowel sounds
3. Deviated tongue and uvula
4. Drooling of food or liquids
5. Auscultation of crackles in the lungs
PRIMEXAM.COM
Chapter 29: Disorders of the Esophagus, Stomach, and Small Intestine
Answer Section
MULTIPLE CHOICE
1. ANS: 1
Chapter: Chapter 29, Disorders of the Esophagus, Stomach, and Small Intestine
Page: 658-659
Objective: N/A
Difficulty: Difficult
Heading: Hiatal Hernia
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Evaluation [Evaluating]
Concept: Digestion; Bowel Elimination
Feedback
1
2
3
4
Hiatal hernia is a structural problem, described as part of the stomach protruding into
the thoracic cavity through an opening in the diaphragm. Laparoscopic fundoplication
is the surgical repair for a hernia when symptoms such as dysphagia and substernal
burning do not respond to other treatments.
Gastritis is the inflammation of the lining of the stomach. Itis usually treated with
antibiotics and antacids, but does not require surgical repair.
Stomach cancer is a rare type of neoplastic condition. Itis treated with chemotherapy,
radiation therapy, and surgical therapy.
A Schatzki ring is a constrictive muscular band of esophageal tissue characterized by
difficulty in swallowing. It is often treated with medications and rehabilitation
measures, but does not require surgical repair.
PTS: 1
CON: Digestion; Bowel Elimination
2. ANS: 2
Chapter: Chapter 29, Disorders of the Esophagus, Stomach, and Small Intestine
Page: 658
Objective: N/A
Difficulty: Moderate
Heading: Hiatal Hernia
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Bowel Elimination; Comfort
Feedback
1
2
Belching is the act of expelling air from the stomach through the mouth. This is a
manifestation of GERD, which is not associated with a rare type of hernia.
Acute chest pain is a characteristic feature of a paraesophageal hernia, which is a rare
PRIMEXAM.COM
3
4
type of hernia. The pain occurs due to strangulation of the hernia.
Substernal burning is a characteristic feature of a sliding hernia, which is more
common.
Epigastric discomfort is a symptom of GERD that is associated with a sliding hernia but
not with a paraesophageal hernia.
PTS: 1
CON: Bowel Elimination; Comfort
3. ANS: 3
Chapter: Chapter 29, Disorders of the Esophagus, Stomach, and Small Intestine
Page: 659
Objective: N/A
Difficulty: Difficult
Heading: Disorders of the Stomach
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Bowel Elimination; Comfort; Fluid and Electrolyte Balance
Feedback
1
2
3
4
A hiatal hernia is described as part of the stomach protruding into the thoracic cavity
through an opening in the diaphragm. It is characterized by dysphagia, substernal
burning, and belching.
Acute gastritis is also called erosive gastritis. It is an inflammation of the lining of the
stomach characterized by heartburn, nausea, and epigastric pain.
Pyloric stenosis is defined as constriction of the pyloric sphincter, characterized by
abdominal pain and distention due to accumulation of fluids. Nausea and vomiting are
common symptoms. Electrolyte disturbances are due to vomiting. On palpation of the
abdomen, the nurse finds firm and visible peristalsis due to decreased emptying.
Peptic ulcer disease is described as inflammatory erosion in the lining of the stomach,
and duodenum characterized by epigastric and abdominal pain.
PTS: 1
CON: Bowel Elimination; Comfort; Fluid and Electrolyte Balance
4. ANS: 2
Chapter: Chapter 29, Disorders of the Esophagus, Stomach, and Small Intestine
Page: 659
Objective: N/A
Difficulty: Easy
Heading: Disorders of the Stomach
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Basic Care and Comfort
Cognitive Level: Knowledge [Remembering]
Concept: Bowel Elimination; Infection; Inflammation
Feedback
1
The body is the center and largest part of the stomach. It does not harbor the H. pylori
bacterium.
PRIMEXAM.COM
2
3
4
The fundus is the uppermost portion of the stomach. Usually, the fundus harbors the H.
pylori bacterium, which is the most common cause of chronic gastritis.
The pylorus is the lower portion of stomach that connects to the duodenum. It does not
harbor the H. pylori bacterium.
The duodenum is the first segment of the small intestine. This is not part of the stomach
and it usually does not harbor H. pylori bacterium.
PTS: 1
CON: Bowel Elimination; Infection; Inflammation
5. ANS: 3
Chapter: Chapter 29, Disorders of the Esophagus, Stomach, and Small Intestine
Page: 662
Objective: N/A
Difficulty: Moderate
Heading: Disorders of the Stomach
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Nutrition; Perioperative
Feedback
1
2
3
4
Gastric bypass is a type of surgery to reduce weight that involves bypassing the whole
duodenum and part of the jejunum.
Gastric banding is a surgery that is performed to reduce weight by placing an inflatable
band around part of the stomach.
Sleeve gastrectomy involves subtotal gastrectomy, in which the stomach size is reduced
to about 15% to 20% of its original size.
Biliopancreatic diversion with duodenal switch involves a 75% gastrectomy that makes
a tubular stomach.
PTS: 1
CON: Nutrition; Perioperative
6. ANS: 4
Chapter: Chapter 29, Disorders of the Esophagus, Stomach, and Small Intestine
Page: 660-661
Objective: N/A
Difficulty: Difficult
Heading: Disorders of the Stomach
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Evaluation [Evaluating]
Concept: Comfort; Digestion; Perioperative; Addiction
Feedback
1
2
Hiatal hernia is characterized by dysphagia, substernal burning, belching, and epigastric
discomfort. Laparoscopic fundoplication is the surgical procedure used to reduce reflux.
Acute gastritis is characterized by heartburn, nausea, and epigastric pain. Surgical
management is very rare and treatment is focused on the cause of injury.
PRIMEXAM.COM
3
4
Pyloric stenosis is characterized by abdominal pain, distension, nausea, and vomiting.
Surgical repair is done to relieve obstruction but not the gastrojejunostomy.
Peptic ulcer disease is characterized by sudden, excruciating abdominal pain, pale skin,
and hematemesis. A gastrojejunostomy is done, which involves the removal of the
lower portion of the stomach and the remaining portion is connected to the jejunum to
reduce ulcer-producing properties.
PTS: 1
CON: Comfort; Digestion; Perioperative; Addiction
7. ANS: 4
Chapter: Chapter 29, Disorders of the Esophagus, Stomach, and Small Intestine
Page: 651
Objective: N/A
Difficulty: Easy
Heading: Disorders of the Stomach
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Comprehension [Understanding]
Concept: Comfort; Digestion; Infection; Perioperative
Feedback
1
2
3
4
A urea breath test is highly accurate in detecting H. pylori. The client swallows urea,
and after sometime the detection of radioactive carbon dioxide in the client’s exhaled
breath indicates that the urea is split.
A stool antigen test is done to detect the presence of H. pylori bacteria.
A blood sample is collected and tested for the presence of antibodies to H. pylori. It is
the most common method of diagnosis.
The tests mentioned above all are used for screening the presence of an H. pylori
infection.
PTS: 1
CON: Comfort; Digestion; Infection; Perioperative
8. ANS: 3
Chapter: Chapter 29, Disorders of the Esophagus, Stomach, and Small Intestine
Page: 661
Objective: N/A
Difficulty: Difficult
Heading: Zollinger-Ellison Syndrome
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Evaluation [Evaluating]
Concept: Comfort; Digestion; Infection; Cellular Regulation
Feedback
1
2
Dumping syndrome is characterized by epigastric fullness, syncope, palpitations, and
hypoglycemia. This does not interfere with gastrin production.
Mallory-Weiss syndrome is characterized by frequent, forceful bouts of vomiting due to
a vertical tear in the lower esophagus. It does not produce tumors.
PRIMEXAM.COM
3
4
Zollinger-Ellison syndrome is characterized by severe symptoms of a peptic ulcer.
Proton pump inhibitors are used to inhibit the activity of parietal cells and neutralize
HCl acid.
Plummer-Vinson syndrome is characterized by trouble swallowing due to congenital or
acquired webs of tissue in the upper esophagus. It is not related to peptic ulcer disease.
PTS: 1
CON: Comfort; Digestion; Infection; Cellular Regulation
9. ANS: 1
Chapter: Chapter 29, Disorders of the Esophagus, Stomach, and Small Intestine
Page: 663
Objective: N/A
Difficulty: Easy
Heading: Dumping Syndrome
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Comprehension [Understanding]
Concept: Comfort; Bowel Elimination; Perfusion
Feedback
1
2
3
4
Dumping syndrome is the gastrointestinal disorder that occurs due to the removal of
part of the stomach. It is characterized by epigastric fullness, syncope, palpitations, and
hypoglycemia.
Mallory-Weiss syndrome is a complication seen in clients with bulimia nervosa
disorder due to forceful vomiting.
Zollinger-Ellison syndrome is a rare complication that occurs following a gastric or
duodenal ulcer. It is caused by a gastrin-secreting tumor.
Plummer-Vinson syndrome is seen in clients with trouble swallowing due to congenital
or acquired webs of tissue in the upper esophagus.
PTS: 1
CON: Comfort; Bowel Elimination; Perfusion
10. ANS: 1
Chapter: Chapter 29, Disorders of the Esophagus, Stomach, and Small Intestine
Page: 664
Objective: N/A
Difficulty: Easy
Heading: Gastroenteritis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Safety and Infection Control
Cognitive Level: Knowledge [Remembering]
Concept: Bowel Elimination; Comfort; Infection; Inflammation
Feedback
1
2
Norovirus is highly contagious and transmitted through a fecal-oral route. This is the
most common etiological agent of gastroenteritis.
E. coli is also one of the bacterial organisms that cause gastroenteritis. This is not as
common as norovirus.
PRIMEXAM.COM
3
4
Candida albicans is the most common causative agent of esophagitis but not
gastroenteritis.
Helicobacter pylori (H. pylori) is the common causative agent of gastric and duodenal
ulcers, and acute and chronic gastritis.
PTS: 1
CON: Bowel Elimination; Comfort; Infection; Inflammation
11. ANS: 3
Chapter: Chapter 29, Disorders of the Esophagus, Stomach, and Small Intestine
Page: 665
Objective: N/A
Difficulty: Easy
Heading: Gastroenteritis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Knowledge [Remembering]
Concept: Bowel Elimination; Comfort; Infection; Inflammation
Feedback
1
2
3
4
Motility diarrhea occurs due to intestinal neuromuscular disorders.
Secretory diarrhea is described as an organism or pathogen that stimulates the intestine
to secrete fluid and mucus.
Inflammatory diarrhea occurs when the mucosal lining of the intestine is injured, or in
the case of edematous, which results in poor absorption of fluids or nutrients.
Osmotic diarrhea occurs when an increase in osmotic load is presented to the intestinal
lumen due to decreased absorption.
PTS: 1
CON: Bowel Elimination; Comfort; Infection; Inflammation
12. ANS: 3
Chapter: Chapter 29, Disorders of the Esophagus, Stomach, and Small Intestine
Page: 666
Objective: N/A
Difficulty: Difficult
Heading: Disorders of the Small Intestine
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Evaluation [Evaluating]
Concept: Comfort; Digestion; Immunity
Feedback
1
2
3
An abdominal CT scan is used for the visualization and measurement of abdominal
organs. This test does not determine the immune reaction.
An ultrasound of the abdomen is used to check ailments of the major abdominal organs.
It does not find the cause of bone pain or excessive weight loss.
A serology celiac panel is used to determine an immune reaction to gluten, which
confirms the diagnosis of celiac disease. Celiac disease is an autoimmune disorder that
occurs from a hypersensitive reaction to gluten.
PRIMEXAM.COM
4
A barium contrast x-ray series is used as a definitive test for short bowel syndrome.
This does not find hypersensitivity reactions or the presence of antibodies.
PTS: 1
CON: Comfort; Digestion; Immunity
13. ANS: 4
Chapter: Chapter 29, Disorders of the Esophagus, Stomach, and Small Intestine
Page: 668-669
Objective: N/A
Difficulty: Easy
Heading: Disorders of the Small Intestine
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Knowledge [Remembering]
Concept: Bowel Elimination; Comfort; Infection; Inflammation
Feedback
1
2
3
4
Endoscopy is a diagnostic procedure used to examine a client’s digestive tract, but it is
not a therapeutic procedure.
Laparotomy is a surgical incision through the abdomen during emergency situations for
the diagnosis of peritonitis. It is not a therapeutic procedure.
Paracentesis is a procedure used to aspirate peritoneal fluid for diagnosing the
condition. It is not a therapeutic procedure.
Peritoneal lavage is a therapeutic procedure that involves sterile cleaning of the
peritoneum.
PTS: 1
CON: Bowel Elimination; Comfort; Infection; Inflammation
14. ANS: 2
Chapter: Chapter 29, Disorders of the Esophagus, Stomach, and Small Intestine
Page: 663
Objective: N/A
Difficulty: Easy
Heading: Disorders of the Stomach
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Knowledge [Remembering]
Concept: Fluid and Electrolyte Balance; Metabolism
Feedback
1
2
3
4
Steatorrhea is the presence of excessive fats in the feces, which is a characteristic
feature in celiac disease.
Diaphoresis is the excessive production of fluids secreted by sweat glands in the skin. It
is a characteristic feature in clients with dumping syndrome.
Colicky pain is a sharp, localized abdominal pain in paroxysms. It is a characteristic
feature in clients with gastroenteritis.
Hematemesis is the characteristic physical feature of chronic gastritis but not dumping
syndrome.
PRIMEXAM.COM
PTS: 1
CON: Fluid and Electrolyte Balance; Metabolism
15. ANS: 4
Chapter: Chapter 29, Disorders of the Esophagus, Stomach, and Small Intestine
Page: 656
Objective: N/A
Difficulty: Difficult
Heading: Disorders of the Esophagus
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Bowel Elimination; Digestion; Fluid and Electrolyte Balance
Feedback
1
2
3
4
Hiatal hernia is described as part of the stomach protruding into the thoracic cavity
through an opening in the diaphragm. The symptoms associated with this condition
include dysphagia, substernal burning, and belching.
Acute gastritis is also called erosive gastritis. It is an inflammation of the stomach
lining. The clinical manifestations of this condition include heartburn, nausea, and
epigastric pain.
Pyloric stenosis is defined as constriction of the pyloric sphincter. The symptoms
associated with this condition include abdominal pain and distention due to
accumulation of fluids.
A client with esophageal varices presents with symptoms of cirrhosis of the liver, such
as dark urine, weight loss, and a distended abdomen. The primary clinical symptoms
associated with this condition include hematemesis and melena. Hematemesis is the
vomiting of the blood. Melena is the presence of black, tarry feces.
PTS: 1
CON: Bowel Elimination; Digestion; Fluid and Electrolyte Balance
16. ANS: 2
Chapter: Chapter 29, Disorders of the Esophagus, Stomach, and Small Intestine
Page: 672
Objective: N/A
Difficulty: Difficult
Heading: Disorders of the Stomach
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Evaluation [Evaluating]
Concept: Bowel Elimination; Digestion; Critical Thinking
Feedback
1
2
Ultrasound does not help in the detection of H. pylori in the stomach. Therefore, the
primary health-care provider will not order an ultrasound test for further confirmation.
Symptoms such as pain in the stomach for two to three hours after eating and
assessment findings such as abdominal pain and tenderness indicate the presence of
duodenal ulcers. A positive urea breath test indicates the presence of H. pylori in the
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4
stomach. Therefore, the primary health-care provider will order a urea breath test for
further confirmation.
Hematemesis and melena are not the clinical manifestations associated with duodenal
ulcers. Therefore, the primary health-care provider will not order a fecal occult blood
test for further confirmation.
A CT scan does not help in the detection of H. pylori in the stomach. Therefore, the
primary health-care provider will not order a CT scan for further confirmation.
PTS: 1
CON: Bowel Elimination; Digestion; Critical Thinking
17. ANS: 4
Chapter: Chapter 29, Disorders of the Esophagus, Stomach, and Small Intestine
Page: 665-666
Objective: N/A
Difficulty: Difficult
Heading: Disorders of the Small Intestine
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Bowel Elimination; Digestion; Critical Thinking; Nursing Roles
1
2
3
4
Feedback
The client’s condition is not aggravated by lifestyle changes such as alcohol ingestion.
Therefore, the nurse will not instruct the client to reduce alcohol ingestion.
The client’s condition is not aggravated by lifestyle changes such as intake of caffeine.
Therefore, the nurse will not instruct the client to reduce coffee consumption.
The client’s condition is not aggravated by consumption of fiber-containing foods.
Therefore, the nurse will not instruct the client to avoid foods rich in fiber.
Symptoms such as steatorrhea, abdominal distension, and muscle wasting indicate
celiac disease. A client with this condition will have effective treatment with
corticosteroid therapy. The client’s condition is aggravated in the presence of gluten
foods. Therefore, the nurse will instruct the client to avoid gluten-containing foods for
effective management of the condition.
PTS: 1
CON: Bowel Elimination; Digestion; Critical Thinking; Nursing Roles
18. ANS: 2
Chapter: Chapter 29, Disorders of the Esophagus, Stomach, and Small Intestine
Page: 673-674
Objective: N/A
Difficulty: Difficult
Heading: Disorders of the Small Intestine
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Evaluation [Evaluating]
Concept: Bowel Elimination; Digestion; Critical Thinking
Feedback
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1
2
3
4
19.
Client 1 with peritonitis is ordered a computed tomography scan to find the source of
peritoneal inflammation, such as a ruptured organ.
Client 2 with celiac disease is ordered a tissue biopsy test to confirm the diagnosis of
celiac disease.
Client 3 with gastroenteritis is ordered a complete blood test to determine a decrease in
albumin levels.
Client 4 with Zollinger-Ellison syndrome is ordered a fasting serum blood test to
determine if there is excessive gastrin.
