PBSC Nursing Unit 2 Sem 3 New Exam With Correct
Answers 100% Verified
When evaluating a 53-year-old client diagnosed with bacterial meningitis, the nurse
gathers the
following information. Which manifestation should be communicated
immediately
to the health care provider?
a. The patient shows nuchal rigidity.
b. The patient demonstrates a positive Kernig's sign.
c. The patient has a temperature of 101°F (38.3°C).
d. The patient's blood pressure is 88/42 mm Hg - ANSWER ANS:
D
Shock is a potentially life-threatening complication of meningitis, and this patient's low
blood pressure suggests the need for treatments such as fluids or vasopressors. Nuchal
rigidity and a positive
Kernig's sign are expected with bacterial meningitis. The nurse should intervene to
lower the
temperature, but this is not as life threatening as the hypotension
A client is diagnosed with acute gastritis secondary to alcoholism and cirrhosis. The
client reports frequent nausea, pain that increases after meals, and black, tarry stools.
The client recently joined Alcoholics Anonymous. The nurse should give priority to
which client history item?
a-Black, tarry stools
b-Frequent nausea
c-Joining Alcoholics Anonymous
d-Pain that increases after meals - ANSWER ANS: A-black, tarry stools
,The priority is black tarry stools indicating upper GI bleeding; the blood is acted upon by
digestive enzymes, which produces tarry stools. Erosion through to blood vessels leads
to hemorrhage. Nausea is a common symptom of gastritis but is not life-threatening.
Efforts at controlling alcoholism should be supported but are a long-term goal;
assessment of bleeding takes priority. The cause of bleeding should be investigated,
and in subsequent times the nurse should assist the client to identify troublesome food
which is aggravating the pain after eating and must be avoided.
A client is admitted to the hospital for acute gastritis and ascites secondary to
alcoholism and cirrhosis. For which condition is it most important for the nurse to
assess this client?
A-Nausea
B-Blood in the stool
C-Food intolerances
D-Hourly urinary output - ANSWER B-Blood in stool
Erosion of blood vessels can result in hemorrhage, a life-threatening event further
complicated by decreased production of prothrombin, which occurs with cirrhosis.
Food intolerances should be identified; however, there is no threat to life. Increased
intraabdominal pressure due to ascites can precipitate nausea; therefore, this is not
life-threatening. There is no need to monitor hourly urine output.
The nurse should expect to find which of the following clinical findings during the
assessment of a child with acute glomerulonephritis (AGN)? Select all that apply.
a-Flank pain
b-Periorbital edema
c-Intermittent fever
d-Increased urine volume
e-Decreased joint mobility - ANSWER Ans: A-Flank pain, b- Periorbital edema
Flank pain results from inflammatory and degenerative changes in renal tissue; renal
damage occurs because antigen-antibody complexes become trapped in the glomeruli.
With dysfunction of the glomeruli, filtration of plasma decreases, leading to fluid
accumulation and sodium retention; congestion and edema result. Fevers do not occur
in association with AGN. A decrease, rather than an increase, in the volume of urine is
generally seen. Decreased mobility of the joints does not occur in AGN.
,A client with hepatitis B (HBV) develops cirrhosis and is admitted to the hospital. One
potential sequela of chronic liver disease is fluid and electrolyte imbalance. The nurse
identifies that this may be due to a decrease in serum albumin level. Which of these
conditions is the result of this imbalance?
a-Hemorrhage with subsequent anemia
b-Diminished resistance to bacterial insult
c-Malnutrition of cells, especially hepatic cells
d-Reduced colloidal osmotic pressure of the blood - ANSWER Ans: d-reduced colloidal
osmotic pressure of the blood
Albumin is a crucial constituent of the blood, which aids in the maintenance of both
osmotic pressure as well as fluid and electrolytes. This is not a cause of hemorrhage.
Constituents present in the blood include platelets, thrombin, and erythrocytes, which
are responsible for preventing hemorrhage or anemia. Diminished resistance to
bacterial insult is not involved with immunity and resistance directly. Similarly, blood
components include T and B lymphocytes that take part in this process, whereas the
liver synthesizes specific proteins intrinsic to the function of antibodies. Serum albumin
level is not related to nutrition of cells.
