HURST Q Bank Physiological Adaptations Questions and Answers

HURST Q Bank Physiological Adaptations Questions and Answers What signs/symptoms would the nurse expect to assess in an elderly client diagnosed with acute decompensated heart failure (ADHF)? a. thick, white sputum b. crackles that clear with coughing c. wheezing d. orthopnea e. apical pulse 88/min f. S3 gallop c. wheezing d. orthopnea f. S3 gallop A client has experienced a cerebrovascular accident (CVA) which resulted in left homonymous hemianopia. Based on this fact, what measures will the nurse include in the client's initial plan of care? a. approach the client from his left side b. place the client's meal on the right side of the over bed table c. request a consult for an ophthalmologist d. stand directly in front of the client when addressing e. have client look at the left side of the body b. place the client's meal on the right side of the over bed table e. have client look at the left side of the body The telemetry nurse sees this ECG strip go across the monitor on a client admitted with unexplained syncope. What initial action should the nurse take? -- VFIB a. initiate the code for cardiac arrest b. begin CPR c. administer epinephrine 1mg IVP d. check for apical pulse d. check for apical pulse A client reports crushing chest pain 3 hours prior to arrival in the emergency department. Initial assessment by the nurse reveals a BP of 90/50, a weak, thready pulse of 108/min, cool, clammy skin, and confusion. Which interventions should the nurse perform? a. initiate cardiac monitoring b. monitor intake and output hourly c. position client in recumbant position d. limit physical activity e. administer dopamine a 5 mcg/kg/min a. initiate cardiac monitoring b. monitor intake and output hourly d. limit physical activity e. administer dopamine at 5 mcg/kg/min The son of an elderly diabetic client reports that his mother is frequently having low blood sugar. What should the nurse teach this family member about symptoms of hypoglycemia in the elderly? a. elders may not be aware that blood sugar is dropping due to decreased release of epinephrine in response to the lowered blood sugar b. suggest that the client and family check with primary healthcare provider to ensure that the medication prescribed has low incidence of hypoglycemic episodes c. symptoms of hypoglycemia may be averted if the client maintains routines and regular meal schedules d. stress the importance of proper foot care and regular eye exams e. check blood glucose levels if client becomes unsteady, has difficulty concentrating, or is tremulous a. elders may not be aware that blood sugar is dropping due to decreased release of epinephrine in response to the lowered blood sugar b. suggest that the client and family check with primary healthcare provider to ensure that the medication prescribed has low incidence of hypoglycemic episodes c. symptoms of hypoglycemia may be averted if the client maintains routines and regular meal schedules e. check blood glucose levels if the client becomes unsteady, has difficulty concentrating, or is tremulous A client with stage III uterine cancer is being discharged following a total abdominal hysterectomy and bilateral oophorectomy. The client asks about physical changes that may occur as a result of surgical menopause. What is the most important information the nurse should provide? a. a Pap will be needed every 3 months b. intercourse must be avoided until chemotherapy is complete c. estrogen medication will alleviate symptoms of menopause d. lubrication will help decrease vaginal dryness and burning d. lubrication will help decrease vaginal dryness and burning How should the nurse interpret the ABG results of a client admitted with dehydration? pH: 7.49 PaO2: 99% PaCO2: 29 HCO3: 23 a. metabolic acidosis b. respiratory acidosis c. metabolic alkalosis d. respiratory alkalosis d. respiratory alkalosis A 9 month old client is admitted to the hospital with a diagnosis of pertussis. Which interventions should the nurse initiate? a. initiate droplet precaution b. place client under mist tent with low humidity c. administer erythromycin 10 mg/kg/dose 4 times daily for 7 days d. use client dedicated and disposable equipment e. keep NPO a. initiate droplet precaution c. administer erythromycin 10 mg/kg/dose 4 times daily for 7 days d. use client dedicated and disposable equipment The emergency