NGN PATHOPHYSIOLOGY FORM A
1. The nurse provides care for a client with a two year history of sickle celldisease.
Which factor increases the risk of vasoocclusivecrisis?
a. Fluid volume overload
b. Influenza infection
c. Decreased protein intake
d. Low serum hemoglobin
Answer: b. Influenza infection
Rationale:
-fluid volume deficit, not overload, is cause of vasoocclusive crisisas decreasedblood
volume increases the risk of occlusion of the smaller blood vessels by abnormally
shaped red cells
-infection, cold temp, fluid vol deficit, exposure to high altitudes, and stress cause local
hypoxemia causing red cells to assume a sickle shape, clump together, andadhere to
blood vessel walls
-no relationship
-decreased hemoglobin levels result from sickle cell disease and donot contributeto
vasoocclusive crisis
2. 5 lb weight loss
a. concerning
b. not concerning
Answer:a. concerning
3. Capillary refill, 2 seconds
a. concerning
b. not concerning
Answer: b. not concerning
4. Drowsiness and lethargy
a. concerning
b. not concerning
Answer: a. concerning
,5. Apical pulse, 110, irregular
a. concerning
b. not concerning
Answer: a. concerning
6. Low pitched vesicular lung sounds
a. concerning
b. not concerning
Answer: b. not concerning
7. Neck veins flat when supine
a. concerning
b. not concerning
Answer: a. concerning
Rationale:
-jugular veins should be full but not distended when a pt is lying supine, flat
jugularveins may indicate hypovolemia or hemothorax
8. Fluid intake less than output
a. concerning
b. not concerning
Answer: a. concerning
9. Urine dark yellow color
a. concerning
b. not concerning
Answer: a. concerning
10. Muscle weakness and limited mobility
a. concerning
b. not concerning
Answer: a. concerning
, 11. The nurse determines the client is experiencing a fluidimbalance
inwhich the concentration of fluids is
a. isotonic
b. hypotonic
c. hypertonic: Answer
Answer: c. hypertonic
Rationale:
-elevated sodium levels indicate client has a hypertonic fluid imbalance, body fluidsare
too concentrated due to loss of more water than salt. In hypotonic imbalances, body
fluids are too dilute due to water excess
12. The nurse is aware that the client is also experiencing a fluidimbalancein
which the volume of extracellular fluid is
a. increased
b. normal
c. decreased
Answer: c. decreased
Rationale:
-nurse recognizes elevated BUN indicates the client has decreasedfluid volumewith
extracellular fluid vol deficit.
13. The nurse provides care for a client who has been involved in a motor vehicle
accident. The client is diagnosed with an epidural hematoma. Epidural hematoma is
most commonly associated with which condition?
a. thrombosis of the internal carotid artery
b. damage to the middle meningeal artery
c. rupture of the bridging veins
d. fracture of the base of the skull
Answer: b. damage to the middle meningealartery
Rationale:
-this is clot formation in the internal carotid artery and is cause oftransient ischemicattacks
(TIAs) or thrombotic stroke
-epidural hematoma is when blood accumulates between the skull and dura materand
typically occur when a skull fracture tears an underlying blood vessel aka temporal
bone fracture which leads tomiddle meningeal artery causing arterial blood to
accumulate in epidural space
1. The nurse provides care for a client with a two year history of sickle celldisease.
Which factor increases the risk of vasoocclusivecrisis?
a. Fluid volume overload
b. Influenza infection
c. Decreased protein intake
d. Low serum hemoglobin
Answer: b. Influenza infection
Rationale:
-fluid volume deficit, not overload, is cause of vasoocclusive crisisas decreasedblood
volume increases the risk of occlusion of the smaller blood vessels by abnormally
shaped red cells
-infection, cold temp, fluid vol deficit, exposure to high altitudes, and stress cause local
hypoxemia causing red cells to assume a sickle shape, clump together, andadhere to
blood vessel walls
-no relationship
-decreased hemoglobin levels result from sickle cell disease and donot contributeto
vasoocclusive crisis
2. 5 lb weight loss
a. concerning
b. not concerning
Answer:a. concerning
3. Capillary refill, 2 seconds
a. concerning
b. not concerning
Answer: b. not concerning
4. Drowsiness and lethargy
a. concerning
b. not concerning
Answer: a. concerning
,5. Apical pulse, 110, irregular
a. concerning
b. not concerning
Answer: a. concerning
6. Low pitched vesicular lung sounds
a. concerning
b. not concerning
Answer: b. not concerning
7. Neck veins flat when supine
a. concerning
b. not concerning
Answer: a. concerning
Rationale:
-jugular veins should be full but not distended when a pt is lying supine, flat
jugularveins may indicate hypovolemia or hemothorax
8. Fluid intake less than output
a. concerning
b. not concerning
Answer: a. concerning
9. Urine dark yellow color
a. concerning
b. not concerning
Answer: a. concerning
10. Muscle weakness and limited mobility
a. concerning
b. not concerning
Answer: a. concerning
, 11. The nurse determines the client is experiencing a fluidimbalance
inwhich the concentration of fluids is
a. isotonic
b. hypotonic
c. hypertonic: Answer
Answer: c. hypertonic
Rationale:
-elevated sodium levels indicate client has a hypertonic fluid imbalance, body fluidsare
too concentrated due to loss of more water than salt. In hypotonic imbalances, body
fluids are too dilute due to water excess
12. The nurse is aware that the client is also experiencing a fluidimbalancein
which the volume of extracellular fluid is
a. increased
b. normal
c. decreased
Answer: c. decreased
Rationale:
-nurse recognizes elevated BUN indicates the client has decreasedfluid volumewith
extracellular fluid vol deficit.
13. The nurse provides care for a client who has been involved in a motor vehicle
accident. The client is diagnosed with an epidural hematoma. Epidural hematoma is
most commonly associated with which condition?
a. thrombosis of the internal carotid artery
b. damage to the middle meningeal artery
c. rupture of the bridging veins
d. fracture of the base of the skull
Answer: b. damage to the middle meningealartery
Rationale:
-this is clot formation in the internal carotid artery and is cause oftransient ischemicattacks
(TIAs) or thrombotic stroke
-epidural hematoma is when blood accumulates between the skull and dura materand
typically occur when a skull fracture tears an underlying blood vessel aka temporal
bone fracture which leads tomiddle meningeal artery causing arterial blood to
accumulate in epidural space
