HESI ADVANCED PATHOPHYSIOLOG Y

HESI ADVANCED PATHOPHYSIOLOG Y FNP V1 100 Practice Questions and Answers   HESI ADVANCED PATHOPHYSIOLOG Y FNP V1 100 Practice Questions and Answers 1. According to Walter B. Cannon, homeostasis is a stable internal environment achieved through a system of: A) Interdependent system-wide adaptive responses B) Variable internal and external conditioning factors C) Coordinated physiologic processes that oppose change D) Compatibility between cells and the internal environment Ans: C Feedback: Walter B. Cannon identified homeostasis, achieved by a coordinated physiologic process that opposes change. Claude Bernard recognized the importance of compatibility between cells and the internal environment. Hans Selye identified the general (systemic) adaptive and interdependent responses to stress. According to Selye, stressors produce different responses due to the influence of adaptive internal or external factors (conditioning factors). 2. A child has been experiencing hypoglycemic episodes. “How does the body know when to secrete insulin and when to stop secreting it?” The best response by the nurse, explaining the physiologic background, would be: A) “The body knows that if the blood glucose level falls, it will inhibit insulin secretion and release glycogen to release glucose from the liver.” B) “It's just a big guessing game; first we give sugar like orange juice, and then we withhold the carbohydrates if the blood glucose level is too high.” C) “Your pituitary gland in the brain is the 'master gland,' and it controls and regulates all the hormones.” D) “Once the child starts getting confused, the brain will send a message to the pancreas to stop producing insulin.” Ans: A Feedback: In the negative feedback mechanism that controls blood glucose levels, an increase in blood glucose stimulates an increase in insulin, which enhances removal of glucose from the blood. When glucose has been taken up by cells and blood glucose levels fall, insulin secretion is inhibited and glucagon and other counterregulatory mechanisms stimulate release of glucose from the liver, which causes blood glucose levels to return to normal. 3. A client presents to the emergency department following a major traffic accident. Though outwardly there are no apparent physical injuries found, the client is experiencing chest pain and heightened alertness, which the health care worker attributes to the first stage of general adaptation syndrome (GAS). The health care worker concludes the client is experiencing manifestations related to the release of: A) Aldosterone, which interferes with sodium absorption B) Epinephrine C) Too little cortisol D) Thyroid-stimulating hormone Ans: B Feedback: The general adaptation syndromes has three stages—the first is alarm (fight or flight); second is resistance (fight); and the third is exhaustion. The alarm stage is characterized by a generalized stimulation of the sympathetic nervous system (SNS) and the HPA, resulting in release of catecholamines and cortisol. Increased insulin release or TSH release is not part of the GAS. 4. Although stress exposure initiates integrated responses by multiple systems, the functional results are first manifested as: Select all that apply. A) Enhanced respiratory rate/depth B) Cravings for high-carbohydrate foods C) Increased alertness and focus D) Increased glucose utilization E) Increased GI peristalsis Ans: A, C, D Feedback: Exposure to stress activates an immediate response by the neuroendocrine system that plays a role in most of the responses to stress and attempts to adapt. Results of the coordinated release of these neurohormones include mobilization of energy, a sharpened focus and awareness, increased cerebral blood flow and glucose utilization, enhanced cardiovascular and respiratory functioning, redistribution of blood flow to the brain and muscles, modulation of the immune response, inhibition of reproductive function, and a decrease in appetite. 5. A client is experiencing significant stress while awaiting the results of her recent lymph node biopsy. Among the hormonal contributors to this response is a release of aldosterone, resulting in which of the following physiologic effects? A) Decreased release of insulin B) Increased cardiac contractility C) Potentiating effects of epinephrine D) Increased sodium absorption Ans: D Feedback: Mineralocorticoids such as aldosterone increase sodium absorption by the kidneys. Changes in insulin release and cardiac contractility are mediated by catecholamines, whereas cortisol potentiates the action of epinephrine. 