room nurse is assessing a client reporting severe abdominal pain for several hours prior to arrival at the hospital. Assessment findings include slight mottling of the lower extremities and a pulsating mass near the umbilicus. Which actions should the nurse implement immediately? a. position client on the left side b. apply warm blankets to legs c. administer IM pain medication d. alert the operating room staff e. notify the primary healthcare provider f. palpate mass to determine size d. alert the operating room staff e. notify the primary healthcare provider A nurse notes that a client with end-stage chronic renal failure has dry, itchy skin, white crystals on the skin, and uremic halitosis. Which nursing interventions would be appropriate for this client? a. encourage use of cotton gloves during sleep b. apply emollients to the skin c. increase protein rich foods in the diet d. cut fingernails short e. provide mouth care prior to meals a. encourage use of cotton gloves during sleep b. apply emollients to the skin d. cut fingernails short e. provide mouth care prior to meals An emergency room nurse is triaging multiple victims from a bus versus tractor trailer accident. Which client would be considered priority? a. a client with an open femur fracture, bleeding profusely b. a client with multiple rib fractures, respiratory rate 32 and shallow c. a client unconscious and responding only to painful stimuli d. a client with a crushed left leg with no palpable pedal pulses c. a client unconscious and responding only to painful stimuli The nurse is teaching a client diagnosed with asthma about using a peak expiratory flow meter. The nurse asks the client what action should be taken if the reading is 65% of the client's personal best value. What statement by the client indicates to the nurse that education was successful? a. "This is a good reading for me, so I can go about my usual activities." b. "I will administer my long-term inhaler medication." c. "My as needed inhaler medication needs to be administered." d. "I need to immediately call 911." c. "My as needed inhaler medication needs to be administered." An elderly homeless client is brought to the emergency room for evaluation following a fall. What assessment findings by the nurse should be reported immediately to the primary healthcare provider for further evaluation? a. the client is unsteady when walking to the bathroom b. the client cannot state day, date, or present location c. the client refuses to remove either shoes or socks d. the client has loss of sensation below the left knee d. the client has loss of sensation below the left knee A nurse monitors the heart rates of four children on a pediatric unit. Which client requires additional assessment by the nurse? a. one year old child who has a heart rate of 150 bpm and is crying b. two year old child who has a heart rate of 165 bpm and is being rocked c. five year old child who has a heart rate of 100 bpm and is playing quietly d. thirteen year old adolescent who has a heart rate of 90 and is watching TV b. two year old child who has a heart rate of 165 bpm and is being rocked What is the priority nursing action for a client that was admitted with tingling of the toes and feet after having the flu for several days when the client begins to have numbness in the legs and hips? a. notify the primary healthcare provider b. monitor for paresthesia in the fingers and hands c. insert an indwelling urinary catheter d. assist the client with performing passive range of motion a. notify the primary healthcare provider What complications in a client diagnosed with placental abruption should the nurse be prepared for? a. hemorrhage b. disseminated intravascular coagulation (DIC) c. renal failure d. hypovolemic shock e. placenta previa a. hemorrhage b. disseminated intravascular coagulation (DIC) c. renal failure d. hypovolemic shock Which cranial nerves should the nurse assess in a client diagnosed with Guillain-Barre Syndrome? a. vagus b. olfactory c. vestibulocochlear d. facial e. trigeminal f. oculomotor a. vagus d. facial e. trigeminal f. oculomotor What signs of cannula displacement should the nurse monitor for at an arterial line insertion site? a. swelling b. fluid leakage c. blanching d. poor arterial waveform e. pyrexia f. purulent drainage a. swelling b. fluid leakage c. blanching d. poor arterial waveform The nurse is caring for a 42 year