PTS: 1
ANS: 1
Chapter: Chapter 29, Disorders of the Esophagus, Stomach, and Small Intestine
Page: 670
Objective: N/A
Difficulty: Difficult
Heading: Disorders of the Esophagus
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Evaluation [Evaluating]
Concept: Bowel Elimination; Inflammation; Critical Thinking
1
2
3
4
Feedback
Esophagitis is the inflammation of the esophagus due to reflux of gastric acid.
Therefore, the nurse instructs client 1 with esophagitis to avoid eating or drinking items
that have an extreme temperature or spices to prevent reflux of gastric acid.
Esophageal cancer is the neoplastic cellular replication of esophageal cells. It is not
associated with the reflux of gastric acid. Therefore, the nurse will not instruct client 2
with esophageal cancer to avoid eating or drinking items that have an extreme
temperature or spices but instead educates the client about proper nutrition.
Dumping syndrome is rapid gastric emptying due to removal of part of the stomach. It
is not associated with the reflux of gastric acid. Therefore, the nurse will not instruct
client 3 with dumping syndrome to avoid eating or drinking items that have an extreme
temperature or spices but instead instructs the client to take fluids only between meals.
UGIB is an area in the esophagus, stomach, or duodenum that is bleeding in small,
moderate, or large amounts. This condition requires blood transfusions or rapid IV
infusions.
PTS: 1
CON: Bowel Elimination; Inflammation; Critical Thinking
MULTIPLE RESPONSE
20. ANS: 2, 3, 4
Chapter: Chapter 29, Disorders of the Esophagus, Stomach, and Small Intestine
Page: 659
Objective: N/A
Difficulty: Difficult
Heading: Disorders of the Stomach
PRIMEXAM.COM
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Comfort; Digestion; Infection; Inflammation
1.
2.
3.
4.
5.
Feedback
This is incorrect. Atrophy of the gastric wall is a clinical symptom of chronic gastritis due
to complete loss of gastric epithelium.
This is correct. Medications such as NSAIDs inhibit prostaglandin production and decrease
the production of gastric mucus. Pain is produced due to an impaired protection and
decreased production of gastric mucus.
This is correct. The increased blood supply at the inflammatory area results in edema of the
mucosal layer that results in increased pressure and causes pain.
This is correct. The erosion of the inner mucosal layer results in increased pressure on the
middle muscle layer and outer serous coat that result in severe pain.
This is incorrect. Accumulation of white blood cells at an inflammatory area is the first
response to inflammation that results in edema.
PTS: 1
CON: Comfort; Digestion; Infection; Inflammation
21. ANS: 1, 2, 5
Chapter: Chapter 29, Disorders of the Esophagus, Stomach, and Small Intestine
Page: 659
Objective: N/A
Difficulty: Difficult
Heading: Disorders of the Stomach
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Comfort; Digestion; Infection; Inflammation
1.
2.
3.
4.
5.
Feedback
This is correct. The production of pepsin is decreased during H. pylori infection due to the
death of chief cells and parietal cells in the gastric mucosa.
This is correct. The gastrin production is increased to increase acid production when HCl
levels are very low in the body.
This is incorrect. The death of chief cells and parietal cells decreases the production of
intrinsic factor rather than increases it.
This is incorrect. Prostaglandins are increased at the inflammatory area caused by a
number of medications or factors.
This is correct. The death of chief cells and parietal cells decreases the production of HCl
acid in a client with H. pylori infection.
PTS: 1
CON: Comfort; Digestion; Infection; Inflammation
22. ANS: 1, 2, 4
Chapter: Chapter 29, Disorders of the Esophagus, Stomach, and Small Intestine
Page: 665
Objective: N/A
PRIMEXAM.COM
Difficulty: Difficult
Heading: Disorders of the Small Intestine
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Evaluation [Evaluating]
Concept: Comfort; Bowel Elimination; Infection; Inflammation
1.
2.
3.
4.
5.
Feedback
This is correct. The nurse administers antibiotics as ordered after identifying the cause of
gastroenteritis is bacterial.
This is correct. The nurse administers intravenous fluids to replace fluids lost through
vomiting and diarrhea.
This is incorrect. The nurse can allow oral fluids as there are no complications. There is no
need of recurrent small tube feeding. Rather, the nurse can encourage the client intake of
small, regular oral feeds.
This is correct. The nurse administers antiemetic medications to control vomiting and
antidiarrheal medications to reduce diarrhea.
This is incorrect. The nurse should not administer NSAIDs as they are indicated for pain
and fever but not for vomiting and diarrhea.
PTS: 1
CON: Comfort; Bowel Elimination; Infection; Inflammation
23. ANS: 1, 3, 4
Chapter: Chapter 29, Disorders of the Esophagus, Stomach, and Small Intestine
Page: 656-657
Objective: N/A
Difficulty: Difficult
Heading: Disorders of the Esophagus
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Digestion; Medication
1.
2.
3.
4.
5.
Feedback
This is correct. Ultrasound is used to diagnose portal hypotension in cases of esophageal
varices and diagnosis is confirmed with endoscopy. The treatment focuses on prevention of
rupture and control of bleeding. Therefore, vasoconstrictors such as octreotide will be
beneficial to the client to control bleeding.
This is incorrect. Vasopressin raises blood pressure by narrowing blood vessels. It is a
vasoconstrictor that helps in the control of bleeding due to a rupture of esophageal
membranes.
This is correct. Propranolol is an adrenergic beta blocker agent. It decreases blood pressure
and thereby reduces portal hypotension.
This is correct. Somatostatin suppresses secretion of gastric hormones and lowers the rate
of gastric emptying. It reduces smooth muscle contraction and blood flow in the small
intestine, therefore, it helps to control bleeding.
This is incorrect. Isosorbide mononitrate decreases blood pressure by dilating blood
vessels. Therefore, it reduces portal hypotension associated with esophageal varices.
PRIMEXAM.COM
PTS: 1
CON: Digestion; Medication
24. ANS: 1, 2, 3
Chapter: Chapter 29, Disorders of the Esophagus, Stomach, and Small Intestine
Page: 658-659
Objective: N/A
Difficulty: Difficult
Heading: Disorders of the Esophagus
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Evaluation [Evaluating]
Concept: Digestion; Bowel Elimination
1.
2.
3.
4.
5.
Feedback
This is correct. Symptoms such as a burning sensation in the throat and dry cough are
associated with gastroesophageal reflux disease (GERD).The nurse elevates the client’s
head to an angle greater than 60° while eating to allow easy swallowing.
This is correct. As the client has a burning sensation, the nurse provides small, frequent
meals to the client to meet the energy demands of the client.
This is correct. Proton pump inhibitors decrease secretion of acid from the stomach and
reduce a burning sensation. Therefore, the nurse will also administer proton pump
inhibitors while caring for the client.
This is incorrect. Nausea and vomiting are the symptoms that cause dehydration. As GERD
does not cause these symptoms, the client will not have an electrolyte imbalance.
Therefore, the nurse will not prepare the client for fluid electrolyte replacement.
This is incorrect. A client with GERD does not make any repeated attempts to swallow.
Therefore, the nurse will not provide fluids to the client after adding thickening powder.
PTS: 1
CON: Digestion; Bowel Elimination
25. ANS: 1, 5
Chapter: Chapter 29, Disorders of the Esophagus, Stomach, and Small Intestine
Page: 669-670
Objective: N/A
Difficulty: Difficult
Heading: Disorders of the Esophagus
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Evaluation [Evaluating]
Concept: Digestion; Bowel Elimination
1.
2.
Feedback
This is correct. Dysphagia is the condition in which the client coughs frequently while
eating and makes repeated attempts to swallow. The client with dysphagia is also at risk for
aspiration pneumonia. Elevated temperature indicates that the client is at risk for aspiration
pneumonia.
This is incorrect. Hyperactive bowel sounds do not indicate the risk for aspiration
pneumonia. Small intestine obstruction and dumping syndrome are the conditions that are
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4.
5.
associated with hyperactive bowel sounds.
This is incorrect. A deviated tongue and uvula does not indicate the risk for aspiration
pneumonia. This condition is associated with dysphagia.
This is incorrect. Drooling of foods or liquids does not indicate the risk for aspiration
pneumonia. This condition is associated with dysphagia.
This is correct. Abnormal lung sounds like crackles indicate that the client is at risk for
aspiration pneumonia.
PTS: 1
CON: Digestion; Bowel Elimination
PRIMEXAM.COM
Chapter 30: Common Disorders of the Large Intestine
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. The nursing instructor taught a group of student nurses about the physical examination of clients with
appendicitis. In the practical session, the instructor asks one of the student nurses to assess the signs of
rebound tenderness in the client. Which assessment by the student nurse indicates effective learning?
1. The student nurse deeply palpates the client’s abdomen and then removes pressure.
2. The student nurse palpates the left lower quadrant of the abdomen.
3. The student nurse asks the client to be in the supine position and actively flex the right
thigh at the hip.
4. The student nurse asks the client to rotate his or her flexed right hip both internally and
externally.
2. The nursing students are learning about precautions to be taken while caring for a client with suspected
appendicitis. Which statement made by the student nurse indicates effective learning?
1. “The client should not be given IV fluids.”
2. “The client should avoid taking ampicillin.”
3. “The client should be given a laxative.”
4. “The client should avoid taking pain medications.”
3. Which part of the gastrointestinal (GI) tract is involved in the production of protective mucous?
1. Goblet cells
2. Submucosal layer
3. Circular muscle layer
4. Columnar epithelial cells
4. Which is the largest serous membrane in the body?
1. Peritoneum
2. Submucosal layer
3. Columnar epithelium
4. Circular muscle layer
5. Which side effect will the nurse observe in a client who is on epinephrine therapy?
1. Gastrocolic reflex
2. Injuries to the gastric epithelium
3. Suppression of the urge to defecate
4. Decreased gastrointestinal secretions
6. What is the significance of propulsive movements in the large intestine?
1. Absorption of water
2. Initiation of defecation
3. Absorption of electrolytes
4. Accumulation of bacteria in the feces
7. Which disorder is characterized by the presence of cobblestoning upon examining the colon?
1. Volvulus
2. Appendicitis
3. Crohn’s disease
PRIMEXAM.COM
4. Ulcerative colitis
8. Which diagnostic test will help the nurse to confirm pancreatitis in the client?
1. Urinalysis
2. Serum amylase test
3. Complete blood count
4. Barium contrast studies
9. Upon physical examination, the nurse detects abdominal tenderness, increased bowel sounds accompanied by
signs of borborygmi, abdominal distension, and tympany on percussion. Which diagnostic test will confirm
Crohn’s disease in the client?
1. Colonoscopy
2. Urinalysis
3. Complete blood count
4. Chest X-ray
10. The nursing instructor is teaching a group of student nurses about the treatment plan for Crohn’s disease.
Which statement made by the student nurse indicates effective learning?
1. “Cholestyramine should be prescribed to clients with ileal disease.”
2. “Loperamide should be administered in clients to reduce abdominal cramps.”
3. “Propantheline dicyclomine should be used to relieve chronic diarrhea.”
4. “Multivitamin supplements are contraindicated since the clients have decreased
absorption.”
11. In a client diagnosed with terminal ileal disease, the primary health care provider prescribed sulfasalazine.
Which outcome in the client indicates the effectiveness of the therapy?
1. The client’s gastrointestinal wall is normalized.
2. The client’s hematocrit percentage is normal.
3. The client is able to absorb bile acids.
4. The client’s urinalysis results show normal values.
12. In a client diagnosed with terminal ileal disease, the nurse administers cholestyramine. Which outcome in the
client indicates the effectiveness of the medication?
1. The urinalysis report shows normal amounts of bile acids.
2. The hematocrit report shows normal red blood cell count.
3. The client no longer experiences abdominal cramps.
4. The client no longer experiences chronic diarrhea.
13. In a client diagnosed with large bowel obstruction, an abdominal x-ray is performed, which shows the
presence of free air under the diaphragm. After the diagnosis, the nurse initiates prophylactic antibiotic
therapy and fluid replacement therapy per the directions of the primary healthcare provider. Which outcome
in the client indicates the effectiveness of the therapy?
1. The client has normal levels of serum amylase.
2. The client has a normal count of red blood cells.
3. The client no longer experiences abdominal cramps.
4. The client no longer experiences chronic diarrhea.
14. The nursing instructor is teaching a group of student nurses about the importance of inserting a nasogastric
tube in clients with large bowel obstruction. Which statement made by the student nurse indicates effective
learning?
1. “A nasogastric tube relieves pressure caused by bowel obstruction.”
PRIMEXAM.COM
2. “A nasogastric tube is primarily used to deliver medications directly to the client’s
stomach.”
3. “A nasogastric tube removes free air present under the client’s diaphragm.”
4. “A nasogastric tube removes the mechanical obstruction in the large intestine.”
15. A female client is admitted to the hospital with a complaint of abdominal pain that originates in the umbilical
region and radiates to the right lower quadrant. The primary health care provider has ordered a urinalysis.
How will this help the primary health care provider in diagnosing the client’s condition?
1. By ruling out the possibility of calcium stones within the appendix
2. By ruling out the possibility of a kidney stone or pyelonephritis
3. By ruling out the possibility of ectopic pregnancy
4. By ruling out the possibility of a gynecological disorder
16. Which diagnostic test should the primary health care provider order to get the most accurate information
related to appendicitis?
1. Urinalysis
2. Abdominal X-ray
3. Abdominal ultrasound
4. Computerized tomography scan
17. The nursing instructor is teaching a group of student nurses about the use of antibiotics in a client diagnosed
with appendicitis. Which statement made by the student nurse indicates effective learning?
1. “Antibiotics should be administered before an operation and should be continued until 48
hours after the operation.”
2. “Antibiotics should not be administered before diagnosis, as they interfere with the
diagnostic signs.”
3. “Antibiotics should be administered only after restoring the fluid and electrolyte balance.”
4. “Antibiotics should only be used when there is no need for surgical removal of the
appendix.”
18. The nursing instructor teaches a group of student nurses about the diagnosis of irritable bowel syndrome.
After the teaching session, the nursing instructor asks the student nurse to determine the presence of lactose
intolerance in a client with irritable bowel syndrome. Which intervention by the student nurse indicates
effective learning?
1. The student nurse performs a complete blood analysis of the client.
2. The student nurse performs a hydrogen breath test on the client.
3. The student nurse performs an upper endoscopy in the client.
4. The student nurse performs an abdominal computerized tomography scan of the client.
19. What is a characteristic feature of ulcerative colitis?
1. Presence of pseudopolyps
2. Continuous areas of inflammation in the large intestine
3. Both A and B
4. None of the above
20. A primary healthcare provider suspects diverticular disease in a client. Which diagnostic test would the
primary health care provider order to visualize the lower bowel?
1. Biopsy
2. Chest x-ray
3. Colonoscopy
4. Sigmoidoscopy
PRIMEXAM.COM
21. Which disorder of the large intestine may require laparoscopic surgery to unwind the intestine?
1. Volvulus
2. Appendicitis
3. Hemorrhoids
4. Diverticular disease
22. The nursing instructor is discussing the physical assessment findings for hemorrhoids. Which statement made
by the student nurse indicates effective learning?
1. “Presence of anal fistulas is observed.”
2. “Presence of blood in stools may be observed.”
3. “McBurney’s point indicates tenderness.”
4. “Auscultation of the abdomen indicates high pitched bowel sounds.”
23. The primary health care provider asks a client to lie down facing upwards and flex the right thigh at the hip.
The client says, “I cannot do this. This position is hurting my abdomen.” Which sign of appendicitis would
the nurse suspect in this client?
1. Psoas sign
2. Rovsing sign
3. Obturator sign
4. Rebound tenderness
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
24. Which condition shows an elevated level of white blood cells? Select all that apply.
1. Appendicitis
2. Constipation
3. Diverticular disease
4. Large bowel obstruction
5. Irritable bowel syndrome
Other
25. Prioritize the order of performing the physical examination of the abdomen in a client with bowel disorder.
(Enter the number of each step in the proper sequence; do not use commas or spaces.)
A. Inspection
B. Palpation
C. Percussion
PRIMEXAM.COM
D. Auscultation
Chapter 30: Common Disorders of the Large Intestine
Answer Section
MULTIPLE CHOICE
1. ANS: 1
Chapter: Chapter 30, Common Disorders of the Large Intestine
Page: 689
Objective: N/A
Difficulty: Hard
Heading: Signs of Appendicitis on Physical Examination
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Evaluation [Evaluating]
Concept: Assessment
1
2
3
4
Feedback
The nurse will assess the sign of rebound tenderness in a client by deeply palpating the
client’s abdomen and then removing the pressure. If the client experiences pain, then
rebound tenderness is established in the client, which is pain upon removal of pressure
from the abdomen. Therefore, this intervention by the student nurse indicates effective
learning.
If the student nurse palpates the left lower quadrant of the client’s abdomen, then it
indicates ineffective learning because this method of physical examination is used to
elicit Rovsing sign.
If the student nurse asks the client to be in the supine position and actively flex the right
thigh at the hip, it indicates ineffective learning, as the student is trying to elicit psoas
sign.
Internal and external rotation of the flexed right hip of the client will help the nurse to
elicit obturator sign in a client.
PTS: 1
CON: Assessment
2. ANS: 4
Chapter: Chapter 30, Common Disorders of the Large Intestine
Page: 690
Objective: N/A
Difficulty: Hard
Heading: Appendicitis
Integrated Processes: Teaching and Learning
Client Need: Physiologic Integrity: Pharmacological and Parenteral Therapies.
Cognitive Level: Evaluation [Evaluating]
Concept: Medication
1
Feedback
This statement is incorrect because IV fluids are given to maintain the electrolyte
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3
4
balance.
This statement is incorrect because ampicillin, which is an antibiotic, is given to clients
with appendicitis as an early treatment.
This statement is incorrect because clients who may have an appendicitis should not be
given laxatives.