6. While looking at cancer cells under a microscope, the instructor asks the students to describe the cells. Which of the student answers are accurate? Select all that apply. A) The cells are in different sizes and shapes. B) The nucleoli are larger than normal. C) The cells are contact inhibited. D) The cells do not resemble the tissue of origin. E) The cells are attached to an extracellular matrix. Ans: A, B, D Feedback: Undifferentiated cancer cells are marked by a number of morphologic changes. Both the cells and nuclei display variations in size and shape. Their nuclei are variable in size and bizarre in shape, their chromatin is coarse and clumped, and their nucleoli are often considerably larger than normal. The cells of malignant tumors are characterized by wide changes of parenchymal cell differentiation from well differentiated to completely undifferentiated. Normal cells that are grown in culture tend to display a feature called cell density– dependent inhibition, in which they stop dividing after the cell population reaches a particular density. This is sometimes referred to as contact inhibition since cells often stop growing when they come into contact with each other. In contrast to normal cells, cancer cells often survive in microenvironments different from those of the normal cells. They frequently remain viable and multiply without normal attachments to other cells and the extracellular matrix. 7. The angiogenesis process, which allows tumors to develop new blood vessels, is triggered and regulated by tumor-secreted: A) Procoagulants B) Growth factors C) Attachment factors D) Proteolytic enzymes Ans: B Feedback: Many tumors secrete growth factors, which trigger and regulate the angiogenesis process. Tumor cells express various cell surface attachment factors, for anchoring. Tumor cells secrete proteolytic enzymes to degrade the basement membrane and migrate into surrounding tissue. Cancer cells may produce procoagulant materials that affect clotting mechanisms. 8. Which of the following processes characterizes an epigenetic contribution to oncogenesis? A) A DNA repair mechanism is disrupted. B) A tumor suppressor gene is present, but it is not expressed. C) Cells lose their normal contact inhibition. D) Regulation of apoptosis in impaired, resulting in accumulation of cancer cells. Ans: B Feedback: Epigenetic mechanisms of cancer growth involve changes in the patterns of gene expression without a change in the DNA. Epigenetic mechanisms may “silence” genes, such as tumor suppressor genes, so that even though the gene is present, it is not expressed and a cancer-suppressing protein is not made. Disruption of DNA repair may contribute to cancer, but this process is not particular to epigenetics. Similarly, loss of contact inhibition and impaired apoptosis are associated with cancer but are not specific manifestations of epigenetic mechanisms. 9. An oncology nurse is caring for a client with newly diagnosed B-cell lymphoma. Extensive blood work has been drawn and sent to the lab. Results reveal an elevated antiapoptotic protein BCL-2 level. The client/family asks, “What does this mean?” The health care provider bases his or her response on the fact that: A) The client's immune system is trying to kill the cancer cell by sending this protein to engulf it. B) This is a good result. Normal cells undergo apoptosis if DNA is damaged in any way. C) This means the cancer cells have found a way to survive and grow even with damaged DNA. D) The client's body is trying to limit the blood supply to the cancer cells by producing high levels of this protein. Ans: C Feedback: Alterations in apoptotic and antiapoptotic pathways have been found in many cancers. One example is the high levels of the antiapoptotic protein BCL-2 that occur secondary to a chromosomal translocation in certain B-cell lymphomas. The mitochondrial membrane is a key regulator of the balance between cell death and survival. Proteins in the BCL-2 family reside in the inner mitochondrial membrane and are either proapoptotic or antiapoptotic. Since apoptosis is considered a normal cellular response to DNA damage, loss of normal apoptotic pathways may contribute to cancer by enabling DNA-damaged cells to survive. 