The parents of a 6-year-old child tell a nurse at the pediatric clinic that their child is
weak and lethargic, has headaches, has no appetite, and has dark, cloudy urine. The
nurse suspects acute poststreptococcal glomerulonephritis (APSGN). What should the
nurse ask the mother?
a-"Has your child lost weight recently?"
b-"Did your child have a sore throat during the past 3 weeks?"
c- "Does your child have migratory pains in the shoulders and knees?"
d- "Has your child had a rash on the palms and soles in the past 2 weeks?" - ANSWER
Ans: B-Did your child have a sore throat during the past 3 weeks?
If the answer to the question suggests a sore throat in the recent past, the practitioner
may choose to order certain investigations to establish the presence of ASPGN. Weight
loss is seen in children with type 1 diabetes and does not occur in glomerulonephritis.
Such pain is associated with rheumatic fever and scarlet fever, neither of which
presents with smoky urine due to hematuria. A rash on the palms and soles is also not a
feature of APSGN.
, The nurse is caring for a client diagnosed with cirrhosis of the liver. Which clinical
manifestations should the nurse expect to find in the client?
A-Ascites
B-Appetite
C- Pruritus
D-Jaundice
E-Headache - ANSWER Ans: A- Ascites, C- Pruritis, D-Jaundice
Ascites is a result of portal hypertension that occurs with cirrhosis. Pruritus is common
because the bile pigments seep into the skin from the bloodstream. Jaundice occurs
because the bile duct becomes obstructed and the bile enters the bloodstream. The
appetite decreases because of the pressure on the abdominal organs from the ascites
and the liver's decreased ability to metabolize food. Headache is not a common
manifestation of cirrhosis of the liver.
A nurse is performing an assessment on a school-aged child who has been admitted to
the pediatric unit with a diagnosis of acute glomerulonephritis. What clinical finding
does the nurse expect?
A-Polyuria
B-Dehydration
C-Periorbital edema
D-Decreased blood pressure - ANSWER Ans: C-Periorbital Edema
Decreased filtration of plasma at the glomeruli results in an excess accumulation of fluid
and sodium, producing edema that is first evident around the eyes. Oliguria, not
polyuria, occurs. There is an excess, not a deficient amount of, body fluid. Hypertension,
not hypotension, occurs.
A nurse is caring for a child with a tentative diagnosis of acute poststreptococcal
glomerulonephritis (APSGN). What test does the nurse expect to be used to confirm the
diagnosis?
A-Renal biopsy
B-Pharyngeal culture
Answers 100% Verified
When evaluating a 53-year-old client diagnosed with bacterial meningitis, the nurse
gathers the
following information. Which manifestation should be communicated
immediately
to the health care provider?
a. The patient shows nuchal rigidity.
b. The patient demonstrates a positive Kernig's sign.
c. The patient has a temperature of 101°F (38.3°C).
d. The patient's blood pressure is 88/42 mm Hg - ANSWER ANS:
D
Shock is a potentially life-threatening complication of meningitis, and this patient's low
blood pressure suggests the need for treatments such as fluids or vasopressors. Nuchal
rigidity and a positive
Kernig's sign are expected with bacterial meningitis. The nurse should intervene to
lower the
temperature, but this is not as life threatening as the hypotension
A client is diagnosed with acute gastritis secondary to alcoholism and cirrhosis. The
client reports frequent nausea, pain that increases after meals, and black, tarry stools.
The client recently joined Alcoholics Anonymous. The nurse should give priority to
which client history item?
a-Black, tarry stools
b-Frequent nausea
c-Joining Alcoholics Anonymous
d-Pain that increases after meals - ANSWER ANS: A-black, tarry stools
,The priority is black tarry stools indicating upper GI bleeding; the blood is acted upon by
digestive enzymes, which produces tarry stools. Erosion through to blood vessels leads
to hemorrhage. Nausea is a common symptom of gastritis but is not life-threatening.
Efforts at controlling alcoholism should be supported but are a long-term goal;
assessment of bleeding takes priority. The cause of bleeding should be investigated,
and in subsequent times the nurse should assist the client to identify troublesome food
which is aggravating the pain after eating and must be avoided.
A client is admitted to the hospital for acute gastritis and ascites secondary to
alcoholism and cirrhosis. For which condition is it most important for the nurse to
assess this client?
A-Nausea
B-Blood in the stool
C-Food intolerances
D-Hourly urinary output - ANSWER B-Blood in stool
Erosion of blood vessels can result in hemorrhage, a life-threatening event further
complicated by decreased production of prothrombin, which occurs with cirrhosis.
Food intolerances should be identified; however, there is no threat to life. Increased
intraabdominal pressure due to ascites can precipitate nausea; therefore, this is not
life-threatening. There is no need to monitor hourly urine output.
