HESI Pathophysiology (Patho & pharm EVOLVE q's)
Study online at https://quizlet.com/_fe94lr
1. The nurse hears short, Crackles in the right and left lower lobes.
high-pitched sounds just be-
fore the end of inspiration in Rationale: Fine crackles are short, high-pitched sounds heard
the right and left lower lobes just before the end of inspiration that are the result of rapid
when auscultating a client's equalization of pressure when collapsed alveoli or terminal
lungs. How should this finding bronchioles suddenly snap open.
be recorded?
-Inspiratory wheezes in both
lungs.
-Crackles in the right and left
lower lobes.
-Abnormal lung sounds in the
bases of both lungs.
-Pleural friction rub in the right
and left lower lobes.
2. The nurse is planning care for Risk for injury related to denial of deficits and impulsiveness.
a client who has a right hemi-
spheric stroke. Which nursing Rationale: With right-brain damage, a client experience diffi-
diagnosis should the nurse in- culty in judgment and spatial perception and is more likely to
clude in the plan of care? be impulsive and move quickly, which places the client at risk
for falls.
-Impaired physical mobility re-
lated to right-sided hemiple-
gia.
-Risk for injury related to de-
nial of deficits and impulsive-
ness.
-Impaired verbal communica-
tion related to speech-lan-
guage deficits.
, HESI Pathophysiology (Patho & pharm EVOLVE q's)
Study online at https://quizlet.com/_fe94lr
-Ineffective coping related to
depression and distress about
disability.
3. The nurse is assessing a post- Cystocele
menopausal woman who is
complaining of urinary ur- Rationale: This constellation of signs in a postmenopausal
gency and frequency and woman are characteristic of a cystocele. These symptoms are
stress incontinence. She also not characteristic of the other options.
reports difficulty in emptying
her bladder. These complaints
are most likely due to which
condition?
-Cystocele.
-Bladder infection.
-Pyelonephritis.
-Irritable bladder.
4. The nurse is caring for a Loss of thirst, weight gain
client with syndrome of in-
appropriate antidiuretic hor- Rationale: SIADH occurs when the posterior pituitary gland re-
mone (SIADH), which is mani- leases too much ADH, causing water retention, a urine output
fested by which symptoms? of less than 20 ml/hour, and dilutional hyponatremia. Other
indications of SIADH are loss of thirst, weight gain, irritability,
-Loss of thirst, weight gain. muscle weakness, and decreased level of consciousness.
-Dependent edema, fever.
-Polydipsia, polyuria.
-Hypernatremia, tachypnea.
5. The nurse is teaching a client Both genes of a pair must be abnormal for the disorder to
with maple syrup urine dis- occur
ease (MSUD), an autosomal re-
, HESI Pathophysiology (Patho & pharm EVOLVE q's)
Study online at https://quizlet.com/_fe94lr
cessive disorder, about the in- Rationale: Maple syrup urine disease (MSUD) is a type of
heritance pattern. Which in- autosomal recessive inheritance disorder in which both genes
formation should the nurse of a pair must be abnormal for the disorder to be expressed.
provide?
-This recessive disorder is car-
ried only on the X chromo-
some.
-Occurrences mainly affect
males and heterozygous fe-
males.
-Both genes of a pair must be
abnormal for the disorder to
occur.
-One copy of the abnormal
gene is required for this disor-
der.
6. What information should the -Smoking
nurse include in a teach- -early menarche
ing plan about the onset of -genetic influence
menopause? (Select all that -chemotherapy exposure
apply).
Rationale: Menopausal symptoms are related to the ces-
-Smoking. sation of ovarian function. Factors influencing the onset of
-Oophorectomy with hysterec- menopause include smoking, genetic influences, early men
tomy.
-Early menarche.
-Cardiac disease.
-Genetic influence.
-Chemotherapy exposure.
, HESI Pathophysiology (Patho & pharm EVOLVE q's)
Study online at https://quizlet.com/_fe94lr
7. The nurse reviews the com- risk for injury
plete blood count (CBC) find-
ings of an adolescent with Rationale: A client with AML is at risk for anemia, neutrope-
acute myelogenous leukemia nia, and thrombocytopenia. These CBC findings indicate that
(AML). The hemoglobin is the platelet count is low (normal 250,000 to 400,000 mm3),
13.8 g/dl, hematocrit is 36.7%, which places this client at an increased risk for injury, usually
white blood cell count is 8,200 manifested as bruising or bleeding.
mm3, and platelet count is
115,000 mm3. Based on these
findings, what is the priori-
ty nursing diagnosis for this
client's plan of care?
-Impaired gas exchange.
-Risk for infection.
-Risk for injury.
-Risk for activity intolerance.
8. A mother is crying as she lay the child down and ask the mother to stay near the child
holds and rocks her child with in the crib
tetanus who is having muscu-
lar spasms and crying. After Rationale: Controlling environmental stimulation such as
administering diazepam (Vali- noise, light, or tactile stimuli helps reduce CNS irritability
um) to the child, what action related to acute tetanus. The mother should be instructed to
should the nurse implement? minimize handling of the child during episodes of muscle
spasticity and to stay calmly near the child. The mother's
-Lay the child down and ask presence with the child provides security and support to the
the mother to stay near the child.
child in the crib.