10. A farmer's long-term exposure to pesticides has made the cells in his alveoli and bronchial tree susceptible to malignancy. Which of the following processes has taken place in the farmer's lungs? A) Promotion B) Progression C) Initiation D) Differentiation Ans: C Feedback: Initiation involves the exposure of cells to appropriate doses of a carcinogenic agent that makes them susceptible to malignant transformation, whereas promotion involves the induction of unregulated accelerated growth in already initiated cells. Progression is the later process whereby tumor cells acquire malignant phenotypic changes, and differentiation is the process of specialization whereby new cells acquire the structural, microscopic, and functional characteristics of the cells they replace. 11. Which of the following practitioners is most likely to be of immediate assistance in the first 24 hours following delivery of an infant with a cleft lip? A) Lactation consultant B) Respiratory therapist C) Occupational therapist D) Social worker Ans: A Feedback: Infants with a cleft lip typically have difficulty with feeding, and the assistance of a lactation consultant may be of help in establishing feeding patterns. Oxygenation is not a typical problem, while activities of daily living and assistive devices are not relevant considerations. While social work is often of assistance when a child is born with a congenital condition, a cleft lip has fewer implications than most other inherited disorders. 12. The newborn has been born with distinctive physical features of trisomy 21, Down syndrome. The mother asks the nurse, “What is wrong? My baby looks different than his brother.” The nurse assesses the infant and notes which of the following characteristics that correlate with trisomy 21? Select all that apply. A) Upward slanting of eyes B) Large, protruding ears C) Large tongue sticking out the mouth D) Long fingers with extra creases E) Flat facial profile Ans: A, C, E Feedback: The physical features of a child with Down syndrome are distinctive, and therefore the condition usually is apparent at birth. These features include growth failure and a small and rather square head. There is a flat facial profile, small nose, and somewhat depressed nasal bridge; upward slanting of the eyes; small, low-set, and malformed ears; and a large, protruding tongue. The child's hands usually are short and stubby, with fingers that curl inward, and there usually is only a single palmar crease (simian crease). 13. A 41-year-old woman has made the recent decision to start a family and is eager to undergo testing to mitigate the possibility of having a child with Down syndrome. Which of the following tests is most likely to provide the data the woman seeks? A) Genetic testing of the woman B) Genetic testing of the woman and the father C) Prenatal blood tests D) Ultrasonography Ans: C Feedback: Down syndrome is a result of chromosomal abnormality and is not a single-gene disorder. As a result, genetic testing of the mother and/or father is not relevant. Ultrasonography does not have predicative value for Down syndrome, but blood tests such as - fetoprotein, human chorionic gonadotropin (HCG), unconjugated estriol, inhibin A, and pregnancy-associated plasma protein A have helped ascertain the risks. 14. Aneuploidy of the X chromosome can result in a monosomy or polysomy disorder. The clinical manifestations of a female with monosomy X include: Select all that apply. A) A short-stature female individual B) Difficulty with fine motor skills C) Large heavy breasts D) Early-onset (age 8) puberty E) Nonpitting lymphedema of the feet Ans: A, B, E Feedback: Turner syndrome produces a female individual who is short, has no secondary sex characteristics, has normal intelligence, and fails to go through puberty due to an absence of ovaries. Polysomy X is a XXY male. XXY males have tall slim stature with breast enlargement, lack of sperm, and normal intelligence. They may have problems with visuospatial organization (driving a car, working math problems, psychomotor skills, etc.). There are variations in the syndrome, with abnormalities ranging from essentially none to webbing of the neck with redundant skin folds and nonpitting lymphedema of the hands and feet. 15. Genetic testing has revealed that a male infant has been born with an extra X chromosome. What are the most likely implications of this finding? The child: A) Is unlikely to survive infancy B) Is likely to have no manifestations of this chromosomal abnormality C) Will have significant neurological and cognitive defects D) Will be unable to reproduce Ans: B Feedback: An extra X chromosome is associated with Klinefelter syndrome, but a majority of XXY males do not exhibit visible effects of this chromosomal abnormality. 