old male client with chronic pyelonephritis. Which lab result noted by the nurse would be the greatest concern? a. estimated glomerular filtration rate - 90 mL/min/1.73 m2 b. serum creatinine - 2.1 mg/dL (186 mmol/dL) c. blood urea nitrogen - 19 mg/dL (6.78 mmol/L) d. urine culture isolates E. coli b. serum creatinine - 2.1 mg/dL (186 mmol/dL) A client has been admitted to the unit recurrent nephrotic syndrome. Which signs and symptoms does the nurse expect to find when examining the client? a. anasarca b. foamy urine c. hypotension d. periorbital edema e. proteinuria a. anasarca b. foamy urine d. periorbital edema e. proteinuria A client is admitted to the hospital due to a deep vein thrombosis (DVT). Which intervention should the nurse initiate? a. ambulate client around room every 2 hours b. assess Homans' sign every 8 hours c. place sequential compression device on both legs d. apply intermittent warm, moist soaks to affected area d. apply intermittent warm, moist soaks to affected area A nurse is receiving morning report on the cardiovascular unit. What client should the nurse's priority assessment? a. a client with ejection fraction of 20% and dyspnea at rest b. a client with a chest tube to suction and sub-q emphysema c. a client two days past abdominal aortic aneurysm repair with decreased pedal pulses d. a client coronary artery bypass graft three days ago with WBC 17,000 mm3 c. a client two days past abdominal aortic aneurysm repair w/ decreased pedal pulses A new nurse asks the charge nurse for assistance in interpreting arterial blood gases (ABGs) for a client. What acid/base imbalance should the charge nurse tell the new nurse these ABGs indicate in the client? pH: 7.5 PaO2: 94% PaCO2: 58 HCO3: 35 a. partially compensated metabolic acidosis b. partially compensated respiratory alkalosis c. partially compensated metabolic alkalosis d. partially compensated respiratory acidosis c. partially compensated metabolic alkalosis The nurse is discussing home management with the parents of a baby diagnosed with RSV. What topics would the nurse include when teaching the client? a. adequate hydration b. antibiotic therapy c. antipyretics d. signs of worsening RSV e. hand washing a. adequate hydration c. antipyretics d. signs of worsening RSV e. hand washing A 37 week pregnant woman presents to triage with reports of a headache and begins to have a seizure. What actions should the nurse take? a. place the client's head in the nurse's lap b. administer oxygen c. monitor tonic-clonic activity d. place an oral airway into the client's mouth e. administer diazepam a. place the client's head in the nurse's lap b. administer oxygen c. monitor tonic-clonic activity A preeclampsia client is being treated with magnesium sulfate. The nursing assessment shows a respiratory rate of 10 with deep tendon reflexes of 0. What is the nurse's priority action? a. place client in trendelenburg position and apply oxygen b. stop magnesium and prepare to give calcium gluconate c. ask another nurse to verify the deep tendon reflexes d. prepare client for an emergency cesarean section b. stop magnesium and prepare to give calcium gluconate Which finding by the nurse would need to be reported to the primary healthcare provider immediately when caring for an infant who was born with a myelomeningocele? a. high pitched cry b. eyes fixed downward c. increasing head circumference d. decrease in a feeding by 30 mL e. projectile vomiting a. high pitched cry b. eyes fixed downward c. increasing head circumference e. projectile vomiting The client diagnosed with a hemorrhagic stroke has been admitted to the intensive care unit. Which nursing intervention would the nurse initiated to minimize the factors that contribute to increased ICP? a. increase the flexion of the hips b. maintain a calming environment c. administer stool softener as prescribed d. instruct family to not wake the client if sleeping e. turn and place pillows behind the client every hour b. maintain a calming environment c. administer a stool softener as prescribed d. instruct family to not wake the client if sleeping A client states, "I have not had a drink for 24 hours and I am beginning to feel anxious." What additional signs/symptoms would indicate to the nurse that the client is in the early phase of alcohol withdrawal? a. agitation b. insomnia c. course tremors d. visual hallucinations e. confabulation