Pain medications should be avoided in the client prior to the diagnosis of appendicitis
because they can mask the signs of diagnosis. Therefore, acetaminophen, which is an
analgesic, should be avoided.
PTS: 1
CON: Medication
3. ANS: 1
Chapter: Chapter 30, Common Disorders of the Large Intestine
Page: 678
Objective: N/A
Difficulty: Easy
Heading: Structure of the GI Wall
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Comprehension [Understanding]
Concept: Bowel Elimination
1
2
3
4
Feedback
The goblet cells of the GI tract are involved in the production of mucous, which
protects the GI tract from injuries.
The submucosal layer contains connective tissue, which secretes digestive enzymes.
The circular muscle layer, along with the longitudinal muscle layer, produces peristaltic
movements in the stomach.
The columnar epithelial cells absorb fluids and electrolytes from the intestine. They are
not responsible for the production of mucous.
PTS: 1
CON: Bowel Elimination
4. ANS: 1
Chapter: Chapter 30, Common Disorders of the Large Intestine
Page: 678, 679
Objective: N/A
Difficulty: Easy
Heading: Structure of the GI Wall
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Knowledge [Remembering]
Concept: Bowel Elimination
1
2
Feedback
Peritoneum is the loosely attached outermost layer of the intestine. It is the largest
serous membrane in the body.
The submucosal layer is the middle layer of the intestine where the digestive enzymes
are secreted; itis not the largest serous membrane in the body.
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4
Columnar epithelium cells are present in the inner layer of the intestine, which absorbs
fluids and electrolytes from the body.
The circular muscle layer is present beneath the submucosal layer, which is responsible
for the peristaltic movements in the intestine.
PTS: 1
CON: Bowel Elimination
5. ANS: 3
Chapter: Chapter 30, Common Disorders of the Large Intestine
Page: 679
Objective: N/A
Difficulty: Medium
Heading: Colonic Motility
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Medication
1
2
3
4
Feedback
Gastrocolic reflex is inhibited in a client who is on epinephrine therapy. Therefore, it is
not observed in clients who are on epinephrine therapy.
Injuries to the gastric epithelium occur due to decreased mucous secretion. Epinephrine
will not result in inhibition of gastric mucous secretion.
Epinephrine suppresses the gastrocolic reflex, which is responsible for the propulsion of
bowels and initiation of the urge to defecate. Therefore, the client who is on
epinephrine therapy will have suppression of the urge to defecate.
The gastrointestinal secretions, like the digestive enzymes, are secreted by the cells
present in the submucosal layer. Epinephrine will not inhibit the gastric secretions.
PTS: 1
CON: Medication
6. ANS: 2
Chapter: Chapter 30, Common Disorders of the Large Intestine
Page: 679
Objective: N/A
Difficulty: Easy
Heading: Colonic Motility
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
1
2
3
Feedback
Absorption of water from the intestine takes place from the columnar epithelial cells.
The propulsive movements do not determine it.
Propulsive movements that are initiated by the gastrocolic reflex will help in the
initiation of the urge to defecate.
Absorption of electrolytes from the intestine takes place from the columnar epithelial
cells. Propulsive movements will not increase the absorption of electrolytes.
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4
Haustrations will increase the accumulation of bacteria in the intestine. Propulsions will
help in the removal of bacteria from the feces.
PTS: 1
CON: Assessment
7. ANS: 3
Chapter: Chapter 30, Common Disorders of the Large Intestine
Page: 681
Objective: N/A
Difficulty: Easy
Heading: Inflammatory Bowel Disease
Integrated Processes: Nursing Process
Client Need: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Bowel Elimination
1
2
3
4
Feedback
There is no presence of cobblestoning in volvulus, as it is the twisting of the intestine.
There is no presence of cobblestoning in appendicitis, as it is the inflammation of the
appendix.
Cobblestoning is the appearance of multiple round projections from the surface. In
Crohn’s disease, the bowel mucosa develops granulomas, which appear like
cobblestones.
In ulcerative colitis, pseudopolyps may be seen upon the examination of the colon, but
not cobblestoning.
PTS: 1
CON: Bowel Elimination
8. ANS: 2
Chapter: Chapter 30, Common Disorders of the Large Intestine
Page: 683
Objective: N/A
Difficulty: Medium
Heading: Physical Examination
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Assessment
1
2
3
4
Feedback
Urinalysis reports of the client can provide information about the renal functioning of
the client. A client with pancreatitis may show normal values in urinalysis.
The serum amylase levels in a client diagnosed with pancreatitis are increased. The
increase is due to increased production of amylase enzyme by the pancreas. Therefore,
the serum amylase test is used as a diagnostic tool to confirm pancreatitis in the client.
The level of white blood cells may be altered in clients with pancreatitis. However, a
complete blood test is not useful to confirm pancreatitis in the client.
Barium contrast studies are used to determine the level of bowel obstruction. They are
not used to determine pancreatitis.
PRIMEXAM.COM
PTS: 1
CON: Assessment
9. ANS: 1
Chapter: Chapter 30, Common Disorders of the Large Intestine
Page: 685
Objective: N/A
Difficulty: Medium
Heading: Inflammatory Bowel Disease
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Analysis [Analyzing]
Concept: Inflammation
1
2
3
4
Feedback
Colonoscopy is the diagnostic test used to distinguish between Crohn’s disease and
ulcerative colitis. It determines the underlying pathology in the colon, which is involved
in the disorder. Therefore, colonoscopy will help the nurse to confirm Crohn’s disease
in the client.
Crohn’s disease and ulcerative colitis do not cause alterations in the urine. Therefore,
urinalysis will not help the nurse to confirm Crohn’s disease in the client.
The blood count will not be altered in clients with Crohn’s disease. Therefore,
information related to complete blood count will not confirm Crohn’s disease in the
client.
Chest x-ray will reveal the presence of free air under the diaphragm. However, it does
not confirm Crohn’s disease in the client.
PTS: 1
CON: Inflammation
10. ANS: 1
Chapter: Chapter 30, Common Disorders of the Large Intestine
Page: 685
Objective: N/A
Difficulty: Hard
Heading: Inflammatory Bowel Disease
Integrated Processes: Teaching and Learning
Client Need: Physiologic Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Evaluation [Evaluating]
Concept: Medication
1
2
3
Feedback
Cholestyramine is a bile acid sequestering agent, which is prescribed for clients with
terminal ileal disease. This will help the client to absorb bile salts normally. This
statement by the student nurse is true and indicates effective learning.
Loperamide is used to reduce chronic diarrhea in clients. This statement by the student
nurse is incorrect and indicates ineffective learning.
Propantheline dicyclomine should be used to relieve abdominal cramps in clients with
Crohn’s disease. This statement by the student nurse is incorrect and indicates
ineffective learning.
PRIMEXAM.COM
4
Clients with Crohn’s disease suffer from chronic diarrhea, which results in malnutrition.
Therefore, multivitamin supplements should be prescribed to the clients with Crohn’s
disease.
PTS: 1
CON: Medication
11. ANS: 1
Chapter: Chapter 30, Common Disorders of the Large Intestine
Page: 685
Objective: N/A
Difficulty: Hard
Heading: Inflammatory Bowel Disease
Integrated Processes: Nursing Process
Client Need: Physiologic Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Evaluation [Evaluating]
Concept: Medication
1
2
3
4
Feedback
Sulfasalazine is a salicylic acid derivative, which is used to reduce gastrointestinal
inflammation caused by the immune response. Therefore, a normalized gastrointestinal
wall represents the effectiveness of sulfasalazine therapy in a client with terminal ileal
disease.
The hematocrit values of the client will not be altered due to terminal ileal disease.
Therefore, normal values in the hematocrit do not represent the effectiveness of
sulfasalazine therapy.
Cholestyramine should be administered in the client with terminal ileal disease for the
normal absorption of bile acids. Sulfasalazine will not help in normal absorption of bile
acids.
The values of urinalysis will not be normal in a client with terminal ileal disease upon
administration of cholestyramine. Administration of sulfasalazine will not result in a
normal urinalysis report.
PTS: 1
CON: Medication
12. ANS: 1
Chapter: Chapter 30, Common Disorders of the Large Intestine
Page: 685
Objective: N/A
Difficulty: Hard
Heading: Inflammatory Bowel Disease
Integrated Processes: Nursing Process
Client Need: Physiologic Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Evaluation [Evaluating]
Concept: Medication
1
Feedback
Cholestyramine is a bile acid sequestering agent, which is used in normal absorption of
bile acids in clients with terminal ileal disease. Therefore, the urinalysis of the client
shows normal levels of bile acids.
PRIMEXAM.COM
2
3
4
The hematocrit of clients with terminal ileal disease will not alter, as there is no
gastrointestinal bleeding. Therefore, normal values of hematocrit do not represent
effectiveness of cholestyramine.
Abdominal cramps in a client with terminal ileal disease are relieved by administering
propantheline dicyclomine. If the client no longer experiences abdominal cramps after
administering cholestyramine, it does not indicate the effectiveness of the medication.
Chronic diarrhea is treated by administering anti-diarrheal medications. Administration
of cholestyramine will not relieve diarrhea in the client.
PTS: 1
CON: Bowel Elimination
13. ANS: 1
Chapter: Chapter 30, Common Disorders of the Large Intestine
Page: 688
Objective: N/A
Difficulty: Hard
Heading: Large Bowel Obstruction
Integrated Processes: Teaching and Learning
Client Need: Physiologic Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Evaluation [Evaluating]
Concept: Bowel Elimination
1
2
3
4
Feedback
In a client with large bowel syndrome, the serum amylase levels are elevated when the
client has perforations in the bowel or the organ. In this case, the chest x-ray showed
the presence of free air under the diaphragm, which indicates the presence of
perforations. Therefore, the presence of normal serum amylase levels indicates
effectiveness of therapy.
The red blood cell count is not elevated in clients with large bowel obstruction disorder.
Therefore, normal levels of red blood cells will not indicate the effectiveness of
antibiotic and fluid replacement therapy in clients with large bowel disease.
Abdominal cramps are not observed in clients with large bowel obstruction disorder.
Therefore, if the client no longer experiences abdominal cramps, it does not indicate the
effectiveness of the therapy.
Chronic diarrhea is not a symptom observed in clients with large bowel obstruction
disorder. Therefore, if the client does not experience chronic diarrhea, it does not
indicate the effectiveness of the therapy.
PTS: 1
CON: Bowel Elimination
14. ANS: 1
Chapter: Chapter 30, Common Disorders of the Large Intestine
Page: 688
Objective: N/A
Difficulty: Hard
Heading: Large Bowel Obstruction
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive Level: Evaluation [Evaluating]
PRIMEXAM.COM
Concept: Bowel Elimination
1
2
3
4
Feedback
A nasogastric tube helps in the aspiration of stomach contents, thereby relieving
pressure caused by bowel obstruction. This statement by the student nurse is true and
indicates effective learning.
A nasogastric tube is used for nutritional support and sometimes to administer
medications. It is not primarily used for administering medications. This statement by
the student nurse is incorrect and indicates ineffective learning.
A nasogastric tube is inserted in the client’s stomach. It will not help to release free air
present under the client’s diaphragm.
The mechanical obstruction in the client’s intestine cannot be removed by using a
nasogastric tube. It helps to release pressure exerted by the mechanical obstruction.
PTS: 1
CON: Bowel Elimination
15. ANS: 2
Chapter: Chapter 30, Common Disorders of the Large Intestine
Page: 689
Objective: N/A
Difficulty: Medium
Heading: Appendicitis
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Assessment
1
2
3
4
Feedback
The presence of calcium stones within the appendix is determined by performing an
abdominal x-ray. Urinalysis will not determine the presence of calcium stones in the
appendix.
Urinalysis will determine the level of urea in urine, which provides information about
kidney stones or pyelonephritis. Therefore, the primary health care provider can rule
out the possibility of kidney stones or pyelonephritis in the client.
The possibility of ectopic pregnancy is ruled out by performing a pelvic exam and betaHCG blood test. Urinalysis will not give clear information about an ectopic pregnancy.
The presence of gynecological disorders is determined by performing a pelvic exam
and beta-HCG blood test. Urinalysis will not give concrete information about
gynecological disorders.
PTS: 1
CON: Assessment
16. ANS: 4
Chapter: Chapter 30, Common Disorders of the Large Intestine
Page: 689
Objective: N/A
Difficulty: Medium
Heading: Signs of Appendicitis on Physical Examination
Integrated Processes: Nursing Process
PRIMEXAM.COM
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Inflammation
1
2
3
4
Feedback
Urinalysis is performed to rule out the possibility of a kidney stone or pyelonephritis in
a client with appendicitis. It will not give the most accurate information related to
appendicitis.
An abdominal x-ray is informative only when calcium stones are present in the
appendix.
Abdominal ultrasound can identify only an inflamed or edematous appendix. It cannot
determine normal appendicitis.
A computerized tomography scan is used to get the most accurate information related to
appendicitis.
PTS: 1
CON: Inflammation
17. ANS: 1
Chapter: Chapter 30, Common Disorders of the Large Intestine
Page: 690
Objective: N/A
Difficulty: Hard
Heading: Appendicitis
Integrated Processes: Teaching/Learning
Client Need: Physiologic Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Evaluation [Evaluating]
Concept: Inflammation
1
2
3
4
Feedback
Antibiotics should be administered in a client with appendicitis, before an operation and
until 48 hours after the operation to prevent infection. This statement by the student
nurse is correct and indicates effective learning.
Pain medications should be avoided before diagnosis of appendicitis, as they interfere
with the diagnostic signs. Antibiotics will not interfere with the diagnostic signs of
appendicitis. This statement by the student nurse is incorrect and indicates ineffective
learning.
Antibiotics need not be administered only after restoring the fluid and electrolyte
balance because fluids and electrolytes will not affect the absorption of antibiotics.
Antibiotics should be used before and after surgical removal of the appendix to prevent
infection. This statement by the student nurse is incorrect and indicates ineffective
learning.
PTS: 1
CON: Inflammation
18. ANS: 2
Chapter: Chapter 30, Common Disorders of the Large Intestine
Page: 691
Objective: N/A
Difficulty: Hard
PRIMEXAM.COM
Heading: Irritable Bowel Syndrome
Integrated Processes: Teaching/Learning
Client Need: Health Promotion and Maintenance
Cognitive Level: Evaluation [Evaluating]
Concept: Bowel Elimination
1
2
3
4
Feedback
A complete blood analysis will help the student nurse to determine anemia, infection or
inflammation. This intervention by the student nurse will not help to determine lactose
intolerance and indicates ineffective learning.
The hydrogen breath test is used to determine lactose intolerance in a client by
determining the amount of hydrogen exhaled. This intervention by the nurse is correct
and indicates effective learning.
Upper endoscopy is used to determine structural or functional abnormalities in a client.
It will not help to determine lactose intolerance.
Abdominal computerized tomography scan helps the nurse to determine abdominal
tumors, obstruction, or pancreatic disease. It is not helpful to determine lactose
intolerance.
PTS: 1
CON: Bowel Elimination
19. ANS: 3
Chapter: Chapter 30, Common Disorders of the Large Intestine
Page: 683
Objective: N/A
Difficulty: Easy
Heading: Inflammatory Bowel Disease
Integrated Processes: Nursing Process
Client Need: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Bowel Elimination
1
2
3
4
Feedback
The presence of pseudopolyps is a characteristic feature of ulcerative colitis.
Continuous areas of inflammation in the large intestine are also a characteristic feature
of ulcerative colitis.
Continuous areas of inflammation in the large intestine are a characteristic feature of
ulcerative colitis. Presence of pseudopolyps is also a characteristic feature of ulcerative
colitis
Presence of pseudopolyps and continuous areas of inflammation in the large intestine
are both characteristic features of ulcerative colitis.
This is incorrect because both presence of pseudopolyps and continuous areas of
inflammation in the large intestine are characteristic features of ulcerative colitis.
PTS: 1
CON: Bowel Elimination
20. ANS: 4
Chapter: Chapter 30, Common Disorders of the Large Intestine
Page: 693
PRIMEXAM.COM
Objective: N/A
Difficulty: Moderate
Heading: Hemorrhoids
Integrated Processes: Nursing Process
Client Need: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Bowel Elimination
1
2
3
4
Feedback
Biopsy is a diagnostic test where a tissue from the body is removed and assessed.
Chest X-ray may be conducted to check for the presence of free air under the
diaphragm when there is perforation of the bowel or abdominal organ.
Colonoscopy is conducted to visualize the large bowel up to the cecum.
Sigmoidoscopy is the insertion of a flexible tube to examine the sigmoid colon.
Therefore, the primary health care provider would order a sigmoidoscopy to visualize
the lower bowel
PTS: 1
CON: Bowel Elimination
21. ANS: 1
Chapter: Chapter 30, Common Disorders of the Large Intestine
Page: 693
Objective: N/A
Difficulty: Easy
Heading: Volvulus
Integrated Processes: Nursing Process
Client Need: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Bowel Elimination
1
2
3
4
Feedback
Volvulus is the twisting of the large intestine around the point of attachment in the
abdomen. Therefore, this disorder of the large intestine requires laparoscopic surgery to
unwind the intestine.
Appendicitis is treated with the use of antibiotics or surgery to remove the appendix.
Hemorrhoids are treated with topical corticosteroid cream or minimal invasive
procedures.
Diverticular disease is treated with the help of surgery after the acute episode has
passed.
PTS: 1
CON: Bowel Elimination
22. ANS: 2
Chapter: Chapter 30, Common Disorders of the Large Intestine
Page: 693
Objective: N/A
Difficulty: Hard
Heading: Hemorrhoids
Integrated Processes: Teaching and Learning
PRIMEXAM.COM
Client Need: Physiological Adaptation
Cognitive Level: Evaluation [Evaluating]
Concept: Bowel Elimination
1
2
3
4
Feedback
Presence of anal fistulas is observed in Crohn’s disease.