16. Although bacterial toxins vary in their activity and effects on host cells, a small amount of gram-negative bacteria endotoxin: A) Is released during cell growth B) Inactivates key cellular functions C) Uses protein to activate enzymes D) In the cell wall activates inflammation Ans: D Feedback: Endotoxins differ from exotoxins in several ways. Endotoxins are found in the cell wall lipids of gram-negative bacteria and are potent activators of life-threatening systemic responses such as acute inflammation with clotting and hypotension. Exotoxins contain protein, are released during cell growth, inactivate key cell functions, and have enzymatic activity. 17. A 9-month-old infant has been diagnosed with botulism after he was fed honey. The child's mother was prompted to seek care because of this child's sudden onset of neuromuscular deficits, which were later attributed to the release of substances by Clostridium botulinum. Which virulence factor contributed to this child's illness? A) Endotoxins B) Adhesion factors C) Exotoxins D) Evasive factors Ans: C Feedback: Exotoxins are proteins released from the bacterial cell during growth, as in the case of botulism poisoning. Adhesion factors, evasive factors, and endotoxins are not evident in this release of botulinum toxin. 18. While explaining evasive factors by microbes to evade various components of the host's immune system, the instructor uses which of the following examples? A) H. Pylori being able to survive in an acidic environment B) Enzymes capable of destroying cell membranes C) S. aureus ability to immobilize IgG D) An infectious agent's ability to produce toxins Ans: A Feedback: A number of factors produced by microorganisms enhance virulence by evading various components of the host's immune system. H. pylori, the infectious cause of gastritis and gastric ulcers, produces a urease enzyme on its outer cell wall. The urease converts gastric urea into ammonia, thus neutralizing the acidic environment of the stomach and allowing the organism to survive in this hostile environment. Infectious agents also produce invasive factors that facilitate the penetration of anatomic barriers and host tissue. Most invasive factors are enzymes capable of destroying cell membranes (e.g., phospholipases), connective tissue (e.g., elastases, collagenases), intercellular matrices (e.g., hyaluronidase), and structural protein complexes (e.g., proteases). The effects of the pathogen's invasive factors and toxins, combined with the antimicrobial and inflammatory substances released by host cells, mediate the tissue damage and pathophysiology of infectious diseases. 19. A client with a long-standing diagnosis of Crohn disease has developed a perianal abscess. Which of the following treatments will this client most likely require? A) Antiviral therapy B) Antibiotic therapy C) Surgical draining D) Pressure dressing Ans: C Feedback: Although antibiotics are likely to form a component of this client's treatment, abscesses most often require surgical draining. A pressure dressing or the use of antivirals is likely unnecessary. 20. In the usual course (stages) after a pathogen has entered the host body, the stage when the host initially develops the appearance of signs/symptoms like a mild fever and body aches is: A) Incubation B) Prodromal C) Acute D) Convalescence Ans: B Feedback: The prodromal stage follows inoculation (the initial stage) and is identified by the initial onset of symptoms in the host. Tissue inflammation and damage is evident during the acute (3rd) stage. Pathogen elimination and containment are characteristics of the convalescent (4th) period, which follows the acute stage. 21. A client who lives with angina pectoris has taken a sublingual dose of nitroglycerin to treat the chest pain he experiences while mowing his lawn. This drug facilitates release of nitric oxide, which will have what physiologic effect? A) Smooth muscle relaxation of vessels B) Decreased heart rate and increased stroke volume C) Increased preload D) Reduction of cardiac refractory periods Ans: A Feedback: Nitroglycerin produces its effects by releasing nitric oxide in vascular smooth muscle of the target tissues, resulting in relaxation of this muscle and increased blood flow. This drug does not decrease heart rate. Because it vasodilates, it decreases preload. Nitroglycerine does not affect cardiac refractory periods. 