f. tachycardia a. agitation b. insomnia c. course tremors f. tachycardia A nurse is caring for a client who was brought into the ED with a gunshot would to the chest. There is an occlusive dressing in place and the client is receiving high flow oxygen. The nurse notes a deviated trachea, asymmetrical chest wall movement, and decreased breath sounds bilaterally. What action should the nurse take first? a. elevate the head of the bed b. initiate CPR c. remove the occlusive dressing d. notify the primary healthcare provider c. remove the occlusive dressing Which arterial blood gas (ABG) results would the nurse expect on a client who has overdosed on aspirin (ASA)? a. pH 7.54, PaCO2 41, PaO2 63, SaO2 91, HCO3 36 b. pH 7.24, PaCO2 37, PaO2 83, SaO2 95, HCO3 18 c. pH 7.49, PaCO2 30, PaO2 88, SaO2 92, HCO3 25 d. pH 7.12, PaCO2 28, PaO2 72, SaO2 93, HCO3 10 c. pH 7.49, PaCO2 30, PaO2 88, SaO2 92, HCO3 25 A client is being evaluated for possible rheumatoid arthritis (RA). Which assessment finding by the nurse would be indicative of RA? a. spindle shaped fingers b. early morning stiffness resolves within 30 minutes c. joint pain relieved by rest d. presence of Bouchard's nodes e. ulnar drift a. spindle shaped fingers e. ulnar drift The mother of a newborn diagnosed with hyperbilirubinemia asks the nursery nurse to explain the difference in physiologic jaundice and pathologic jaundice. What information should the nurse include? a. physiologic jaundice typically appears during the third to fourth day of life and then begins to decline rapidly over the next several weeks b. physiologic jaundice occurs within the first 24 hours of life and the newborn's bilirubin level rises rapidly c. a common condition associated with pathologic jaundice in the newborn is blood incompatibility of the mother and the newborn d. physiologic jaundice is the manifestation of the normal hyperbilirubinemia commonly seen in newborns e. pathologic jaundice is more likely to lead to severe hyperbilirubinemia than physiologic jaundice a., c., d., e. What signs/symptoms would the nurse expect to find in a client diagnosed with osteoarthritis (OA) in the knee? a. Sjogren's syndrome b. clicking sound when knee bends c. fever d. pain that is worse after activity e. severe fatigue b. clicking sound when knee bends d. pain that is worse after activity The obstetrical client with a history of abruption asks the clinic nurse if placental abruption is likely to recur during this pregnancy. Which risk factors for placental abruption should the nurse include in the discussion with the client? a. abdominal trauma b. primigravida c. advanced maternal age d. prior placental abruption e. substance use f. chronic hypertension a. abdominal trauma c. advanced maternal age d. prior placental abruption e. substance use f. chronic hypertension Which signs/symptoms should the nurse assess for the presence of in a client diagnosed with valvular heart disease? a. orthopnea b. paroxysmal nocturnal dyspnea c. petechiae on the trunk d. increasing CVP with decreasing BP e. pericardial friction rub f. widening pulse pressure a. orthopnea b. paroxysmal nocturnal dyspnea Which arterial blood gas value would the nurse expect to see when monitoring a client in a hyperosmolar hyperglycemic state (HHS)? a. pH 7.32 b. PaCO2 47 c. HCO3 22 d. PaO2 78 c. HCO3 22 A client with a diagnosis of embolic stroke is admitted to the medical unit. After 2 hours on the unit the client presents with agitation. Which nursing intervention would the nurse initially implement? a. assess the client for any seizure activity b. assess the client with the Glasgow Coma Scale c. place the client's neck in the midline position d. adjust the head elevation to 15 degrees c. place the client's neck in the midline position The clinic nurse is reviewing pre-op teaching with a client diagnosed with uterine prolapse who is scheduled for vaginal hysterectomy. The client asks the nurse if having three pregnancies caused the prolapse. The nurse correctly identifies which factors increase the risk for uterine prolapse? a. obesity b. vaginal deliveries c. urinary incontinence d. menopause e. dyspareunia a. obesity b. vaginal deliveries d. menopause How should the nurse document the cardiac rhythm on a client admitted with a diagnosis of syncope? a. atrial flutter b. first degree AV block c. normal sinus rhythm (NSR) d. sinus arrhythmia c. normal sinus rhythm The