Hemorrhoids are the swollen, dilated venous blood vessels in the lower rectum. The
physical assessment findings for hemorrhoids may show hematochezia, which is the
presence of blood in stools.
McBurney’s point indicates tenderness in case of appendicitis.
Auscultation of the abdomen indicates high-pitched bowel sounds in partial bowel
obstruction.
PTS: 1
CON: Bowel Elimination
23. ANS: 1
Chapter: Chapter 30, Common Disorders of the Large Intestine
Page: 689
Objective: N/A
Difficulty: Medium
Heading:
Integrated Processes: Nursing Process
Client Need: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Inflammation
1
2
3
4
Feedback
Psoas sign can be identified if the client complains of pain upon flexing the right thigh
at the hip.
Rovsing sign can be identified if the client complains of pain upon palpating the left
lower quadrant of the abdomen.
Obturator sign can be identified if the client complains of pain upon internal and
external rotation of the client’s flexed right hip.
Rebound tenderness can be identified if the client complains of pain upon deeply
palpating the abdomen and release of the hand.
PTS: 1
CON: Inflammation
MULTIPLE RESPONSE
24. ANS: 1, 3, 4
Chapter: Chapter 30, Common Disorders of the Large Intestine
Page: 694, 695
Objective: N/A
Difficulty: Easy
Heading: Common Disorders of the Large Intestine
Integrated Processes: Nursing Process
Client Need: Physiological Adaptation
PRIMEXAM.COM
Cognitive Level: Knowledge [Remembering]
Concept: Bowel Elimination
1.
2.
3.
4.
5.
Feedback
An elevated level of white blood cells is seen in appendicitis due to inflammation.
In constipation, there is no increase in the level of white blood cells.
An elevated level of white blood cells is seen in diverticular disease due to inflammation.
An elevated level of white blood cells is seen in large bowel obstruction due to
inflammation and perforation.
Irritable bowel syndrome is the alteration of the GI motility. The blood count shows no
elevated levels of white blood cells.
PTS: 1
CON: Bowel Elimination
ORDERED RESPONSE
25. ANS:
ADCB
Chapter: Chapter 30, Common Disorders of the Large Intestine
Page: 682
Objective: N/A
Difficulty: Medium
Heading: Physical Examination
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Assessment
Feedback: While performing the physical examination of the abdomen, the nurse should first visually inspect
the abdomen. If the abdomen is filled with gas, it appears distended. Next, the nurse should auscultate the
client’s abdomen. Bowel sounds will be normal in the early course of bowel disorder, but they may become
quiet or rushing as the disorder progresses. Percussion of the abdomen reveals tympany when the bowel is
filled with gas. Palpation should be the next step, revealing tenderness, rigidity, and involuntary guarding.
PTS: 1
CON: Assessment
PRIMEXAM.COM
Chapter 31: Infection, Inflammation, and Cirrhosis of the Liver
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. What is the mode of transmission for the hepatitis D virus?
1. Blood transfusion
2. Oral-fecal route
3. Sexual contact
4. Both A and C
2. Which virus helper function is needed for the replication of hepatitis D virus?
1. Hepatitis A virus (HAV)
2. Hepatitis B virus (HBV)
3. Hepatitis C virus (HCV)
4. Hepatitis E virus (HEV)
3. What is the risk factor for nonalcoholic fatty liver disease (NAFLD)?
1. Hepatitis B
2. Exposure to isoniazid
3. Protein malnutrition
4. Cell mediated immunity
4. The registered nurse is teaching about the pathophysiology of nonalcoholic fatty liver disease (NAFLD) to
student nurses. Which statement made by the student nurse indicates effective learning?
1. “NAFLD is linked to metabolic syndrome.”
2. “Exposure to vinyl chloride can cause NAFLD.”
3. “Increased level of adiponectin is associated with NAFLD.”
4. “NAFLD is caused by accumulation of fat in the adipose tissue.”
5. The nurse suspects hepatic encephalopathy in a client with severe liver dysfunction. Which symptom may
support the nurse’s conclusion?
1. Stupor
2. Ascites
3. Hematemesis
4. Spider angiomata
6. While assessing a client who has liver dysfunction, the nurse finds that the client has shifting abdominal
dullness. Which condition does the nurse suspect in the client?
1. Ascites
2. Splenomegaly
3. Spider angiomata
4. Esophageal varices
7. The registered nurse is teaching about portal hypertension to a group of student nurses. Which statement by
the student nurse indicates the need for further teaching?
1. “Caput medusa is a sign of portal hypertension.”
2. “Portal hypertension can cause hematemesis.”
3. “Ascites is associated with portal hypertension.”
4. “Portal hypertension causes coagulation abnormalities.”
PRIMEXAM.COM
8. While reviewing the medical file of a client with cirrhosis, the nurse finds that the client has steatorrhea. What
reason might the nurse suspect for this condition in the client?
1. Hyperbilirubinemia
2. Activation of stellate cells
3. Diminished synthesis of bile
4. Nitrogenous waste accumulation in the blood
9. While assessing a client with liver cirrhosis, the nurse observes that the client has asterixis. What is the reason
for this condition of the client?
1. Osteoporosis
2. Iron overload
3. Coagulopathy
4. Encephalopathy
10. Which condition is commonly seen in the case of protein loss in clients with liver cirrhosis?
1. Pruritus
2. Muscle wasting
3. Hypersplenism
4. Skin telangiectasias
11. After assessing a client with biliary cirrhosis, the nurse suspects xanthelasmas. Which laboratory test will
support the nurse’s conclusion?
1. Endoscopy
2. Lipid levels
3. Bilirubin levels
4. Prothrombin time
12. The nurse finds ursodiol in a client’s prescription. Which condition does the nurse suspect in the client?
1. Gilbert’s syndrome
2. Alcoholic liver disease
3. Crigler-Najjar syndrome
4. Primary biliary cirrhosis
13. A client complains of fatigue and arthralgia to the nurse. On physical assessment, the nurse finds that the
client has hyperpigmentation of the skin. Which lab test should the nurse suggest for safe and effective care of
the client?
1. Bilirubin levels
2. Serum ferritin levels
3. Ceruloplasmin levels
4. Immunoglobulins level
14. The laboratory report of a client is as given below. Which condition does the nurse suspect in the client?
Serum albumin
4 g/dL
Indirect bilirubin
1.5mg/dL
Prothrombin time
14 sec
Alkaline phosphatase
100 U/mL
1. Coagulopathy
2. Biliary cirrhosis
3. Hypoalbuminemia
PRIMEXAM.COM
4. Gilbert’s Disease
15. The client with alcoholic liver disease is experiencing bruising, nosebleed, and hematemesis. Which treatment
option does the nurse suspect to be effective in this client?
1. Diuretics
2. Vitamin K
3. Band ligation
4. Phototherapy
16. Which stage in the viral life cycle of hepatitis involves the production of antibodies?
1. Stage 1
2. Stage 2
3. Stage 3
4. Stage 4
17. The registered nurse is teaching a group of student nurses about the functions of the liver. Which response of
the student nurse indicates the need for further teaching?
1. “The liver synthesizes glucagon.”
2. “The liver synthesizes thrombopoietin.”
3. “The liver synthesizes angiotensinogen.”
4. “The liver synthesizes insulin-like growth factor 1.”
18. The primary health-care provider suggests the hepatitis C virus (HCV) genotyping test to a client with liver
disease. What is the rationale for this?
1. To predict prognosis
2. To determine the severity of the disease
3. To predict the likelihood of response and the duration of treatment
4. To detect the presence of antibodies against two or more antigens
19. Which type of hepatitis is caused by a deoxyribonucleic acid (DNA) virus?
1. Hepatitis A (HAV)
2. Hepatitis B (HBV)
3. Hepatitis C (HCV)
4. Hepatitis D (HDV)
20. What reason does the nurse suspect for the change of urine color in a client with liver disease?
1. Failure of bilirubin to reach intestine
2. Accumulation of bilirubin in the bloodstream
3. Accumulation of bile salts in the bloodstream
4. Infiltration of liver with fat
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
21. The laboratory reports of an alcoholic client show hepatic encephalopathy and portal hypertension. Which
nursing interventions will be beneficial for the client? Select all that apply.
1. Provide a low-sodium diet.
2. Provide a low-calorie diet.
3. Provide a high-protein diet.
4. Administer calcium compounds.
PRIMEXAM.COM
5. Encourage the use of thiamine supplements.
22. The laboratory reports of a client with alcoholic liver disease reveal low hemoglobin levels. What reasons
might the nurse suspect for this condition? Select all that apply.
1. Hypersplenism
2. Hemochromatosis
3. Hypoalbuminemia
4. Folic acid deficiency
5. Decreased levels of thrombopoietin
23. The nurse is caring for a client with glucuronyl transferase enzyme deficiency. The laboratory reports show
elevated serum bilirubin levels. Which treatment does the nurse suspect to be effective in the client? Select all
that apply.
1. Phenobarbital
2. Phototherapy
3. Paracentesis
4. Desferoxamine
5. Penicillamine
24. Which findings can the nurse observe in the laboratory reports of a client after 4 weeks of hepatitis A
infection? Select all that apply.
1. A rise in liver enzymes
2. Appearance of IgM antibodies
3. Appearance of IgG antibodies
4. Appearance of hepatitis A virus (HAV) in the stool
5. Presence of antimitochondrial antibodies (AMAs)
Other
25. Arrange the processes occurring in four developmental stages of primary biliary cirrhosis in their correct
order (1-4).(Enter the number of each step in the proper sequence; do not use commas or spaces.)
A. Destruction of the liver cells, fibrotic tissue taking over hepatic cells, and loss of intralobular bile ducts
B. Progression of inflammation
C. Development of micronodular or macronodular cirrhosis
PRIMEXAM.COM
D. Inflammation of the portal triads and destruction of small and medium bile ducts
Chapter 31: Infection, Inflammation, and Cirrhosis of the Liver
Answer Section
MULTIPLE CHOICE
1. ANS: 4
Chapter: Chapter 31, Infection, Inflammation, and Cirrhosis of the Liver
Page: 713
Objective: N/A
Difficulty: Easy
Heading: Select Pathophysiologic Disorders of the Liver
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Infection
Feedback
1
2
3
4
The hepatitis D virus is particularly concentrated in the blood of an infected person.
Therefore, it is transmitted through contact with infected blood or blood products.
The hepatitis A and E viruses are transmitted by the oral-fecal route, usually via
contaminated food or water.
The hepatitis D virus is found in the body fluids of an infected person. Therefore, it can
be transmitted through sexual contact.
Hepatitis D is concentrated both in the blood and body fluids of the infected person.
Therefore, transmission can occur via blood/blood product transfusion and sexual
contact.
PTS: 1
CON: Infection
2. ANS: 2
Chapter: 31, Infection, Inflammation, and Cirrhosis of the Liver
Page: 713
Objective: N/A
Difficulty: Easy
Heading: Select Pathophysiologic Disorders of the Liver
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Infection
Feedback
1
HDV replication needs HBV, but not HAV.
2
HDV is an incomplete defective RNA virus. It uses the enzymes produced by HBV to
reproduce. Therefore, HDV uses the helper function of HBV for replication and
propagation.
HCV does not help HDV for replication.
3
PRIMEXAM.COM
4
HEV does not have any supportive role in the replication of HDV.
PTS: 1
CON: Infection
3. ANS: 3
Chapter: Chapter 31, Infection, Inflammation, and Cirrhosis of the Liver
Page: 713, 714
Objective: N/A
Difficulty: Easy
Heading: Select Pathophysiologic Disorders of the Liver
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Nutrition
Feedback
1
2
3
4
Progression of hepatitis B can cause chronic hepatitis. Hepatitis B is not a risk factor for
NAFLD.
Exposure to the isoniazid drug may cause toxic hepatitis. It is not associated with
NAFLD.
Lack of proteins in the diet leads to a deficiency of amino acids that are needed by the
liver for the conversion of fat to phospholipids, lipoproteins, and transportation of
fat/cholesterol from the cells. This can cause fat accumulation in the liver, resulting in
NAFLD.
Cell-mediated immunity plays an important role in autoimmune hepatitis. However, it
is not associated with NAFLD.
PTS: 1
CON: Assessment
4. ANS: 1
Chapter: Chapter 31, Infection, Inflammation, and Cirrhosis of the Liver
Page: 714, 715
Objective: N/A
Difficulty: Hard
Heading: Select Pathophysiologic Disorders of the Liver
Integrated Process: Teaching and Learning
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Evaluation [Evaluating]
Concept: Nursing Roles
Feedback
1
2
3
Metabolic syndrome is characterized by insulin resistance, obesity, and hyperlipidemia.
It can lead to excess fat accumulation in the liver. Therefore, NAFLD is linked to
metabolic syndrome.
Exposure to chemical agents like vinyl chloride may cause toxic hepatitis. Drugs such
as amiodarone, tamoxifen, and methotrexate can cause NAFLD.
Adiponectin reduces the accumulation of glucose and fats in the liver by inhibiting
gluconeogenesis and suppressing lipogenesis. Therefore, decreased adiponectin results
PRIMEXAM.COM
4
in NAFLD.
NAFLD is caused by the accumulation of fatty acids in the liver.
PTS: 1
CON: Nursing Roles
5. ANS: 1
Chapter: Chapter 31, Infection, Inflammation, and Cirrhosis of the Liver
Page: 716, 717
Objective: N/A
Difficulty: Medium
Heading: Select Pathophysiologic Disorders of the Liver
Integrated Process: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Nursing Roles
Feedback
1
2
3
4
The accumulation of toxins in the brain results in hepatic encephalopathy and leads to
decreased mental function, thus causing stupor. Stupor is the lack of critical cognitive
function and level of consciousness (confusion and disorientation).
Ascites is excess fluid accumulation in the peritoneal cavity. It is seen in clients with
portal hypertension.
Hematemesis is the vomiting of blood, which is seen in clients with esophageal variceal
bleeding.
The clients with portal hypertension will have spider angiomata on the skin.
PTS: 1
CON: Nursing Roles
6. ANS: 1
Chapter: Chapter 31, Infection, Inflammation, and Cirrhosis of the Liver
Page: 716
Objective: N/A
Difficulty: Medium
Heading: Select Pathophysiologic Disorders of the Liver
Integrated Process: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Nursing Roles
Feedback
1
2
3
4
Shifting dullness is a clinical sign that is an indication of fluid buildup in the abdomen
(ascites).
For clients with splenomegaly, physical examination of the left upper abdomen shows
an enlargement of the spleen.
Spider angiomata is characterized by the central red arteriole representing the body of a
spider. It is surrounded by a radial pattern of thin-walled capillaries, which appears on
the skin of clients with portal hypertension.
Clients with esophageal varices show symptoms such as melena and hematuria. Its
diagnosis is confirmed by performing endoscopic examination.
PRIMEXAM.COM
PTS: 1
CON: Nursing Roles
7. ANS: 4
Chapter: Chapter 31, Infection, Inflammation, and Cirrhosis of the Liver
Page: 717
Objective: N/A
Difficulty: Hard
Heading: Select Pathophysiologic Disorders of the Liver
Integrated Process: Teaching and Learning
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Evaluation [Evaluating]
Concept: Nursing Roles
Feedback
1
2
3
4
In portal hypertension, the increased pressure within the portal vein causes a back-up of
pressure to the gastrointestinal veins and collaterals, leading to the appearance of
dilated and superficial veins around the umbilicus (caput medusa).
Portal hypertension leads to the development of esophageal varices, which are fragile
and prone to bleeding. Due to esophageal variceal bleeding, clients may experience
hematemesis.
Portal hypertension increases pressure in the portal blood vessels and causes proteincontaining fluid from the surface of the liver and intestine to leak and accumulate
within the abdomen, thus leading to ascites.
Liver cirrhosis leads to coagulation abnormalities because of impaired clotting factor
synthesis. However, portal hypertension does not cause any coagulation abnormalities.
PTS: 1
CON: Nursing Roles
8. ANS: 3
Chapter: Chapter 31, Infection, Inflammation, and Cirrhosis of the Liver
Page: 717
Objective: N/A
Difficulty: Medium
Heading: Select Pathophysiologic Disorders of the Liver
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Nursing Roles
Feedback
1
2
3
Liver dysfunction may decrease the ability of the liver to process bilirubin, leading to
bilirubin buildup within the bloodstream, also known as hyperbilirubinemia. This can
cause jaundice in the client.
Activation of stellate cells occurs if there is a cell injury. These cells produce an
abundant amount of collagenous fibrous tissue, leading to liver cirrhosis.
Bile is produced by the liver and is essential for the digestion of fats. In liver cirrhosis,
the production of bile is diminished, leading to the accumulation of undigested fat in
PRIMEXAM.COM
4
the liver, causing steatorrhea.
Liver failure may cause the accumulation of nitrogenous waste in the blood, leading to
high ammonia levels, which may, in turn, increase the risk of hepatic encephalopathy.
PTS: 1
CON: Nursing Roles
9. ANS: 4
Chapter: Chapter 31, Infection, Inflammation, and Cirrhosis of the Liver
Page: 717
Objective: N/A
Difficulty: Medium
Heading: Select Pathophysiologic Disorders of the Liver
Integrated Process: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Nursing Roles
Feedback
1
2
3
4
Clients with liver disease will have malabsorption of vitamin D. Low vitamin D causes
lack of calcium absorption, leading to bone demineralization and osteoporosis.
Therefore, osteoporosis does not cause asterixis.
Clients with alcoholic liver disease may have increased hepatic iron content. This
excessive iron deposition may cause hemochromatosis.
Coagulopathy in clients with alcoholic liver disease is caused by impaired synthesis of
clotting factors. Clients with coagulopathy may have bleeding and bruising.
Failure of the liver to remove nitrogenous wastes results in the accumulation of toxins
and causes encephalopathy. Hepatic encephalopathy may cause neurologic
disturbances, including asterixis, which is characterized by flapping tremors of the
hands.