22. Following a kitchen accident with a knife, the client's cut has experienced a decrease in the amount of bleeding and has developed a clot. The nurse knows this is primarily a result of humoral control of blood flow with the release of: A) Histamine B) Bradykinin C) Serotonin D) Prostaglandin E2 Ans: C Feedback: Serotonin release causes vasoconstriction of blood vessels and plays a major role in control of bleeding. Histamine, bradykinin, and prostaglandin E2 cause vasodilation of blood vessels. 23. A client has had a myocardial infarction (MI) that damaged the right atrium, which has interfered with the SA node. The compensatory mechanism, the AV node, becomes the pacemaker of the heart and beats how many times/minute? A) 10 to 20 beats/minute B) 21 to 30 beats/minute C) 45 to 50 beats/minute D) 55 to 60 beats/minute Ans: C Feedback: The AV nodal fibers, when not stimulated, discharge at an intrinsic rate of 45 to 50 times a minute, and the Purkinje fibers discharge 15 to 40 times/minute. The SA node has the fastest intrinsic rate of firing (60–100 beats/minute) and normally functions as the pacemaker of the heart. Should the SA node fail to discharge, the AV node can assume the pacemaker function of the heart, and the Purkinje system can assume the pacemaker function of the ventricles should the AV junction fail to conduct impulses from the atria to the ventricles. 24. A client asks why he has not had major heart damage since his cardiac catheterization revealed he has 98% blockage of the right coronary artery. The nurse's best response is: A) “You must have been taking a blood thinner for a long time.” B) “You have small channels between some of your arteries, so you can get blood from a patent artery to one severely blocked.” C) “You are just a lucky person since most people would have had a massive heart attack by now.” D) “With this amount of blockage, your red blood cells get through the vessel one-by-one and supply oxygen to the muscle.” Ans: B Feedback: Collateral circulation is a mechanism for the long-term regulation of local blood flow. In the heart, anastomotic channels exist between some of the smaller arteries. These channels permit perfusion of an area by more than one artery. When one artery becomes occluded, these anastomotic channels increase in size, allowing blood from a patent artery to perfuse the area supplied by the occluded vessel. For example, persons with extensive obstruction of a coronary blood vessel may rely on collateral circulation to meet the oxygen needs of the myocardial tissue normally supplied by that vessel. There is no indication that the client is on a blood thinner. 25. The parasympathetic nervous system causes a slowing of the heart rate by increasing: A) Norepinephrine B) Vessel constriction C) Cardioinhibitory center D) Smooth muscle tone Ans: C Feedback: The medullary cardiovascular neurons are grouped into three distinct pools that lead to sympathetic innervation of the heart and blood vessels and parasympathetic innervation of the heart. The cardioinhibitory center controls parasympathetic-mediated slowing of heart rate. The parasympathetic system has little or no control over blood vessels (constriction, tone). Norepinephrine is the main neurotransmitter for sympathetic neurons. 26. The shortness of breath and cyanosis that occur in clients experiencing acute heart failure syndrome are primarily caused by: Select all that apply. A) Accumulation of fluid in the alveoli and airways B) Lung stiffness C) Worsening renal failure D) Myocardial muscle necrosis E) Impaired gas exchange Ans: A, B, E Feedback: Acute pulmonary edema is the most dramatic symptom of AHFS. It is a life-threatening condition in which capillary fluid moves into the alveoli. The accumulated fluid in the alveoli and airways causes lung stiffness, makes lung expansion more difficult, and impairs the gas exchange function of the lung. With the decreased ability of the lungs to oxygenate the blood, the hemoglobin leaves the pulmonary circulation without being fully oxygenated, resulting in shortness of breath and cyanosis. Worsening renal failure and MI may cause volume overload but are more likely secondary causes of chronic heart failure. 