nurse is caring for a client with cirrhosis of the liver and suspects that the client may be developing hepatic encephalopathy. Which assessments by the nurse suggest that the client is developing this complication? a. asterixis b. lethargy c. amnesia d. behavioral changes e. Kussmaul respirations a. asterixis b. lethargy c. amnesia d. behavioral changes A client presents in the emergency department with acute onset of fever, headache, stiff neck, nausea/vomiting, and mental status changes. What interventions should the nurse initiate? a. elevate HOB 30 degrees b. pad side rails c. provide sponge bath if temperature greater than 101 F (38.3 C) d. initiate airborne isolation precautions e. darken room a. elevate HOB 30 degrees b. pad side rails c. provide sponge bath if temperature greater than 101 F e. darken room The nurse is caring for a 17 year old primigravida at 36 weeks of gestation who has been admitted to the unit with severe manifestations of preeclampsia. Nursing care and assessment is based on the knowledge that which symptoms indicate worsening disease and impending seizures? a. pounding headache b. blurred vision c. hyporeflexia d. epigastric pain e. mental confusion f. diuresis a. pounding headache b. blurred vision d. epigastric pain e. mental confusion What assessment findings would the nurse expect when evaluating whether treatment has been effective for a client hospitalized with systolic heart failure? a. 3+ pedal edema b. CVP of 6 mmHg c. one day weight loss of 2 lbs (0.9 kg) d. purse-lip breathing e. pale nail beds f. urine output at 50 mL/hr b. CVP of 6 mmHg c. one day weight loss of 2 lbs (0.9 kg) f. urine output at 50 mL/hr A hiker that was lost in the mountains for 3 days experienced exposure to below freezing temperatures. Upon arrival to the ED, the nursing assessment reveals hard, mottled, bluish-white toes bilaterally, and the client reports being unable to feel the toes. Which actions should the nurse initially take? a. remove any wet or constricting clothing b. initiate a controlled and rapid rewarming process with warm water c. wrap each toe individually with sterile gauze d. encourage the client to walk e. apply a heating pad to the feet f. massage the frozen digits a. remove any wet or constricting clothing b. initiate a controlled and rapid rewarming process with warm water c. wrap each toe individually with sterile gauze The nurse is providing care to a client who has returned to the long-term facility following cataract surgery. Which finding would indicate a possible complication? a. slightly swollen eyelid b. slight discomfort of the eye c. "bloodshot" appearance of the eye d. extreme pain in the eye d. extreme pain in the eye What is the first intervention the ED nurse should implement when caring for a lethargic toddler with a diagnosis of near-drowning? a. torso warming b. start intravenous infusion c. administer oxygen d. prepare for nasogastric intubation c. administer oxygen The nurse is observing a new RN explain phototherapy to the mother of a newborn with a bilirubin of 12 mg/dL one day after birth. The nurse determines the new RN understands the phototherapy process when what statements are made to the mother? a. "The infant's eyes must be covered throughout the light session." b. "The heat from the light may cause some harmless swelling in arms." c. "Body temperature must be checked frequently to monitor for fever." d. "It is important to restrict feedings during the phototherapy sessions." e. "We check bilirubin levels several times daily to be sure it's decreasing." a. "The infant's eyes must be covered throughout the light session." c. "Body temperature must be checked frequently to monitor for fever." e. "We check bilirubin levels several times daily to be sure it's decreasing." A client is admitted to the ED with digoxin toxicity. Nursing assessment reveals cool skin, a slow, weak pulse, and a BP of 86/44. What initial action should the nurse take based on the assessment and cardiac rhythm strip? a. administer sodium nitroprusside 0.3 mcg/kg/min IV b. set up for transcutaneous pacing c. have client perform vagal maneuver d. draw blood for potassium level b. set up for transcutaneous pacing What signs/symptoms would the nurse expect to assess in a client diagnosed with Guillain-Barre syndrome? a. opisthotonos b. seizures c. paresthesia d. hemiplegia e. hypotonia f. muscle aches c. paresthesia