PTS: 1
CON: Nursing Roles
10. ANS: 3
Chapter: Chapter 31, Infection, Inflammation, and Cirrhosis of the Liver
Page: 718
Objective: N/A
Difficulty: Easy
Heading: Select Pathophysiologic Disorders of the Liver
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Digestion
Feedback
1
2
3
Pruritus is caused by the accumulation of bile salts in clients with liver cirrhosis.
Protein is very important for maintaining muscle mass. Liver cirrhosis in the advanced
state is characterized by protein wasting and it can cause muscle loss.
Hypersplenism is caused by portal hypertension. It results in anemia and
thrombocytopenia in clients.
PRIMEXAM.COM
4
Skin telangiectasia is a manifestation of portal hypertension.
PTS: 1
CON: Digestion
11. ANS: 2
Chapter: 31, Infection, Inflammation, and Cirrhosis of the Liver
Page: 720
Objective: N/A
Difficulty: Easy
Heading: Select Pathophysiologic Disorders of the Liver
Integrated Process: Nursing Process
Client Need: Safe and Effective Environment: Management of Care
Cognitive Level: Knowledge [Remembering]
Concept: Digestion
Feedback
1
2
3
4
Endoscopy will help in the diagnosis of esophageal varices.
Xanthelasmas are cholesterol deposits around the eyes. These are caused by elevated
lipid levels. Therefore, a lipid profile test will help to confirm the diagnosis.
Measurement of bilirubin levels will be useful in the diagnosis of jaundice.
A prothrombin time test is performed to detect clotting abnormalities and bleeding in
clients with liver dysfunction.
PTS: 1
CON: Digestion
12. ANS: 4
Chapter: Chapter 31, Infection, Inflammation, and Cirrhosis of the Liver
Page: 719
Objective: N/A
Difficulty: Medium
Heading: Select Pathophysiologic Disorders of the Liver
Integrated Process: Nursing Process
Client Need: Safe and Effective Care: Management of Care
Cognitive Level: Application [Applying]
Concept: Digestion
Feedback
1
Gilbert’s syndrome is characterized by the decreased amount of glucuronyl transferase
made by the liver. No treatment is needed for Gilbert’s syndrome.
2
Anti-inflammatory drugs are used in the case of alcoholic liver disease. Diuretics are
used in the treatment of edema and paracentesis for ascites.
Calcium compounds can bind bilirubin and aid in excretion in clients who have CriglerNajjar syndrome. Phenobarbital can also lower the bilirubin levels.
Ursodiol helps to move bile out of the liver and intestine. It reduces serum alkaline
phosphatase and aminotransferase levels in primary biliary cirrhosis. This is why the
nurse suspects primary biliary cirrhosis in the client.
3
4
PRIMEXAM.COM
PTS: 1
CON: Digestion
13. ANS: 2
Chapter: Chapter 31, Infection, Inflammation, and Cirrhosis of the Liver
Page: 720
Objective: N/A
Difficulty: Hard
Heading: Select Pathophysiologic Disorders of the Liver
Integrated Process: Nursing Process
Client Need: Safe and Effective Care: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Nursing Roles
Feedback
1
Bilirubin levels are important in clients with hepatitis and other liver diseases. These
levels do not have any role in hematochromatosis.
2
Signs and symptoms such as fatigue, arthralgia, and hyperpigmentation of the skin are
due to iron overload in clients with hematochromatosis. Clients with
hematochromatosis have high iron, serum ferritin, and transferrin levels. So, serum
ferritin levels are important to confirm the diagnosis.
Low ceruloplasmin levels are seen in clients with Wilson disease. Therefore, the
ceruloplasmin test plays an important role in the diagnosis of Wilson disease.
High immunoglobulins are seen in clients with biliary cirrhosis. Therefore, the
immunoglobulins test does not have any significance in hematochromatosis.
3
4
PTS: 1
CON: Nursing Roles
14. ANS: 4
Chapter: Chapter 31, Infection, Inflammation, and Cirrhosis of the Liver
Page: 724
Objective: N/A
Difficulty: Hard
Heading: Select Pathophysiologic Disorders of the Liver
Integrated Process: Nursing Process
Client Need: Safe and Effective Care: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Nursing Roles
Feedback
1
2
3
4
Coagulopathy is a condition in which the clotting ability of the blood is impaired.
Prolonged prothrombin time is a lab test that indicates clotting deficiency. However, the
client’s prothrombin time is 14 seconds, which is normal. Therefore, the nurse will not
suspect coagulopathy in the client.
Clients with biliary cirrhosis will have elevated alkaline phosphatase levels (ALP).
However, the client’s report shows normal levels of ALP.
Hypoalbuminemia is seen in clients with alcoholic liver disease. However, the client’s
serum albumin level is normal.
The normal range of indirect bilirubin is less than 0.8 mg/dL, but the client has
PRIMEXAM.COM
increased indirect bilirubin levels. This increase in the indirect bilirubin levels is seen in
clients with Gilbert’s disease because of elevated unconjugated bilirubin in the
bloodstream.
PTS: 1
CON: Nursing roles
15. ANS: 2
Chapter: Chapter 31, Infection, Inflammation, and Cirrhosis of the Liver
Page: 704
Objective: N/A
Difficulty: Hard
Heading: Pathophysiologic Disorders of the Liver
Integrated Process: Nursing Process
Client Need: Safe and Effective Care: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Nursing Roles
Feedback
1
Diuretics are used to treat edema in clients with alcoholic liver disease.
2
The lack of synthesis of the coagulation factors occurs in the case of liver diseases
resulting in prolonged prothrombin time. Therefore, the client experiences bruising,
nosebleed, and hematemesis. The nurse suspects vitamin K to be useful in this client
because it helps in the synthesis of the clotting factors.
Band ligation is a treatment option for bleeding esophageal varices in clients with
alcoholic liver disease.
Phototherapy is useful in clients with Crigler-Najjar syndrome to excrete excess
bilirubin from the blood.
3
4
PTS: 1
CON: Nursing Roles
16. ANS: 4
Chapter: Chapter 31, Infection, Inflammation, and Cirrhosis of the Liver
Page: 710
Objective: N/A
Difficulty: Easy
Heading: Acute Hepatitis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Assessment
Feedback
1
In stage 1 of the viral life cycle, active replication of the virus takes place without
elevation of liver enzymes. Antibodies are not produced in stage 1.
2
In stage 2, antigens such as the e antigen (HBeAg) and hepatitis surface antigen
(HBsAg) as well as hepatitis B virus (HBV) DNA are detected in the bloodstream.
PRIMEXAM.COM
3
HBV DNA levels are lower or undetectable, and the liver enzymes decrease to normal
in stage 3.
4
In stage 4 of the viral life cycle, the virus cannot be detected and the antibodies HBsAg,
hepatitis B core antigen (HBcAg), and HBeAg are produced.
PTS: 1
CON: Assessment
17. ANS: 1
Chapter: Chapter 31, Infection, Inflammation, and Cirrhosis of the Liver
Page: 702
Objective: N/A
Difficulty: Hard
Heading: Normal Hepatic Physiology
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Evaluation [Evaluating]
Concept: Nursing Roles
Feedback
1
2
3
4
Glucagon is a hormone produced by the alpha cells of the pancreas, but acts in the liver.
It stimulates lipolysis, hepatic glycogenolysis, and gluconeogenesis. Therefore, this
statement of the client is incorrect and indicates the need for further teaching.
Thrombopoietin is synthesized by the liver. It regulates the production of the platelets
by the bone marrow.
The liver synthesizes angiotensinogen, which takes part in the renin-angiotensinaldosterone system by regulating the blood pressure.
Liver synthesizes insulin-like growth factor, which plays an important role in childhood
growth and has anabolic effects in adults.
PTS: 1
CON: Nursing Roles
18. ANS: 3
Chapter: Chapter 31, Infection, Inflammation, and Cirrhosis of the Liver
Page: 712
Objective: N/A
Difficulty: Hard
Heading: Diagnosis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Critical Thinking
Feedback
1
2
3
4
Liver biopsy is the gold standard test for predicting the prognosis of a disease.
Liver biopsy is used for diagnosing the stages and severity of liver disease.
HCV genotyping is a diagnostic test that is performed in a client with liver disease to
predict the likelihood of response and duration of treatment.
Detection of antibodies against two or more antigens is performed by recombinant
immunoblot assay.
PRIMEXAM.COM
PTS: 1
CON: Critical Thinking
19. ANS: 2
Chapter: Chapter 31, Infection, Inflammation, and Cirrhosis of the Liver
Page: 708
Objective: N/A
Difficulty: Easy
Heading: Acute Hepatitis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Assessment
Feedback
1
2
3
4
An RNA virus is responsible for causing Hepatitis A.
HBV is the only hepatitis caused by an RNA virus.
An RNA virus is responsible for causing hepatitis C.
An RNA virus is responsible for causing hepatitis D.
PTS: 1
CON: Assessment
20. ANS: 2
Chapter: Chapter 31, Infection, Inflammation, and Cirrhosis of the Liver
Page: 708
Objective: N/A
Difficulty: Medium
Heading: Acute Hepatitis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Assessment
Difficulty: Medium
Feedback
1
2
3
4
When the bilirubin is not excreted into the intestine, steatorrhea occurs. It is
characterized by light-colored and soft stools.
The urine is dark in clients with liver disease because of the backup of bilirubin into the
bloodstream. Therefore, the nurse suspects that the accumulation of bilirubin in the
bloodstream is responsible for change in the urine color.
Accumulation of bile salts in the blood leads to itching or pruritus in a client with liver
disease.
The liver becomes infiltrated with fats in nonalcoholic fatty liver disease (NAFLD) and
nonalcoholic steatosis (NASH).
PTS: 1
CON: Assessment
MULTIPLE RESPONSE
PRIMEXAM.COM
21. ANS: 1, 3, 5
Chapter: Chapter 31, Infection, Inflammation, and Cirrhosis of the Liver
Page: 716
Objective: N/A
Difficulty: Hard
Heading: Select Pathophysiologic Disorders of the Liver
Integrated Process: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Nursing Roles
Feedback
1.
This is correct. The client with portal hypertension will have esophageal varices and
ascites. Therefore, a low-sodium diet is important for reducing the fluid accumulation.
2.
This is incorrect. A low-calorie diet is important for clients who have nonalcoholic fatty
liver disease (NAFLD). A low-calorie diet does not have any significance in
hypoalbuminemia or portal hypertension.
This is correct. Hepatic encephalopathy develops due to the accumulation of toxic
nitrogenous wastes in the brain. High protein in the diet may result in increased production
of ammonia and can aggravate hepatic encephalopathy. Therefore, a high-protein diet is
given to the client.
This is incorrect. Administration of calcium compounds will be beneficial for clients with
Crigler-Najjar syndrome. Calcium compounds do not have any role in the treatment of
portal hypertension.
This is correct. Thiamine deficiency is common in alcoholic clients with hepatic
encephalopathy. Therefore, thiamine supplementation is beneficial to prevent further
complications.
3.
4.
5.
PTS: 1
CON: Nursing Roles
22. ANS: 1, 4
Chapter: Chapter 31, Infection, Inflammation, and Cirrhosis of the Liver
Page: 718
Objective: N/A
Difficulty: Medium
Heading: Select Pathophysiologic Disorders of the Liver
Integrated Process: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Nursing Roles
Feedback
1.
2.
This is correct. Low hemoglobin levels causes anemia. Hypersplenism occurs due to portal
hypertension in clients with alcoholic liver disease. It is a disorder that causes the spleen to
prematurely destroy the red blood cells (hemolysis), leading to anemia.
This is incorrect. Hemochromatosis is the excessive accumulation of iron, which is caused
by frequent blood transfusions. It does not cause anemia.
PRIMEXAM.COM
3.
4.
5.
This is incorrect. Hypoalbuminemia is caused by a decrease in the synthesis of albumin by
the liver. This decreases the colloid oncotic pressure, which allows the hydrostatic pressure
to go unbalanced, causing ascites.
This is correct. Clients with liver disease will have disturbed folic acid metabolism,
resulting in folic acid deficiency and anemia.
This is incorrect. Thrombopoietin is a glycoprotein hormone produced by the liver and
kidneys, which helps in the production of platelets. Decreased levels of thrombopoietin
cause thrombocytopenia.
PTS: 1
CON: Nursing Roles
23. ANS: 1, 2
Chapter: Chapter 31, Infection, Inflammation, and Cirrhosis of the Liver
Page: 720
Objective: N/A
Difficulty: Hard
Heading: Select Pathophysiologic Disorders of the Liver
Integrated Process: Nursing Process
Client Need: Safe and Effective Care: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Critical Thinking
Feedback
1.
2.
3.
4.
5.
This is correct. Glucuronyl transferase enzyme deficiency is associated with Crigler-Najjar
syndrome. Glucose transferase enzyme is used to conjugate bilirubin in the liver.
Therefore, its deficiency causes increased bilirubin in the blood (hyperbilirubinemia).
Phenobarbital is used to decrease the bilirubin levels in the client.
This is correct. Phototherapy aids in the breakdown and excretion of bilirubin in clients
who are diagnosed with Crigler-Najjar syndrome.
This is incorrect. Paracentesis is a procedure used to remove fluid from the peritoneal
cavity. It is used to treat ascites in clients with alcoholic liver disease.
This is incorrect. Desferoxamine is a chelating agent used in the treatment of
hematochromatosis.
This is incorrect. Penicillamine is a chelating agent used in the treatment of Wilson’s
disease.
PTS: 1
CON: Critical Thinking
24. ANS: 1, 2
Chapter number and title: Chapter 31: Infection, Inflammation, and Cirrhosis of the Liver
Chapter page reference: 707
Chapter/learning objective: N/A
Heading: Diagnosis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Critical Thinking
Difficulty: Hard
PRIMEXAM.COM
Feedback
1.
2.
3.
4.
5.
This is correct. The incubation period of HAV is 2 to 4 weeks. After the first 4 weeks, there
is a rise in liver enzymes, such as alanine aminotransferases and aspartate
aminotransferases.
This is correct. IgM antiHAV antibodies can be generally detected after the first 4 weeks in
a client with hepatitis A.
This is incorrect. After 8 to 12 weeks of initial infection with HAV, IgM antiHAV
antibodies appear in the blood.
This is incorrect. The stool of a client with hepatitis A shows HAV within 2 to 4 weeks
after the infection.
This is incorrect. The presence of antimitochondrial antibodies is the hallmark of primary
biliary cirrhosis.
PTS: 1
CON: Critical Thinking
ORDERED RESPONSE
25. ANS:
DBAC
Chapter: Chapter 31, Infection, Inflammation, and Cirrhosis of the Liver
Page: 719
Objective: N/A
Difficulty: Hard
Heading: Select Pathophysiologic Disorders of the Liver
Integrated Process: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Digestion
Feedback: The process of primary biliary cirrhosis begins with the inflammation of the portal triads, leading
to the destruction of small and medium bile ducts. The progression of the inflammation causes destruction of
the liver cells. Then fibrotic tissue takes over hepatic cells, leading to the development of micronodular or
macronodular cirrhosis.
PTS: 1
CON: Digestion
PRIMEXAM.COM
Chapter 32: Gallbladder, Pancreatic, and Bile Duct Dysfunction
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. A nurse is assessing a client who has had pain in the right upper quadrant for4 hours. The client reports that
the pain is radiating to the upper thoracic region. A laboratory report suggests elevated liver enzymes and
serum bilirubin. What condition should the nurse suspect from the findings?
1. Biliary tract disorder
2. Biliary colic
3. Cholecystitis
4. Acute pancreatitis
2. A physical examination of a client exhibits Cullen sign and Grey-Turner sign. Which condition should the
nurse suspect in the client?
1. Acute cholecystitis
2. Biliary disorders
3. Acute pancreatitis
4. Emphysematous cholecystitis
3. After providing a volume replacement in a client, a nurse still finds the client to be hypotensive. Which action
should the nurse perform in the client to provide effective care?
1. Initiate use of a nasogastric suction
2. Initiate use of a central catheter
3. Initiate use of a transhepatic T-tube
4. Initiate use of a percutaneous transhepatic biliary catheter
4. A nurse is assessing a client who has episodic abdominal pain, constipation, and flatulence. Upon physical
assessment and review of the laboratory findings, the nurse concludes that the client has jaundice and elevated
serum amylase. Which condition should the nurse suspect in the client?
1. Cholelithiasis
2. Cholecystitis
3. Acute pancreatitis
4. Chronic pancreatitis
5. A nurse finds increased glucose levels in a client who has chronic pancreatitis. What should the nurse
interpret from the finding?
1. The client’s beta cells are damaged.
2. The client has decreased pancreatic enzymes.
3. The client has high bile salts in the blood.
4. The client’s gallbladder was surgically removed.
6. A nurse instructor is teaching a group of nursing students about the pathophysiology of cholecystitis. The
nursing instructor asks, “What happens during chronic cholecystitis?” Which statement of a student nurse
indicates effective learning?
1. “The gallbladder is filled with purulent effusion.”
2. “Perforation and gangrene are developed on the wall of the gallbladder.”
3. “The gallstone passes from the cystic duct into the common bile duct.”
4. “The gallbladder becomes thickened and functions poorly.”
PRIMEXAM.COM
7. A nurse instructor is teaching a group of nursing students about laparoscopic cholecystectomy. Which
statement of a student nurse indicates effective learning?
1. “The client should be on bed rest for 2 weeks.”
2. “The client will have severe pain after the surgery.”
3. “The procedure has a high risk of complications.”
4. “The client has to stay in the health care setting for less than 24 hours after the surgery.”
8. A nurse is caring for a client who reports abdominal distention and pain in the right upper quadrant. The nurse
suspects a biliary disorder in the client. Which medication should the nurse expect the health-care provider to
prescribe for the client to relieve pain?