The nurse should expect to find which of the following clinical findings during the
assessment of a child with acute glomerulonephritis (AGN)? Select all that apply.
a-Flank pain
b-Periorbital edema
c-Intermittent fever
d-Increased urine volume
e-Decreased joint mobility - ANSWER Ans: A-Flank pain, b- Periorbital edema
Flank pain results from inflammatory and degenerative changes in renal tissue; renal
damage occurs because antigen-antibody complexes become trapped in the glomeruli.
With dysfunction of the glomeruli, filtration of plasma decreases, leading to fluid
accumulation and sodium retention; congestion and edema result. Fevers do not occur
in association with AGN. A decrease, rather than an increase, in the volume of urine is
generally seen. Decreased mobility of the joints does not occur in AGN.
,A client with hepatitis B (HBV) develops cirrhosis and is admitted to the hospital. One
potential sequela of chronic liver disease is fluid and electrolyte imbalance. The nurse
identifies that this may be due to a decrease in serum albumin level. Which of these
conditions is the result of this imbalance?
a-Hemorrhage with subsequent anemia
b-Diminished resistance to bacterial insult
c-Malnutrition of cells, especially hepatic cells
d-Reduced colloidal osmotic pressure of the blood - ANSWER Ans: d-reduced colloidal
osmotic pressure of the blood
Albumin is a crucial constituent of the blood, which aids in the maintenance of both
osmotic pressure as well as fluid and electrolytes. This is not a cause of hemorrhage.
Constituents present in the blood include platelets, thrombin, and erythrocytes, which
are responsible for preventing hemorrhage or anemia. Diminished resistance to
bacterial insult is not involved with immunity and resistance directly. Similarly, blood
components include T and B lymphocytes that take part in this process, whereas the
liver synthesizes specific proteins intrinsic to the function of antibodies. Serum albumin
level is not related to nutrition of cells.
The parents of a 6-year-old child tell a nurse at the pediatric clinic that their child is
weak and lethargic, has headaches, has no appetite, and has dark, cloudy urine. The
nurse suspects acute poststreptococcal glomerulonephritis (APSGN). What should the
nurse ask the mother?
a-"Has your child lost weight recently?"
b-"Did your child have a sore throat during the past 3 weeks?"
c- "Does your child have migratory pains in the shoulders and knees?"
d- "Has your child had a rash on the palms and soles in the past 2 weeks?" - ANSWER
Ans: B-Did your child have a sore throat during the past 3 weeks?
If the answer to the question suggests a sore throat in the recent past, the practitioner
may choose to order certain investigations to establish the presence of ASPGN. Weight
loss is seen in children with type 1 diabetes and does not occur in glomerulonephritis.
Such pain is associated with rheumatic fever and scarlet fever, neither of which
presents with smoky urine due to hematuria. A rash on the palms and soles is also not a
feature of APSGN.
, The nurse is caring for a client diagnosed with cirrhosis of the liver. Which clinical
manifestations should the nurse expect to find in the client?
A-Ascites
B-Appetite
C- Pruritus
D-Jaundice
E-Headache - ANSWER Ans: A- Ascites, C- Pruritis, D-Jaundice
Ascites is a result of portal hypertension that occurs with cirrhosis. Pruritus is common
because the bile pigments seep into the skin from the bloodstream. Jaundice occurs
because the bile duct becomes obstructed and the bile enters the bloodstream. The
appetite decreases because of the pressure on the abdominal organs from the ascites
and the liver's decreased ability to metabolize food. Headache is not a common
manifestation of cirrhosis of the liver.
A nurse is performing an assessment on a school-aged child who has been admitted to
the pediatric unit with a diagnosis of acute glomerulonephritis. What clinical finding
does the nurse expect?
A-Polyuria
B-Dehydration
C-Periorbital edema
D-Decreased blood pressure - ANSWER Ans: C-Periorbital Edema
Decreased filtration of plasma at the glomeruli results in an excess accumulation of fluid
and sodium, producing edema that is first evident around the eyes. Oliguria, not
polyuria, occurs. There is an excess, not a deficient amount of, body fluid. Hypertension,
not hypotension, occurs.
A nurse is caring for a child with a tentative diagnosis of acute poststreptococcal
glomerulonephritis (APSGN). What test does the nurse expect to be used to confirm the
diagnosis?
A-Renal biopsy
B-Pharyngeal culture
