HESI PATHO, PRACTICE QUESTIONS AND ANSWERS+RATIONALES PART 1 A+ GRADE

HESI PATHO, PRACTICE QUESTIONS AND ANSWERS+RATIONALES PART 1 A+ GRADE Which rationale best supports an older client's risk of complications related to a dysrhythmia? - ANS- An older client is intolerant of decreased cardiac output which may cause dizziness and falls In an older client, cardiac output is decreased and a loss of contractility and elasticity reduces systemic and cerebral blood flow, so dysrhythmias, such as bradycardia or tachycardia is poorly tolerated, and increases the client's risk for syncope, falls, transient ischemic attacks, and possibly dementia. - ANS- The nurse is assessing an older client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the nurse use to document this finding? - ANS-Ptosis of the left eyelid Ptosis is the term to describe an eyelid droop that covers a large portion of the iris astigmatism -- distortion of the lens of the eye, causing decreased visual acuity. nystagmus - ANS-eye makes uncontrolled movements; oculomotor nerve or eyelid muscle disorder that is characterized by rapid, rhythmic movement of both eyes. exophthalmos - ANS-protrusion of the eyeballs that occurs with hyperthyroidism The nurse is measuring blood pressure on all four extremities of a child with coarctation of the aorta. Which blood pressure finding should the nurse expect to obtain? - ANS-Lower in the legs than the arms In coarctation of the aorta, a congenital constriction is found at the aorta near the ductus arteriosus region that lies past the left subclavian arteries, which perfuses the upper extremities. the child should have higher blood pressures in the upper extremities than in the legs. The nurse reviews the CBC findings of an adolescent with acute myelogenous leukemia. The hemoglobin is 13.8, hematocrit is 36.7 WBC is 8,200 and platelet count is 115,000., Based on these findings, what is the priority nursing dx for this client's plan of care? - ANS