1. Morphine
2. Codeine
3. Dilaudid
4. None of the above
9. A primary health-care provider prescribes dilaudid to a client who has cholecystitis. What should the nurse
anticipate from this finding?
1. The client has itching.
2. The client has gallstones.
3. Both A and B
4. The client has epigastric pain.
10. A nurse is administering cholestyramine (Questran) to a client who is diagnosed with biliary disease. Which
test should the primary health-care provider prescribe for the client to ensure safety in the client?
1. Liver function test
2. Serum cholesterol
3. Both A and B
4. None of the above
11. A client is brought to the hospital because of severe abdominal pain, nausea, and vomiting. The client reports
increased pain in the abdomen and in the epigastric region radiating to the back when lying supine. Upon
physical assessment, the nurse finds that the client has fever and hypotension. What should the nurse infer
from these findings?
1. The client has cholelithiasis.
2. The client has cholecystitis.
3. The client has acute pancreatitis.
4. The client has chronic pancreatitis.
12. A nurse is caring for a client who has cholecystitis and was diagnosed with pruritus. Which medication should
the nurse expect the health-care provider to prescribe for the client?
1. Urosodiol (Actigall)
2. Dilaudid
3. Chenodiol (Chenix)
4. Cholestyramine (Questran)
13. Which client will benefit from early endoscopic retrograde cholangiopancreatography (ERCP)?
1. A client who has cholelithiasis
2. A client who has cholecystitis
3. A client who has acute pancreatitis
4. A client who has severe gallstone pancreatitis
PRIMEXAM.COM
14. Which diagnostic procedure would a primary health-care provider use to confirm advanced chronic
pancreatitis with exocrine insufficiency in a client?
1. Ultrasound
2. Cholecystogram
3. Fecal chymotrypsin
4. Endoscopic retrograde cholangiopancreatography (ERCP)
15. Which is a common risk factor that leads one susceptible to forming gallstones?
1. Estrogen level
2. Obesity
3. Oral contraceptives
4. Liver enzymes
5. All of the above
16. Where does the liver release its bile?
1. Cystic duct
2. Hepatic duct
3. Pancreatic duct
4. All of the above
17. The clinical reports of a client indicate high levels of bilirubin. What should the nurse infer from the report?
1. The client has stones in the common bile duct.
2. The client has decreased pancreatic enzymes.
3. Both A and B
4. None of the above
18. Which hormone produced by the intestine triggers the release of pancreatic enzymes?
1. Secretin
2. Somatostatin
3. Insulin
4. All of the above
19. Which complication should be suspected in a client who has an obstruction of the common bile duct?
1. Cholecystitis
2. Pancreatic cancer
3. Jaundice
4. All the above
20. Which hormone is released by the pancreas?
1. Glucagon
2. Secretin
3. Both A and B
4. None of the above
21. Which factors may lead to an acute inflammation of the pancreas?
1. Excessive alcohol intake
2. High triglyceride level
3. Both A and B
4. None of the above
Multiple Response
PRIMEXAM.COM
Identify one or more choices that best complete the statement or answer the question.
22. A nurse is reviewing Ranson’s criteria to assess the severity of pancreatitis in a client. Which findings
observed in the client by the nurse within a 48-hour period indicate that the client has chronic pancreatitis?
Select all that apply.
1. Glucose of 10 mmol/L
2. White blood cell count of 15,000 mm3
3. Fluid sequestration of 4 L
4. Partial pressure of oxygen of 40 mmHg
5. Blood urea nitrogen of 1.0 mmol/L
23. The radiographic investigation reports of a client show the presence of stones in the common bile duct. Which
complications should a nurse suspect in the client? Select all that apply.
1. Increase in blood glucose levels
2. Increase in bilirubin levels
3. Increase in bile salts
4. Increase in lipase levels
5. Increase in amylase levels
24. Which complications should a nurse suspect in a client when bile is obstructed from flowing into the
intestine? Select all that apply.
1. Steatorrhea
2. Calculus
3. Jaundice
4. Pruritus
5. Autodigestion
25. Which suggestions should a nurse provide to a client who has chronic pancreatitis? Select all that apply.
1. “You should consume low-fat food.”
2. “You can drink sweetened beverages.”
3. “You should drink plenty of fluids.”
4. “You should take fat-soluble vitamins.”
5. None of the above
PRIMEXAM.COM
Chapter 32: Gallbladder, Pancreatic, and Bile Duct Dysfunction
Answer Section
MULTIPLE CHOICE
1. ANS: 2
Chapter: Chapter 32, Gallbladder, Pancreatic, and Bile Duct Dysfunction
Page: 729
Objective: N/A
Difficulty: Difficult
Heading: Basic Pathophysiologic Concepts of Gallbladder, Pancreas, and Biliary Dysfunction
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Comfort
1
2
3
4
Feedback
Biliary tract disorder is caused by an obstruction of gallstones. Clients who have biliary
tract disorder will exhibit nausea, vomiting, and epigastric pain after eating. In biliary
tract disorders, the pain will radiate to the back.
Calculous biliary colic is pain caused by an irritation of the gallbladder in which the
pain lasts for several hours. Clients who have calculous biliary colic will exhibit
nausea, vomiting, and pain in the right upper quadrant and right flank.
Cholecystitis is an inflammation of the gall bladder due to gallstones. Clients who have
cholecystitis will exhibit epigastric pain in the right upper quadrant, which radiates to
the shoulder. These clients may experience heartburn, anorexia, nausea, vomiting, and
Murphy’s sign.
Acute pancreatitis is an inflammation of the pancreas. The client exhibits a dull and
steady pain in the epigastric region radiating to back as well as hypotension and
tachycardia.
PTS: 1
CON: Comfort
2. ANS: 3
Chapter: Chapter 32, Gallbladder, Pancreatic, and Bile Duct Dysfunction
Page: 734
Objective: N/A
Difficulty: Moderate
Heading: Disorders of the Gallbladder, Pancreas, and Biliary Tract
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Assessment
1
Feedback
In clients who have acute cholecystitis, Murphy’s sign would be observed during a
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physical examination of the right upper quadrant.
In clients who have biliary disorders, a yellowish discoloration of the skin and sclera
would be observed during a physical examination.
Cullen sign is a bluish discoloration that is present around the umbilicus and the GreyTurner sign is a reddish-brown discoloration that is present along the flanks. The Cullen
sign and Grey-Turner sign would be observed during the physical examination of
clients who have acute pancreatitis.
Gangrene is observed in clients who have emphysematous cholecystitis.
PTS: 1
CON: Assessment
3. ANS: 2
Chapter: Chapter 32, Gallbladder, Pancreatic, and Bile Duct Dysfunction
Page: 735
Objective: N/A
Difficulty: Moderate
Heading: Acute Pancreatitis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Nursing
1
2
3
4
Feedback
A nasogastric suction should be inserted for a client who has pancreatitis and is
experiencing vomiting. This action helps to maintain fluid and electrolyte balance in the
client.
Central catheters are used to provide nutrition and medicines to clients to manage the
fluid and electrolyte balance; therefore, the nurse should initiate use of a central
catheter in the client who is hypotensive after a volume replacement has been
performed.
When gallstones are moved into the common bile duct, a transhepatic T-tube is used to
reduce the inflammation, maintain the patency of the duct, and promote the passage of
bile in the client.
A percutaneous transhepatic biliary catheter is used in clients who are symptomatic and
are at high risk clients for gallbladder disease. The client’s gallbladder can also be
visualized by radiographic study.
PTS: 1
CON: Critical Thinking
4. ANS: 4
Chapter: Chapter 32, Gallbladder, Pancreatic, and Bile Duct Dysfunction
Page: 735, 736
Objective: N/A
Difficulty: Difficult
Heading: Chronic Pancreatitis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Evaluation [Evaluating]
Concept: Nursing
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4
Feedback
Clients who have cholelithiasis experience upper left quadrant pain, indigestion, and
eructations. Symptoms such as hypotension and fever are not associated with this
condition. Murphy’s sign is observed in clients who have cholelithiasis.
Clients who have cholecystitis experience upper left quadrant pain, indigestion, and
eructations. Symptoms such as hypotension and fever are not associated with this
condition.
Clients who have acute pancreatitis experience severe abdominal and epigastric pain
radiating to the back when lying supine. Nausea and vomiting are also associated with
this condition. Acute pancreatitis also results in hypotension, fever, and jaundice in the
client.
Clients who have chronic pancreatitis experience episodic epigastric, upper left
quadrant pain, anorexia, constipation, and flatulence. Elevation of serum amylase and
lipase occurs with pancreatic inflammation. Pancreatic malfunctioning results in
jaundice; therefore, the nurse should suspect that the client has chronic pancreatitis.
PTS: 1
CON: Critical Thinking
5. ANS: 1
Chapter: Chapter 32, Gallbladder, Pancreatic, and Bile Duct Dysfunction
Page: 736
Objective: N/A
Difficulty: Difficult
Heading: Chronic Pancreatitis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Nursing
1
2
3
4
Feedback
Glucose levels increase when there is a damage of insulin-producing cells, which are
known as beta cells, in the pancreatitis. During chronic pancreatitis, the insulinproducing cells may get damaged and result in a rise in glucose levels.
Lack of pancreatic enzymes leads to malabsorption. Glucose levels do not increase with
the lack of enzymes.
An increase of bile salts in blood causes pruritus. Increased bile salts do not cause a rise
in glucose in the blood.
The gallbladder would be removed when it is inflamed. Removal of the gallbladder
does not cause a rise in glucose levels.
PTS: 1
CON: Nursing
6. ANS: 4
Chapter: Chapter 32, Gallbladder, Pancreatic, and Bile Duct Dysfunction
Page: 731
Objective: N/A
Difficulty: Difficult
Heading: Cholecystitis
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Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Evaluation [Evaluating]
Concept: Nursing Roles
1
2
3
4
Feedback
This is incorrect. The gallbladder is filled with purulent effusion as a result of a
bacterial infection during acute cholecystitis. This condition is known as empyema;
therefore, this statement by the student nurse is not valid and indicates ineffective
learning.
This is incorrect. Perforation and gangrene are developed on the wall of the gallbladder
during emphysematous cholecystitis; therefore, this statement by the student nurse is
not valid and indicates ineffective learning.
This is incorrect. The gallstone passes from the cystic duct and gallbladder into the
common bile duct during choledocholithiasis; therefore, this statement of the student
nurse is not valid and indicates ineffective learning.
This is correct. Chronic cholecystitis is the repetitive attacks of inflammation of the
gallbladder. During chronic cholecystitis, the gallbladder becomes thickened, rigid,
fibrotic, and functions poorly; therefore, this statement by the student nurse is valid and
indicates effective learning.
PTS: 1
CON: Nursing Roles
7. ANS: 4
Chapter: Chapter 32, Gallbladder, Pancreatic, and Bile Duct Dysfunction
Page: 732
Objective: N/A
Difficulty: Difficult
Heading: Cholecystitis
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Reduction of risk potential
Cognitive Level: Evaluation [Evaluating]
Concept: Nursing Roles
1
2
3
4
Feedback
A laparoscopic cholecystectomy does not require the muscle of the abdomen to be cut
to remove the gallbladder. Since the incisions are smaller, the client will recover very
soon and carry on with his or her daily activities rapidly; therefore, this statement from
the student nurse is not valid and indicates ineffective learning.
A laparoscopic cholecystectomy requires smaller incisions to remove the gallbladder.
Since the incisions are smaller, the client will have less pain after the surgery; therefore,
this statement from the student nurse is not valid and indicates ineffective learning.
Since the muscles of the abdomen are not required to be opened, the procedure has a
lesser risk for acquiring infections and adhesions in the client; therefore, this statement
from the student nurse is not valid and indicates ineffective learning.
Since the incisions are smaller and have a low risk of complications, this procedure
requires a shorter stay in the health-care setting after the surgery; therefore, this
statement from the student nurse is valid and indicates effective learning.
PRIMEXAM.COM
PTS: 1
CON: Nursing Roles
8. ANS: 3
Chapter: Chapter 32, Gallbladder, Pancreatic, and Bile Duct Dysfunction
Page: 732
Objective: N/A
Difficulty: Moderate
Heading: Cholecystitis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Medication
1
2
3
4
Feedback
Morphine is an opioid analgesic that causes contraction of the muscle of the biliary duct
and sphincter of Oddi; therefore, the primary health-care provider should not prescribe
morphine to the client.
Codeine is an opioid analgesic that causes spasm to the muscle of the biliary duct and
sphincter of Oddi; therefore, the primary health-care provider should not prescribe
codeine to the client.
Narcotic analgesics are preferred to relieve pain in biliary disorders, as they do not
cause contraction of muscles. Dilaudid is a narcotic analgesic that helps in relieving
pain; therefore, the primary health-care provider should prescribe dilaudid to ensure the
client’s safety.
One option, dilaudid, is correct; therefore, the option “none of the above” is incorrect.
PTS: 1
CON: Medication
9. ANS: 4
Chapter: Chapter 32, Gallbladder, Pancreatic, and Bile Duct Dysfunction
Page: 732
Objective: N/A
Difficulty: Difficult
Heading: Cholecystitis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Medication
1
2
3
4
Feedback
Clients who have cholecystitis experience itching when the level of bile salts in the
blood is increased. Cholestyramine (Questran) helps in eliminating the bile salts
through feces and relieves the client from itching.
Clients who have cholecystitis may present with gallstones. Urosodiol (Actigall) is an
anticholelithic agent that helps in dissolving the cholesterol in the gallstones.
Dilaudid medication does not help in reducing itching and dissolving cholesterol in the
gallstones. Dilaudid helps in relieving pain.
Clients who have cholecystitis experience pain in the epigastric region. Dilaudid is a
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narcotic analgesic that helps in relieving the pain; therefore, the nurse should anticipate
that the client has epigastric pain.
PTS: 1
CON: Medication
10. ANS: 3
Chapter: Chapter 32, Gallbladder, Pancreatic, and Bile Duct Dysfunction
Page: 732
Objective: N/A
Difficulty: Moderate
Heading: Cholecystitis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Nursing
1
2
3
4
Feedback
Cholestyramine (Questran) is used to eliminate bile salts in clients who have biliary
disorders. Cholestyramine causes abnormal liver function as an adverse effect;
therefore, the primary health-care provider should prescribe a liver function test.
Cholestyramine (Questran) is used to remove accumulated bile salts in clients who have
biliary disorders. Cholestyramine increases the serum cholesterol as an adverse effect;
therefore, the primary health-care provider should prescribe a serum cholesterol test.
Cholestyramine (Questran) causes diarrhea, abnormal liver function, and increases
serum cholesterol as adverse effects; therefore, the primary health-care provider should
prescribe a liver function test and a serum cholesterol test.
Cholestyramine (Questran) causes increased serum cholesterol and abnormal liver
functioning as adverse effects; therefore, the primary health-care provider would
prescribe both a liver function test and a serum cholesterol test to monitor for side
effects in the client.
PTS: 1
CON: Nursing
11. ANS: 3
Chapter: Chapter 32, Gallbladder, Pancreatic, and Bile Duct Dysfunction
Page: 733
Objective: N/A
Difficulty: Difficult
Heading: Acute Pancreatitis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Nursing
1
Feedback
Clients who have cholelithiasis experience right upper quadrant pain, indigestion, and
eructations. Symptoms such as hypotension and fever are not associated with this
condition. Murphy’s sign is observed in clients who have cholelithiasis; therefore, the
client does not have cholelithiasis.
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Clients who have cholecystitis experience right upper quadrant pain, indigestion, and
eructations. Symptoms such as hypotension and fever are not associated with this
condition; therefore, the client does not have cholecystitis.
Clients who have acute pancreatitis experience severe abdominal and epigastric pain
radiating to the back when lying supine. Nausea and vomiting are also associated with
this condition. Acute pancreatitis also results in hypotension, fever, and jaundice in the
client; therefore, the nurse should conclude that the client has acute pancreatitis.
Clients who have chronic pancreatitis experience episodic epigastric and upper left
quadrant pain, anorexia, nausea, and vomiting. Fever is not associated with this
condition; therefore, the client does not have chronic pancreatitis.
PTS: 1
CON: Nursing
12. ANS: 4
Chapter: Chapter 32, Gallbladder, Pancreatic, and Bile Duct Dysfunction
Page: 732, 733
Objective: N/A
Difficulty: Moderate
Heading: Acute Pancreatitis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Medication
1
2
3
4
Feedback
Urosodiol (Actigall) is an anticholelithogenic agent used to dissolve the cholesterol in
gallstones.
Clients who have cholecystitis experience severe pain in the epigastric region. Dilaudid
is a painkiller used to relieve pain; therefore, the nurse should give dilaudid to clients
who are experiencing pain.
Chenodiol (Chenix) is an anticholelithogenic agent used to dissolve the cholesterol in
gallstones.
Pruritus occurs when bile salts accumulate in the blood. This is caused by the biliary
obstruction of the bile in the common bile duct. Cholestyramine (Questran) binds with
the bile salts and helps it to be excreted in the feces; therefore, the nurse should expect
the health-care provider to prescribe cholestyramine (Questran) for the client who has
pruritus.
PTS: 1
CON: Medication
13. ANS: 4
Chapter: Chapter 32, Gallbladder, Pancreatic, and Bile Duct Dysfunction
Page: 730
Objective: N/A
Difficulty: Difficult
Heading: Acute pancreatitis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
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Concept: Informatics
1
2
3
4
Feedback
Ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), and
hepatobiliary (HIDA) scans are found to be beneficial in clients who have
cholelithiasis.
Ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), and
hepatobiliary (HIDA) scans can show gallstones, an inflamed gallbladder wall, bile
stasis or sludge, and are found to be beneficial in clients who have cholecystitis.
Clients who have acute pancreatitis will benefit from ERCP, endoscopic ultrasound, and
magnetic resonance cholangiopancreatography (MRCP).
Clients who have severe gallstone pancreatitis will benefit mostly from an ERCP
procedure. This diagnostic procedure provides accurate visualization of the pancreatic
ductal system.