27. While in the ICU, a client's status changes. The health care providers suspect heart failure. Which of the following diagnostic procedures would give the staff information about pulmonary capillary pressures, which will lead to the most appropriate interventions? A) Echocardiography B) Radionuclide ventriculography C) Cardiac magnetic resonance imaging D) Hemodynamic monitoring Ans: D Feedback: Invasive hemodynamic monitoring may be used for assessment in acute, life-threatening episodes of heart failure. These monitoring methods include central venous pressure (CVP), pulmonary artery pressure monitoring, measurements of cardiac output, and intra-arterial measurements of blood pressure. Echocardiography plays a key role in assessing ejection fraction, right and left ventricular wall, wall thickness, ventricular chamber size, valve function, heart defects, and pericardial disease. Radionuclide ventriculography is recommended if there is reason to suspect coronary artery disease or ischemia as the underlying cause for heart failure. Cardiac magnetic resonance imaging and cardiac computed tomography are used to document ejection fraction, ventricular preload, and regional wall motion. 28. A nurse is performing client health education with a 68-year- old man who has recently been diagnosed with heart failure. Which of the following statements demonstrates an accurate understanding of his new diagnosis? A) “I'll be sure to take my beta blocker whenever I feel short of breath.” B) “I'm going to avoid as much physical activity as I can so that I preserve my strength.” C) “I know it's healthy to drink a lot of water, and I'm going to make sure I do this from now on.” D) “I'm trying to think of ways that I can cut down the amount of salt that I usually eat.” Ans: D Feedback: Salt and fluid restrictions are indicated for most clients with heart failure (HF). Beta blockers do not address shortness of breath, and cardiac medications are not normally taken in response to acute symptoms. Clients should be encouraged to maintain, and increase, physical activity within the limits of their condition. 29. A client with a diagnosis of heart failure has returned from a visit with his primary care provider with a prescription for a change in his daily medication regimen. Which of the following drugs is likely to improve the client's cardiac function by increasing the force and strength of ventricular contractions? A) A -adrenergic blocker B) A diuretic C) A cardiac glycoside D) An ACE inhibitor Ans: C Feedback: Cardiac glycosides improve cardiac function by increasing the force and strength of ventricular contractions. -Adrenergic blockers decrease left ventricular dysfunction associated with activation of the sympathetic nervous system. ACE inhibitors block the conversion of angiotensin I to II, whereas diuretics promote the excretion of fluid. 30. A client awaiting a heart transplant is experiencing decompensation of her left ventricle that will not respond to medications. The physicians suggest placing the client on a ventricular assist device (VAD). The client asks what this equipment will do. The health care providers respond: A) “Pull your blood from the right side of the heart and run it through a machine to oxygenate it better, and then return it to your body.” B) “Measure the pressures inside your heart continuously to asses pumping ability of your left ventricle.” C) “Have a probe at the end of a catheter to obtain thermodilution measures, so cardiac output can be calculated.” D) “This device will decrease the workload of the myocardium while maintaining cardiac output and systemic arterial pressure.” Ans: D Feedback: Refractory heart failure reflects deterioration in cardiac function that is unresponsive to medical or surgical interventions. Ventricular assist devices (VADs) are mechanical pumps used to support ventricular function. VADs are used to decrease the workload of the myocardium while maintaining cardiac output and systemic arterial pressure. This decreases the workload on the ventricle and allows it to rest and recover. The rest of the distractors relate to the monitoring in an ICU of cardiac functioning. Invasive hemodynamic monitoring may be used for assessment in acute, life-threatening episodes of heart failure. With the balloon inflated, the catheter monitors pulmonary capillary pressures (i.e., pulmonary capillary wedge pressure or pulmonary artery occlusion pressure), which reflect pressures from the left ventricle. The pulmonary capillary pressures provide a means of assessing the pumping ability of the left ventricle. One type of pulmonary artery catheter is equipped with a thermistor probe to obtain thermodilution measurements of cardiac output. 