e. hypotonia f. muscle aches What assessment data would a nurse expect to find in a client diagnosed with a severe episode of acute inflammatory bowel disease? a. dark yellow urine b. fever c. frequent, hard stools d. lower abdominal cramping e. tachycardia a. dark yellow urine b. fever d. lower abdominal cramping e. tachycardia A client had an open cholecystectomy several days ago. What finding by the nurse should be reported to the primary healthcare provider immediately? a. respiratory rate of 30 b. blood pressure reading of 104/50 c. incisional pain with foul, green drainage d. urinary output of 75 mL straw colored urine c. incisional pain with foul, green drainage The nurse in the pediatric intensive care unit (PICU) is caring for a preschool child three days after open heart surgery. What assessment finding should the nurse report immediately to the primary healthcare provider? a. increased episodes of fussy crying b. a hacking, non-productive cough c. oral temperature of 100.9 F d. chest tube draining 30 mL per shift c. oral temperature of 100.9 F A high school nurse is assessing multiple students reporting general flu-like symptoms. Which additional symptoms reported by a student would prompt the nurse to immediately call an ambulance? a. blurred vision and Trousseau's sign b. vomiting and a Murphy's sign c. sensitivity to light and Kernig's sign d. fever and Chvostek's sign c. sensitivity to light and Kernig's sign A client who had a triple lumen catheter placed in the right subclavian vein 30 minutes ago reports chest discomfort and shortness of breath. The assessment reveals BP 92/58, HR 104, resp 28, and unequal breath sounds over lung fields. What problem should the nurse suspect this client is exhibiting? a. myocardial infarction b. atelectasis c. pneumothorax d. pneumonia c. pneumothroax What would the nurse expect to see when performing a neurological assessment on a 1 day old neonate suspected of having asphyxia in utero? a. grasps nurse's finger when placed in neonate's hand b. toes curl downward when soles of feet stroked c. turns toward nurse's finger when cheek is touched d. extends arms when nurse claps hands b. toes curl downward when soles of feet stroked A client requires external radiation therapy. The nurse knows external radiation may cause which problems? a. pancytopenia b. leukocytosis c. erythema d. fever e. fatigue a. pancytopenia c. erythema e. fatigue What lab values should the nurse monitor when caring for a client diagnosed with acute leukemia? a. hemoglobin b. hematocrit c. lactate dehydrogenase (LDH) d. platelets e. white blood cells f. metanephrine a. hemoglobin b. hematocrit d. platelets e. white blood cells A client returns to the clinic two days after receiving treatment for diarrhea caused by a Campylobacter jejuni infection. The client reports a tingling sensation that began in the toes yesterday and has spread to the feet and legs today. The nurse notes muscle weakness in the legs and that the client is having difficulty walking steadily. Based on this data, what does the nurse suspect is wrong with the client? a. Guillain-Barre Syndrome b. Multiple Sclerosis c. Myasthenia Gravis d. Systemic Lupus Erythematosus a. Guillain-Barre Syndrome A client rescued from a house fire is being treated for burns to both arms and suspected inhalation injury. What data collected by the nurse has the highest priority? a. estimation of total surface burn area b. characteristics of cough and sputum c. calculation of client weight and age d. extent of edema to arms b. characteristics of cough and sputum The nurse, caring for a client post motor vehicle accident who sustained multiple crushing injuries, suspects that the client may be developing disseminated intravascular coagulation (DIC). Which assessment findings by the nurse suggest that the client is developing this complication? a. chest pain b. frothy sputum c. intermittent claudication d. subcutaneous emphysema e. petechiae f. blood oozing from chest tube insertion site e. petechiae f. blood oozing from chest tube insertion site The nurse is reinforcing teaching to a group of parents about transmission of the chickenpox virus and the importance of vaccination. Which modes of transmission for chickenpox should be included in the discussion? a. direct contact b. indirect contact c. airborne d. droplet e. common vehicle a. direct contact b. indirect contact c. airborne