-Encourage the mother to take
a break and leave the room to
stop crying.
Study online at https://quizlet.com/_fe94lr
1. The nurse hears short, Crackles in the right and left lower lobes.
high-pitched sounds just be-
fore the end of inspiration in Rationale: Fine crackles are short, high-pitched sounds heard
the right and left lower lobes just before the end of inspiration that are the result of rapid
when auscultating a client's equalization of pressure when collapsed alveoli or terminal
lungs. How should this finding bronchioles suddenly snap open.
be recorded?
-Inspiratory wheezes in both
lungs.
-Crackles in the right and left
lower lobes.
-Abnormal lung sounds in the
bases of both lungs.
-Pleural friction rub in the right
and left lower lobes.
2. The nurse is planning care for Risk for injury related to denial of deficits and impulsiveness.
a client who has a right hemi-
spheric stroke. Which nursing Rationale: With right-brain damage, a client experience diffi-
diagnosis should the nurse in- culty in judgment and spatial perception and is more likely to
clude in the plan of care? be impulsive and move quickly, which places the client at risk
for falls.
-Impaired physical mobility re-
lated to right-sided hemiple-
gia.
-Risk for injury related to de-
nial of deficits and impulsive-
ness.
-Impaired verbal communica-
tion related to speech-lan-
guage deficits.
, HESI Pathophysiology (Patho & pharm EVOLVE q's)
Study online at https://quizlet.com/_fe94lr
-Ineffective coping related to
depression and distress about
disability.
3. The nurse is assessing a post- Cystocele
menopausal woman who is
complaining of urinary ur- Rationale: This constellation of signs in a postmenopausal
gency and frequency and woman are characteristic of a cystocele. These symptoms are
stress incontinence. She also not characteristic of the other options.
reports difficulty in emptying
her bladder. These complaints
are most likely due to which
condition?
-Cystocele.
-Bladder infection.
-Pyelonephritis.
-Irritable bladder.
4. The nurse is caring for a Loss of thirst, weight gain
client with syndrome of in-
appropriate antidiuretic hor- Rationale: SIADH occurs when the posterior pituitary gland re-
mone (SIADH), which is mani- leases too much ADH, causing water retention, a urine output
fested by which symptoms? of less than 20 ml/hour, and dilutional hyponatremia. Other
indications of SIADH are loss of thirst, weight gain, irritability,
-Loss of thirst, weight gain. muscle weakness, and decreased level of consciousness.
-Dependent edema, fever.
-Polydipsia, polyuria.
-Hypernatremia, tachypnea.
5. The nurse is teaching a client Both genes of a pair must be abnormal for the disorder to
with maple syrup urine dis- occur
ease (MSUD), an autosomal re-
, HESI Pathophysiology (Patho & pharm EVOLVE q's)
Study online at https://quizlet.com/_fe94lr
cessive disorder, about the in- Rationale: Maple syrup urine disease (MSUD) is a type of
heritance pattern. Which in- autosomal recessive inheritance disorder in which both genes
formation should the nurse of a pair must be abnormal for the disorder to be expressed.
provide?
-This recessive disorder is car-
ried only on the X chromo-
some.
-Occurrences mainly affect
males and heterozygous fe-
males.
-Both genes of a pair must be
abnormal for the disorder to
occur.
-One copy of the abnormal
gene is required for this disor-
der.
6. What information should the -Smoking
nurse include in a teach- -early menarche
ing plan about the onset of -genetic influence
menopause? (Select all that -chemotherapy exposure
apply).
Rationale: Menopausal symptoms are related to the ces-
-Smoking. sation of ovarian function. Factors influencing the onset of
-Oophorectomy with hysterec- menopause include smoking, genetic influences, early men
tomy.
-Early menarche.
-Cardiac disease.
-Genetic influence.
-Chemotherapy exposure.
, HESI Pathophysiology (Patho & pharm EVOLVE q's)
Study online at https://quizlet.com/_fe94lr
7. The nurse reviews the com- risk for injury
plete blood count (CBC) find-
ings of an adolescent with Rationale: A client with AML is at risk for anemia, neutrope-
acute myelogenous leukemia nia, and thrombocytopenia. These CBC findings indicate that
(AML). The hemoglobin is the platelet count is low (normal 250,000 to 400,000 mm3),
13.8 g/dl, hematocrit is 36.7%, which places this client at an increased risk for injury, usually
white blood cell count is 8,200 manifested as bruising or bleeding.
mm3, and platelet count is
115,000 mm3. Based on these
findings, what is the priori-
ty nursing diagnosis for this
client's plan of care?
-Impaired gas exchange.
-Risk for infection.
-Risk for injury.
-Risk for activity intolerance.
8. A mother is crying as she lay the child down and ask the mother to stay near the child
holds and rocks her child with in the crib
tetanus who is having muscu-
lar spasms and crying. After Rationale: Controlling environmental stimulation such as
administering diazepam (Vali- noise, light, or tactile stimuli helps reduce CNS irritability
um) to the child, what action related to acute tetanus. The mother should be instructed to
should the nurse implement? minimize handling of the child during episodes of muscle
spasticity and to stay calmly near the child. The mother's
-Lay the child down and ask presence with the child provides security and support to the
the mother to stay near the child.
child in the crib.
-Encourage the mother to take
a break and leave the room to
stop crying.