31. A car accident client is admitted with a chest tube following pneumothorax. He also has an elevated blood alcohol level. When the nurse enters his room, she notes the client is dyspneic, short of breath, and holding his chest tube in his hand. When the nurse pulls the linens back, she finds a “sucking” chest wound. After calling a “code blue,” the next priority intervention would be to: A) Place the client's meal napkin over the wound B) Observe and wait for the code blue team to bring equipment C) Try to calm the patient down by maintaining therapeutic communication D) Apply a Vaseline gauze (airtight) dressing over the insertion site Ans: D Feedback: The client has a medical emergency. Sucking chest wounds, which allow air to pass in and out of the chest cavity, should be treated by promptly covering the area with an airtight covering. Chest tubes are inserted as soon as possible. The other interventions will not help minimize the amount of air entering the pleural space. 32. A client with a history of heart failure and COPD (caused by 60 pack/year smoking) presents to the clinic with the following complaints: auscultation of breath sounds reveal absent/diminished breath sounds in the right lower lobe. Which other manifestations lead the health care provider to suspect the client may have developed atelectasis? Select all that apply. A) Respiratory rate—32; pulse rate—122 beats/minute. B) “Having a hard time catching my breath.” C) “Seems like I'm not making much water (decreased urine production).” D) Using accessory muscles to help him breathe. E) Copious amounts of thick, green sputum. Ans: A, B, D Feedback: Atelectasis is caused most commonly by airway obstruction rather than a vascular obstruction. The clinical manifestations of atelectasis include tachypnea (respiratory rate of 32), tachycardia (pulse rate of 122) dyspnea (hard time catching breath), cyanosis, signs of hypoxemia, diminished chest expansion, absence of breath sounds, and intercostal retractions (use of accessory muscles). Both chest expansion and breath sounds are decreased on the affected side. There may be intercostal retraction (pulling in of the intercostal spaces) over the involved area during inspiration. Urine production is not related to atelectasis. Copious green sputum is associated with infection. 33. A client has just been admitted to the postsurgical unit following a below-the-knee amputation. Which of the following measures should her care team prioritize to prevent atelectasis during the client's immediate recovery? A) Bedrest and supplementary oxygen by nasal cannula B) Administration of bronchodilators by nebulizer C) Deep-breathing exercises and early mobilization D) Adequate hydration and a high-humidity environment Ans: C Feedback: Coughing and deep breathing and early ambulation decrease the likelihood of atelectasis developing in surgical clients; bedrest should be avoided when possible. Oxygen, bronchodilators, hydration, and high humidity do not prevent atelectasis. 34. Which of the following is most likely to precipitate an asthmatic attack in a child with a diagnosis of extrinsic, or atopic, asthma? A) Pet dander B) Cold weather C) Stress D) Respiratory tract infections Ans: A Feedback: Extrinsic or atopic asthma is typically initiated by a type I hypersensitivity reaction induced by exposure to an extrinsic antigen or allergen such as pet dander. Intrinsic or nonatopic asthma triggers include respiratory tract infections, exercise, hyperventilation, cold air, drugs and chemicals, hormonal changes and emotional upsets, airborne pollutants, and gastroesophageal reflux. 35. Which of the following manifestations typically accompanies an asthmatic attack? A) Decreased residual volume B) Decreased pulmonary arterial pressure C) Prolonged inspiration D) Hyperinflation of the lungs Ans: D Feedback: During a prolonged attack, air becomes trapped behind the occluded and narrowed airways, causing hyperinflation of the lungs. This produces an increase in the residual volume of the lungs. Pulmonary arterial pressure tends to increase and expiration becomes prolonged. 