PTS: 1
CON: Informatics
14. ANS: 3
Chapter: Chapter 32, Gallbladder, Pancreatic, and Bile Duct Dysfunction
Page: 736
Objective: N/A
Difficulty: Moderate
Heading: Chronic Pancreatitis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Comprehension [Understanding]
Concept: Nursing
1
2
3
4
Feedback
Ultrasound is the primary gold standard diagnostic test that is commonly used by the
health-care providers to detect the presence of gallstones. It is not used to confirm
advanced chronic pancreatitis with exocrine insufficiency in a client.
Cholecystogram cannot confirm advanced chronic pancreatitis with exocrine
insufficiency in a client. This test is used to assess the function of the gallbladder.
Fecal chymotrypsin is used to confirm advanced chronic pancreatitis with exocrine
insufficiency in a client.
Endoscopic retrograde cholangiopancreatography (ERCP) is an invasive technique used
to diagnose bile and pancreatic problems. This test is not used to confirm advanced
chronic pancreatitis with exocrine insufficiency in a client.
PTS: 1
CON: Nursing
15. ANS: 5
Chapter: Chapter 32, Gallbladder, Pancreatic, and Bile Duct Dysfunction
Page: 736
Objective: N/A
Difficulty: Easy
Heading: Cholecystitis
Integrated Processes: Nursing Process
PRIMEXAM.COM
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Metabolism
1
2
3
4
5
Feedback
An increase in the levels of estrogen can lead to the formation of gallstones.
Obesity is one of the common factors that leads to the formation of gallstones.
Oral contraceptive therapy is one of the common factors that leads to the formation of
gallstones.
Alteration in liver enzymes is a common risk factor for pancreatitis.
The common risk factors that increase the susceptibility of gallstone formation include
antihyperlipidemia medications, high cholesterol levels, elevated estrogen levels,
obesity, oral contraceptives, and rapid weight loss.
PTS: 1
CON: Metabolism
16. ANS: 2
Chapter: Chapter 32, Gallbladder, Pancreatic, and Bile Duct Dysfunction
Page: 728
Objective: N/A
Difficulty: Easy
Heading: Gallbladder, Pancreatic, and Bile Duct Dysfunction
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Metabolism
1
2
3
4
Feedback
The gallbladder releases its bile into a duct called the cystic duct.
The liver releases its bile into a duct called the hepatic duct.
The pancreas releases its enzymes into a duct called the pancreatic duct.
The liver does not release its bile into all of the ducts provided. The liver releases its
bile only into the hepatic duct.
PTS: 1
CON: Metabolism
17. ANS: 1
Chapter: Chapter 32, Gallbladder, Pancreatic, and Bile Duct Dysfunction
Page: 728
Objective: N/A
Difficulty: Easy
Heading: Basic Pathophysiologic Concepts of Gallbladder, Pancreas, and Biliary Dysfunction
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Metabolism
1
Feedback
The presence of gallstones in the common bile duct leads to the obstruction of bile. This
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obstruction leads to a backup of bile into the gallbladder and liver, which causes a rise
in the levels of bilirubin.
A decrease in the pancreatic enzymes results in malabsorption, which leads to a
deficiency in required nutrients and fat absorption.
The presence of gallstones in the common bile duct leads to a backup of bile, which
causes a rise in bilirubin levels. A decrease in pancreatic enzymes does not cause a rise
in bilirubin levels.
The presence of gallstones in the common bile duct leads to the obstruction of bile,
which causes a backup of bile into the liver and gallbladder. This backup of bile results
in an increased amount of bilirubin levels in the bloodstream.
PTS: 1
CON: Metabolism
18. ANS: 1
Chapter: Chapter 32, Gallbladder, Pancreatic, and Bile Duct Dysfunction
Page: 728
Objective: N/A
Difficulty: Easy
Heading: Basic Concepts of Gallbladder, Pancreas, and Biliary Function
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Metabolism
1
2
3
4
Feedback
Secretin is a hormone released by the intestine, which helps in stimulating the release of
pancreatic enzymes and bile from the bile ducts when food enters into the stomach.
The pancreas releases somatostatin. This hormone inhibits the secretion of insulin and
glucagon in the pancreas.
The pancreas releases insulin to regulate blood glucose levels. Insulin does not trigger
the release of pancreatic enzymes.
The intestine does not release insulin and somatostatin. The pancreas releases insulin
and somatostatin.
PTS: 1
CON: Metabolism
19. ANS: 3
Chapter: Chapter 32, Gallbladder, Pancreatic, and Bile Duct Dysfunction
Page: 736, 737
Objective: N/A
Difficulty: Easy
Heading: Gall Bladder Dysfunction
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Metabolism
1
Feedback
Cholecystitis is an inflammation of the gallbladder. Cholecystitis should be suspected in
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a client who has an obstruction of the cystic duct that is caused by gallstones.
Pancreatic cancer should be suspected in a client who has developed tumors on the head
of the pancreas.
An obstruction of the common bile duct leads to a backup of bile into the gallbladder
and liver. This results in an increase of bilirubin levels, which leads to jaundice;
therefore, jaundice should be suspected in a client who has an obstruction of the
common bile duct.
An obstruction of the common bile duct does not cause cholecystitis or pancreatic
cancer. It causes jaundice.
PTS: 1
CON: Metabolism
20. ANS: 1
Chapter: Chapter 32, Gallbladder, Pancreatic, and Bile Duct Dysfunction
Page: 727
Objective: N/A
Difficulty: Easy
Heading: Gallbladder, Pancreatic, and Bile Duct Dysfunction
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Metabolism
1
2
3
4
Feedback
The glucagon hormone helps in controlling blood glucose levels. The pancreas releases
the glucagon hormone.
Secretin helps in stimulating the release of pancreatic enzymes and bile from the bile
ducts. The intestine releases secretin.
The pancreas does not release the secretin hormone. The intestine releases the secretin
hormone.
The pancreas releases glucagon, which helps in controlling glucose levels.
PTS: 1
CON: Metabolism
21. ANS: 3
Chapter: Chapter 32, Gallbladder, Pancreatic, and Bile Duct Dysfunction
Page: 729
Objective: N/A
Difficulty: Easy
Heading: Pancreatic Exocrine Dysfunction
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Knowledge [Remembering]
Concept: Metabolism
1
2
Feedback
Excessive alcohol consumption is one of the factors that leads to the acute
inflammation of the pancreas.
An increase in the levels of triglycerides is one of the factors that leads to the acute
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inflammation of the pancreas.
Both excessive alcohol consumption and high levels of triglycerides are factors that
cause acute inflammation of the pancreas.
Excessive alcohol consumption, gallstones, high levels of triglycerides in the blood, and
abdominal injury can lead to the acute inflammation of the pancreas.
PTS: 1
CON: Metabolism
MULTIPLE RESPONSE
22. ANS: 4, 5
Chapter: Chapter 32, Gallbladder, Pancreatic, and Bile Duct Dysfunction
Page: 734
Objective: N/A
Difficulty: Difficult
Heading: Ranson’s Criteria for Assessment of Severity of Pancreatitis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Nursing
1.
2.
3.
4.
5.
Feedback
This is incorrect. Ranson’s criteria for assessing the severity of pancreatitis in a client are
used at two stages. Glucose levels are assessed during the admission stage.
This is incorrect. White blood cell count is assessed during admission because it reflects
the intensity of the inflammatory response.
This is incorrect. Fluid sequestration can be assessed in a client during an initial 48-hour
period because it would reflect whether serious complications are present in the client. If
the fluid sequestration is greater than 6 liters, severe pancreatitis is indicated and the client
would require hospitalization.
This is correct. Partial pressure of oxygen can be assessed during an initial 48-hour period
because it would reflect whether serious complications are present in the client. If the
partial pressure of oxygen is less than 60 mm Hg, severe pancreatitis is indicated and the
client would require hospitalization.
This is correct. Blood urea nitrogen can be assessed during an initial 48-hour period
because it would reflect whether serious complications are present in the client. If blood
urea nitrogen is greater than 0.9 mmol/L, severe pancreatitis is indicated and the client
would require hospitalization.
PTS: 1
CON: Nursing
23. ANS: 2, 3
Chapter: Chapter 32, Gallbladder, Pancreatic, and Bile Duct Dysfunction
Page: 737
Objective: N/A
Difficulty: Difficult
Heading: Basic Pathophysiologic Concepts of Gallbladder, Pancreas, and Biliary Dysfunction
Integrated Processes: Nursing Process
PRIMEXAM.COM
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Nursing
1.
2.
3.
4.
5.
Feedback
This is incorrect. Blood glucose levels are increased when the insulin-producing cells in
the pancreas are damaged.
This is correct. Stones in the common bile duct cause a backup of the bile into the
gallbladder and liver; therefore, an increased amount of bile is stored in the liver and
gallbladder, which leads to increased levels of bilirubin.
This is correct. Stones in the common bile duct cause a backup of bile into the gallbladder
and liver. As a result, more amounts of bile salts will be present in the blood.
This is incorrect. Lipase is an enzyme that is produced by the pancreas; therefore, lipase
levels would be increased during pancreatic inflammation.
This is incorrect. Amylase is an enzyme produced by the pancreas; therefore, amylase
levels would be increased during pancreatic inflammation.
PTS: 1
CON: Critical Thinking
24. ANS: 1, 3, 4
Chapter: Chapter 32, Gallbladder, Pancreatic, and Bile Duct Dysfunction
Page: 737
Objective: N/A
Difficulty: Moderate
Heading: Cholecystitis
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Inflammation
1.
2.
3.
4.
5.
Feedback
This is correct. Bile helps in the digestion of fatty foods. Obstruction of bile can cause the
indigestion of fatty foods and result in the formation of fat in the stools, called steatorrhea.
This is incorrect. Calculus, more commonly known as a gallstone, is formed when
cholesterol precipitates out of bile.
This is correct. When bile is obstructed, it flows backward, leading to the accumulation of
more bile and resulting in hyperbilirubinemia, which causes jaundice.
This is correct. Obstruction of bile leads to the accumulation of bile salts in the blood,
which causes pruritus.
This is incorrect. Autodigestion is caused when the pancreatic enzymes backup into the
pancreas.
PTS: 1
CON: Inflammation
25. ANS: 1, 3
Chapter: Chapter 32, Gallbladder, Pancreatic, and Bile Duct Dysfunction
Page: 735, 736
Objective: N/A
Difficulty: Moderate
PRIMEXAM.COM
Heading: Chronic Pancreatitis
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Nursing Roles
1.
2.
3.
4.
5.
Feedback
This is correct. Clients who have chronic pancreatitis will have a lack of lipase enzyme that
helps in the digestion of fatty foods; therefore, the nurse should suggest the client to
consume low-fat foods.
This is incorrect. Clients who have chronic pancreatitis have a lack of insulin hormone
because of the damage of insulin-producing cells, which contribute to a risk of developing
diabetes; therefore, the nurse should suggest that the client avoid drinking sweetened
beverages.
This is correct. Dehydration increases the size of the pancreas; therefore, the nurse should
suggest that the client drink plenty of fluids to avoid dehydration.
This is incorrect. The nurse should suggest that clients who have cholecystitis take fatsoluble vitamins.
This is incorrect. Clients who have chronic pancreatitis will have a lack of the lipase
enzyme. Clients who have dehydration should drink plenty of fluids.
PTS: 1
CON: Nursing Roles
PRIMEXAM.COM
Chapter 33: Cerebrovascular Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. Why is the incidence of strokes rising every year?
1. There is an increased number of older adults.
2. There is an increased incidence of cardiovascular disease.
3. Both A and B.
4. None of the above.
2. The caregiver of a client tells a nurse that the client has paralysis of the upper and lower left limbs. On
assessment, the nurse finds motor and sensory loss in the client’s limbs. Which diagnostic procedure should
the nurse expect the primary health-care provider to prescribe?
1. Blood studies
2. Electrocardiogram
3. Magnetic resonance angiography (MRA)
4. Computed tomography (CT) scan with contrast
3. A nurse finds that a client has motor and sensory loss on the right side of the body. The diagnostic tests reveal
ischemia. The nurse suspects that an ischemic stroke has occurred. Which other finding indicates that the
client has ischemia in the left hemisphere?
1. Speech problem
2. Hearing problem
3. Learning problem
4. Smelling problem
4. On assessment of an older adult client, a nurse finds the blood pressure to be severely increased. A magnetic
resonance imaging (MRI) test reveals a small area of infarction. The primary health-care provider instructs
the nurse to initiate anticoagulant therapy. Which condition should the nurse expect in the client?
1. Lacunar infarct
2. Ischemic stroke
3. Hemorrhagic stroke
4. Transient ischemic attack
5. Which lobe of the cerebrum is responsible for the governing of proprioception?
1. Frontal lobe
2. Parietal lobe
3. Occipital lobe
4. Temporal lobe
6. Which cultural and ethnic group of Americans has a lower risk of stroke when compared to other cultural and
ethnic groups of Americans?
1. Native Americans
2. African Americans
3. Hispanic Americans
4. Caucasian Americans
7. A nurse is examining a client who had a motor vehicle accident. The client is unable to recall past events and
places visited prior to the accident. Which lobe of the cerebrum is involved in the memory loss of the client?
PRIMEXAM.COM
1.
2.
3.
4.
Frontal lobe
Parietal lobes
Occipital lobes
Temporal lobes
8. What is the function of cranial nerve XII in the human body?
1. Hearing
2. Gag reflex
3. Facial sensation
4. Tongue movement
9. A nurse instructs a client to show teeth, raise eyebrows, and squeeze the eyes. What is the nurse trying to
evaluate in the client?
1. Facial palsy
2. Best language
3. Level of consciousness (LOC) commands
4. Sensory response
10. Which part of the brain regulates cardiac and respiratory functions?
1. The pons
2. The midbrain
3. The cerebellum
4. The medulla oblongata
11. A nurse is assessing the level of consciousness of a client who has a head injury. The client is totally
unresponsive. What could be the score using the National Institutes of Health Stroke Scale (NIHSS)?
1. 0
2. 1
3. 2
4. 3
12. A research nurse, while participating in clinical trials, finds that a client has receptive aphasia. Which
pathophysiological change should the nurse expect to be the cause of this condition in the client?
1. Damage to the brain stem
2. Dysfunction in Broca’s area
3. Dysfunction in Wernicke’s area
4. Damage to one side of cerebellum
13. A computed tomography (CT) scan report of a client who has a neurological disorder reveals the presence of
bleeding in a specific area of the brain. On assessment, the nurse finds elevated blood pressure and cerebral
edema. The primary health care provider instructs the nurse to administer intravenous (IV) mannitol. Which
condition should the nurse expect the client to have?
1. Lacunar infarct
2. Ischemic stroke
3. Hemorrhagic stroke
4. Transient ischemic attack
14. A nursing instructor is teaching a group of student nurses about cerebrovascular disorders and associated
pathophysiology. Which statement of the student nurse requires correction?
1. “A small blood vessel infarction that is associated with hypertension is known as a lacunar
infarct.”
PRIMEXAM.COM
2. “The right atrium undergoes atrial fibrillation with stasis of blood and clot formation in an
ischemic stroke.”
3. “The ischemia of the brain is caused by a thromboembolism from a carotid stenosis in a
transient ischemic attack.”
4. “The cerebral artery ruptures and causes a large amount of blood to compress the brain
tissue in a hemorrhagic shock.”
15. A nurse administers intravenous (IV) recombinant tissue-type plasminogen activator (rt-PA) to a client who
was diagnosed with an ischemic stroke. On further evaluation, the nurse finds that the client still has
persistent vessel occlusion. Which treatment strategy should the nurse expect the primary health-care provider
to prescribe for the client?
1. Thrombectomy
2. Endarterectomy
3. Dabigatran (Pradaxa)
4. Dipyrimadole (Aggrenox)
16. Which lobe of cerebrum is associated with analyzing and interpreting visual information?
1. Frontal
2. Parietal
3. Occipital
4. Temporal
17. After performing a neurological examination of a client who is suspected of having a stroke, a nurse
concludes that the client has a moderately severe impairment based on the National Institutes of Health Stroke
Scale (NIHSS). Which score enabled the nurse to reach this conclusion?
1. 4
2. 10
3. 16
4. 28
18. A nurse is assessing the visual fields in a client who was diagnosed with a stroke. The nurse uses the National
Institutes of Health Stroke Scale (NIHSS) to document a score of 3 in the client’s assessment records. Which
condition is associated with the score?
1. No visual loss
2. Partial hemianopia
3. Bilateral hemianopia
4. Complete hemianopia
NARRBEGIN: Exhibit
Exhibit
NARREND
19. A nurse is caring for four clients who were diagnosed with different cerebrovascular disorders.
Client
Condition
Client 1
Lacunar infarct
Client 2
Ischemic stroke
Client 3
Hemorrhagic stroke
Client 4
Transient ischemic attack
Which client requires an endarterectomy surgical procedure to prevent the reoccurrence of the condition?
PRIMEXAM.COM
1.
2.
3.
4.
Client 1
Client 2
Client 3
Client 4
20. A nurse is caring for four clients who have different cerebrovascular disorders.
Client
Client 1
Client 2
Client 3
Client 4
Condition
Brain tumor
Cerebral abscess
Carotid artery aneurysm
Brain stroke
Which client would require a magnetic resonance angiography (MRA) to accurately confirm the client’s
condition?
1. Client 1
2. Client 2
3. Client 3
4. Client 4
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
21. A nurse is assessing an older adult client, who has had a previous transient ischemic attack (TIA). The nurse
finds elevated blood pressure and also suspects injury to the trigeminal nerve. Which findings enable the
nurse to suspect cranial nerve injury? Select all that apply.
1. Impaired chewing
2. Excessive salivation
3. No facial expressions
4. Loss of facial sensation
5. Decreased extraocular movements
22. A primary health care provider instructs a nurse to administer thrombolytic therapy to a client who is
diagnosed with an ischemic stroke. Which detail should the nurse check in the client’s health history prior to
administering the medication to the client? Select all that apply.
1. A history of diabetes
2. A history of bleeding ulcers
3. A history of a recent head injury
4. A history of aspirin use
5. A history of warfarin (Coumadin) use
23. Which cranial nerves are associated with extraocular movements? Select all that apply.
1. Trochlear
2. Abducens
3. Trigeminal
4. Hypoglossal
5. Oculomotor
PRIMEXAM.COM
24. A nurse is teaching a group of student nurses about cranial nerves and their functions. Which cranial nerves
should the nurse refer to as mixed cranial nerves during teaching? Select all that apply.
1. IV
2. VI
3. VII
4. IX
5. X
Completion
Complete each statement.
PRIMEXAM.COM
25. While performing a neurological examination in a client who was diagnosed with a stroke, a nurse finds that
the client does not answer the birth month and age correctly but opens and closes both eyes correctly. The
nurse notes that the client drifts the motor arm to the left and right when elevated and does not speak when
asked to name any items. Based on the National Institute of Health Stroke Scale (NIHSS), what total score
should the nurse obtain from these findings? Record your answer as a whole number.
Chapter 33: Cerebrovascular Disorders
Answer Section
MULTIPLE CHOICE
1. ANS: 1
Chapter: Chapter 33, Cerebrovascular Disorders
Page: 755
Objective: N/A
Difficulty: Easy
Heading: Epidemiology
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Comprehension [Understanding]
Concept: Neurologic Regulation; Safety
1
2
3
4
Feedback
The rising number of older adults accounts for the reason for the high incidence of
strokes occurring every year.
The increased incidence of cardiovascular diseases in men poses them at high risk for
stroke but does not account for a rising incidence of strokes every year.
The increased incidence of cardiovascular disease does not have an effect on the rise in
the incidence of strokes that occur every year. The rising number of older adults
accounts for the reason for the high incidence of strokes occurring every year.
This is incorrect. The rising number of older adults accounts for the reason for the high
incidence of strokes occurring every year.
PTS: 1
CON: Neurologic Regulation; Safety
2. ANS: 3
Chapter: Chapter 33, Cerebrovascular Disorders
Page: 756, 757
Objective: N/A
Difficulty: Hard
Heading: Ischemic Stroke
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Evaluation [Evaluating]
Concept: Neurologic Regulation; Mobility
PRIMEXAM.COM
1
2
3
4
Feedback
Blood studies are helpful for determining the physiological and biochemical changes
associated with strokes, but blood studies do not provide confirmation of strokes.
An electrocardiogram is used to determine the problems related to cardiac function in
association with strokes.
MRA is the test used to further confirm whether a stroke has occurred because it
determines the presence of a clot or aneurysm. The MRA test is also used to distinguish
cerebral hemorrhage and ischemia.
A CT scan with contrast is not used to confirm whether a stroke has occurred because
the contrast dye interferes with the etiological factors of strokes.
PTS: 1
CON: Neurologic Regulation; Mobility
3. ANS: 1
Chapter: Chapter 33, Cerebrovascular Disorders
Page: 761
Objective: N/A
Difficulty: Hard
Heading: Ischemic Stroke
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Evaluation [Evaluating]
Concept: Neurologic Regulation; Mobility
1
2
3
4
Feedback
The left hemisphere contains areas for language comprehension and speech and word
formation; therefore, an ischemic attack in the left hemisphere of the cerebrum would
render speech problems in the client.
The temporal lobes, located at the sides of the right and left hemispheres of the
cerebrum, are responsible for hearing function. If the ischemic attack involves the
temporal lobes, then hearing problems would be detected.
The temporal lobe of the cerebrum is responsible for learning, located on both sides. If
the ischemic attack involves the temporal lobe, then learning impairment will occur.
The temporal lobe of the cerebrum is responsible for smelling function, located on both
sides. If the ischemic attack involves the temporal lobe, then the client cannot identify
or differentiate smells.
PTS: 1
CON: Neurologic Regulation; Mobility
4. ANS: 1
Chapter: Chapter 33, Cerebrovascular Disorders
Page: 761
Objective: N/A
Difficulty: Hard
Heading: Making the Connections
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Evaluation [Evaluating]
PRIMEXAM.COM
Concept: Clotting; Neurologic Regulation; Mobility
1
2
3
4
Feedback
Lacunar infarct is a type of stroke that causes small blood vessel infarction. It is
associated with hypertension and does not impact neurological functions. Anticoagulant
therapy or aspirin is used in the treatment of this type of stroke to prevent further injury.
Ischemic stroke is characterized by motor and sensory loss to one or two sides of the
body. Thrombolytic therapy is initiated rather than anticoagulant therapy to prevent
complications.
Hemorrhagic stroke is characterized by the deterioration of motor and sensory
functions. Generally, supportive or symptomatic care is initiated instead of
anticoagulant therapy.
Transient ischemic attack is characterized by the deterioration of motor and sensory
functions and elevated blood pressure. Anticoagulant therapy may be initiated to
prevent reoccurrence.
PTS: 1
CON: Clotting; Neurologic Regulation; Mobility
5. ANS: 2
Chapter: Chapter 33, Cerebrovascular Disorders
Page: 747
Objective: N/A
Difficulty: Medium
Heading: Brain Lobes and Responsibilities
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Sensory Perception; Neurologic Regulation; Mobility
1
2
3
4
Feedback
The frontal lobe is responsible for the voluntary movement of the body, memory, and
emotions, but this region does not involve proprioception.
Proprioception is the awareness of one’s body and body parts in space and in relation to
each other. The parietal lobe regions of the cerebrum are responsible for governing
proprioception.
The occipital lobes are responsible for analyzing and interpreting visual information.
The temporal lobes are responsible for sensory functions, such as hearing, smelling, and
learning, but these regions do not involve proprioception.
PTS: 1
CON: Sensory Perception; Neurologic Regulation; Mobility
6. ANS: 4
Chapter: Chapter 33, Cerebrovascular Disorders
Page: 755
Objective: N/A
Difficulty: Easy
Heading: Chapter Summary
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
PRIMEXAM.COM
Cognitive Level: Knowledge [Remembering]
Concept: Diversity; Ethics; Neurologic Regulation; Mobility
1
2
3
4
Feedback
Native Americans are at a higher risk of stroke than other cultural and ethnic groups of
Americans.
African Americans are at a higher risk of stroke than other cultural and ethnic groups of
Americans because of their cultural practices.
Hispanic Americans have a higher risk of stroke than non-Hispanic Caucasian
Americans because of their cultural norms and practices.
Caucasian Americans have a lower risk of stroke when compared to other cultural and
ethnic groups of Americans. Their cultural and religious practices reduce the incidence
of stroke.
PTS: 1
CON: Diversity; Ethics; Neurologic Regulation; Mobility
7. ANS: 1
Chapter: Chapter 33, Cerebrovascular Disorders
Page: 747
Objective: N/A
Difficulty: Medium
Heading: Brain Lobes and Responsibilities
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Sensory Perception; Neurologic Regulation; Mobility
1
2
3
4
Feedback
The client lost memory temporarily or permanently as a result of an accidental injury.
Since the frontal lobe of the cerebrum is responsible for memory, the injury affected the
frontal lobe of the cerebrum.
The parietal lobes are responsible for receiving and interpreting sensations of the body,
but not memory; therefore, these regions of the cerebrum were not affected by the
injury.
The occipital lobes are responsible for analyzing and interpreting visual information,
but not memory; therefore, these regions of the cerebrum were not affected by the
injury.
The temporal lobes are responsible for hearing and smelling, but not for memory;
therefore, these regions of the cerebrum were not affected by the injury.
PTS: 1
CON: Sensory Perception; Neurologic Regulation; Mobility
8. ANS: 4
Chapter: Chapter 33, Cerebrovascular Disorders
Page: 750
Objective: N/A
Difficulty: Medium
Heading: Cranial Nerves and Their Function
Integrated Processes: Nursing Process
PRIMEXAM.COM
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Sensory Perception; Neurologic Regulation
1
2
3
4
Feedback
Hearing is the function of cranial nerve VIII, which is the auditory nerve.
The gag reflex is the function of cranial nerve X, which is the vagus nerve.
Facial sensation is the function of cranial nerve V, which is the trigeminal nerve.
In the human body, cranial nerve XII is the hypoglossal nerve, which is the nerve
responsible for tongue movement.
PTS: 1
CON: Sensory Perception; Neurologic Regulation
9. ANS: 1
Chapter: Chapter 33, Cerebrovascular Disorders
Page: 757
Objective: N/A
Difficulty: Medium
Heading: National Institutes of Health Stroke Scale
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Sensory Perception; Neurologic Regulation;
1
2
3
4
Feedback
The nurse instructs the client to show teeth, raise eyebrows, and squeeze the eyes to
assess whether the client has facial nerve palsy.
To evaluate best language, the nurse would instruct the client to name an item, describe
a picture, or read a sentence.
To evaluate LOC commands, the nurse would instruct the client open and close the eyes
and make and release a fist.
To evaluate sensory response, the nurse would use a pin to prick the face, arms, and
legs. The comparison between the elicited responses helps in the evaluation of the
client.
PTS: 1
CON: Sensory Perception; Neurologic Regulation;
10. ANS: 4
Chapter: Chapter 33, Cerebrovascular Disorders
Page: 747
Objective: N/A
Difficulty: Easy
Heading: Brainstem
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Knowledge [Remembering]
Concept: Neurologic Regulation; Oxygenation; Perfusion
Feedback
PRIMEXAM.COM
1
2
3
4
The pons is one of the regions of the brainstem that controls arousal, sleep, and
autonomic functions, but not respiratory functions.
The midbrain controls auditory and visual responses, but not cardiac and respiratory
functions.
The cerebellum is the part of brain that is responsible for smooth and coordinated
movements.
The medulla oblongata, also known as the vital sign center, regulates both cardiac and
respiratory functions.
PTS: 1
CON: Neurologic Regulation; Oxygenation; Perfusion
11. ANS: 4
Chapter: Chapter 33, Cerebrovascular Disorders
Page: 757
Objective: N/A
Difficulty: Easy
Heading: National Institutes of Health Stroke Scale
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Knowledge [Remembering]
Concept: Neurologic Regulation; Sensory Perception
1
2
3
4
Feedback
The score would be 0 if the client is alert while assessing the level of consciousness
(LOC).
The score would be 1 if the client is drowsy while assessing the LOC.
The score would be 2 if the client is not alert while assessing the LOC.
The score is 3 if the client is totally unresponsive, flaccid, or areflexic.
PTS: 1
CON: Neurologic Regulation; Sensory Perception
12. ANS: 3
Chapter: Chapter 33, Cerebrovascular Disorders
Page: 757
Objective: N/A
Difficulty: Medium
Heading: Receptive Aphasia
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Development, Cognition, Sensory Perception
1
2
3
Feedback
Damage to the brain stem does not cause receptive aphasia; however, it affects cranial
nerve function, which includes changes in pupil size.
The ability to speak is controlled by a region called Broca’s area. Dysfunction of this
area causes expressive aphasia.
Wernicke’s area is critical for language comprehension and is connected to Broca’s
area. Dysfunction of this area causes receptive aphasia; therefore, the nurse should
PRIMEXAM.COM
4
expect that dysfunction in Wernicke’s area is the cause for the client’s condition.
Damage to one side of cerebellum does not cause receptive aphasia; however, it may
affect the damaged side of the body and lead to a variety of disorders, depending on the
location of the damaged areas.
PTS: 1
CON: Development, Cognition, Sensory Perception
13. ANS: 3
Chapter: Chapter 33, Cerebrovascular Disorders
Page: 758
Objective: N/A
Difficulty: Hard
Heading: Hemorrhagic stroke
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Evaluation [Evaluating]
Concept: Assessment, Neurologic Regulation; Critical Thinking
1
2
3
4
Feedback
A lacunar infarct is not associated with the presence of bleeding in a specific area of the
brain, elevated blood pressure, or cerebral edema. Lacunar infarct is the result of small
blood vessel infarction that is associated with hypertension.
An ischemic stroke is not associated with the presence of bleeding in a specific area of
the brain, elevated blood pressure, or cerebral edema; however, it is associated with the
obstruction of a branch of a cerebral artery caused by thromboembolism and atrial
fibrillation.
A hemorrhagic stroke is the rupture of a cerebral artery that causes a large amount of
blood to compress the brain tissue. The presence of bleeding in a specific area of the
brain, elevated blood pressure, and cerebral edema are associated with hemorrhagic
stroke. Administration of IV mannitol decreases cerebral edema.
Transient ischemic attack is not associated with the presence of bleeding in a specific
area of the brain, elevated blood pressure, or cerebral edema; however, it is associated
with thromboembolism from carotid stenosis or atrial fibrillation.
PTS: 1
CON: Assessment, Neurologic Regulation; Critical Thinking
14. ANS: 2
Chapter: Chapter 33, Cerebrovascular Disorders
Page: 761
Objective: N/A
Difficulty: Hard
Heading: Ischemic Stroke
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Evaluation [Evaluating]
Concept: Nursing Roles; Neurologic Regulation; Critical Thinking; Nursing Roles
1
Feedback
A lacunar infarct is a small blood vessel infarction associated with hypertension. This
PRIMEXAM.COM
2
3
4
statement of the student nurse does not require any correction.
The left atrium undergoes atrial fibrillation with stasis of blood and clot formation in an
ischemic stroke; therefore, this statement of the student nurse requires correction.
The ischemia of the brain is caused by a thromboembolism from a carotid stenosis in a
transient ischemic attack. This statement of the student nurse does not require any
correction.
The cerebral artery ruptures and causes a large amount of blood to compress the brain
tissue in a hemorrhagic shock. This statement of the student nurse does not require any
correction.
PTS: 1
CON: Nursing Roles; Neurologic Regulation; Critical Thinking; Nursing Roles
15. ANS: 1
Chapter: Chapter 33, Cerebrovascular Disorders
Page: 759
Objective: N/A
Difficulty: Hard
Heading: Treatment for Ischemic Stroke
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Evaluation [Evaluating]
Concept: Nursing Roles; Critical Thinking
1
2
3
4
Feedback
The nurse administered IV rt-PA to the client to dissolve the clot causing the ischemia
of the brain tissue. Since the client still has persistent vessel occlusion, the nurse should
expect the primary health-care provide to prescribe a thrombectomy as a treatment
strategy for the client.
The client who was diagnosed with an ischemic stroke does not require an
endarterectomy surgical procedure. Clients who are diagnosed with a transient ischemic
attack would require this surgical procedure to prevent its reoccurrence.
Clients who are diagnosed with an ischemic stroke should be prescribed with newer
anticoagulant agents, such as dabigatran (Pradaxa), for the long-term management of
the condition.
If the client who was diagnosed with an ischemic stroke is not eligible for thrombolytic
therapy, aspirin and antiplatelet agents, such as dipyridamole (Aggrenox), to dissolve
clots should be prescribed for the client.
PTS: 1
CON: Nursing Roles; Critical Thinking
16. ANS: 3
Chapter: Chapter 33, Cerebrovascular Disorders
Page: 747
Objective: N/A
Difficulty: Easy
Heading: Brain Lobes and Responsibilities
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
PRIMEXAM.COM
Concept: Neurologic Regulation; Cognition
1
2
3
4
Feedback
The frontal lobe of the cerebrum is associated with memory, emotion, reasoning, and
aggression.
The parietal lobe of the cerebrum is associated with receiving and interpreting bodily
sensations.
The occipital lobe of the cerebrum is associated with analyzing and interpreting visual
information.
The temporal lobe of the cerebrum is associated with hearing, smelling, learning, and
emotional behavior.
PTS: 1
CON: Neurologic Regulation; Cognition
17. ANS: 3
Chapter: Chapter 33, Cerebrovascular Disorders
Page: 757
Objective: N/A
Difficulty: Medium
Heading: National Institutes of Health Stroke Scale
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Communication; Assessment
1
2
3
4
Feedback
A score of less than 5 indicates that the client has a mild impairment; therefore, a score
of 4 indicates that the client has a mild impairment.
A score between 5 and 15 indicates that the client has a mild to moderate impairment;
therefore, a score of 10 indicates that the client has a mild to moderate impairment.
A score between 15 and 25 indicates that the client has a moderate to severe
impairment; therefore, a score of 16 indicates that the client has a moderate to severe
impairment.
A score greater than 25 indicates that the client has a very severe impairment; therefore,
a score of 28 indicates that the client has a very severe impairment.
PTS: 1
CON: Communication; Assessment
18. ANS: 3
Chapter: Chapter 33, Cerebrovascular Disorders
Page: 757
Objective: N/A
Difficulty: Medium
Heading: National Institutes of Health Stroke Scale
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Communication; Assessment
PRIMEXAM.COM
1
2
3
4
Feedback
The nurse documents a score of 0 when the client has no visual loss.
The nurse documents a score of 1 if the client has partial hemianopia.
The nurse documents a score of 3 if the client has bilateral hemianopia.
The nurse documents a score of 2 if the client has complete hemianopia.
PTS: 1
CON: Communication; Assessment
19. ANS: 4
Chapter: Chapter 33, Cerebrovascular Disorders
Page: 761
Objective: N/A
Difficulty: Hard
Heading: Ischemic Stroke
Integrated Processes: Nursing Process
Client Need: Physiological Adaptation
Cognitive Level: Evaluation [Evaluating]
Concept: Nursing Roles; Neurologic Regulation; Critical Thinking
1
2
3
4
Feedback
Client 1 suffered from a lacunar infarct. Clients who had a lacunar infarct do not require
any surgical procedures. The client would require pharmacological treatments, such as
aspirin or anticoagulant therapy.
Client 2 suffered from an ischemic stroke. Clients who had ischemic strokes do no