36. A client has been recently undergone diagnostic testing for possible Berger disease. The nurse caring for this client would anticipate the primary clinical manifestations include which of the following? Select all that apply. A) Gross hematuria B) Recent upper respiratory infection C) Elevated ketone levels in the urine D) Fever, chills, and general body aches Ans: A, B, D Feedback: Early in the disease, many people with the disorder have no obvious symptoms, and the disorder is discovered during screening or examination for another condition. In others, the disorder presents with gross hematuria that is preceded by upper respiratory tract infection, GI tract symptoms, or flulike illness. The hematuria lasts 2 to 6 days. Elevated ketones are usually associated with acidosis, fasting, high-protein diet, or diabetes to name a few. 37. A 43-year-old female has recently been diagnosed with systemic lupus erythematosus (SLE) glomerulonephritis. She has presented to the out-client department to have a renal biopsy. Knowing the usual treatment options, the nurse should anticipate educating the client (who has a positive biopsy result) on which of the following medications being prescribed? Select all that apply. A) Lasix, a diuretic B) Prednisone, a corticosteroid C) Captopril, an ACE inhibitor D) Ampicillin, an antibiotic Ans: B, C Feedback: Treatment depends on the extent of glomerular involvement. Oral corticosteroids and angiotensin-converting enzyme (ACE) inhibitors are the mainstays of treatment. Diuretics and antibiotics are not part of the treatment protocol. 38. The most recent assessment of a client with a diagnosis of type 1 diabetes indicates a heightened risk of diabetic nephropathy. Which of the following assessment findings is most suggestive of this increased risk? A) Microalbuminuria B) Hematuria C) Orthostatic hypotension D) Diabetic retinopathy Ans: A Feedback: The increased glomerular filtration rate (GFR) that occurs in persons with early alterations in renal function is associated with microalbuminuria, which is an important predictor of future diabetic nephropathies. Hematuria is not directly suggestive of diabetic nephropathy, although it is a highly significant assessment finding. Orthostatic hypotension and diabetic retinopathy are not direct indicators of diabetic nephropathy. 39. Which of the following diagnostic and assessment results support the diagnosis of chronic pyelonephritis? Select all that apply. A) Polyuria (excess urine output) B) Nocturia (voiding at night) C) Bilateral flank pain D) Blood pressure 140/92 E) Severe pain in upper outer quadrant of the abdomen Ans: A, B Feedback: The symptoms of chronic pyelonephritis often include a history of recurrent episodes of UTI or acute pyelonephritis. Loss of tubular function and the ability to concentrate urine give rise to polyuria and nocturia, and mild proteinuria is common. Severe hypertension often is a contributing factor in the progress of the disease. A BP of 140/92 is not considered “severe” hypertension. Flank and upper outer quadrant pain is usually associated with kidney stones. 40. An elderly female client has been hospitalized for the treatment of acute pyelonephritis. Which of the following characteristics of the client is most likely implicated in the etiology of her current health problem? The client: A) Has been diagnosed with type 2 diabetes several years earlier B) Takes a diuretic and an ACE inhibitor each day for the treatment of hypertension C) Recently had a urinary tract infection D) Has peripheral vascular disease Ans: C Feedback: There are two routes by which bacteria can gain access to the kidney: ascending infection from the lower urinary tract and through the bloodstream. Ascending infection from the lower urinary tract is the most important and common route by which bacteria reach the kidney, resulting in acute pyelonephritis. Diabetes, hypertension controlled by a diuretic and an ACE inhibitor, and peripheral vascular disease are not associated with acute pyelonephritis. 41. A client is experiencing bladder hyperactivity. The nurse should be prepared to educate the client about which of the following medications that may be injected to help decrease the bladder hyperactivity? A) Capsaicin, a specific C-fiber afferent neurotoxin B) Botulinum toxin type A C) Oxybutynin, an antimuscarinic agent D) Urecholine, a cholinergic agonist Ans: A Feedback: Intravesical injection of medications, such as capsaicin and resiniferatoxin, that are specific C-fiber afferent neurotoxins may be used to decrease bladder hyperactivity. Botulinum toxin type A is used to produce paralysis of striated muscles of the external sphincter. Oxybutynin, an antimuscarinic agent, will decrease detrusor muscle tone. Urecholine, a cholinergic agonist, stimulates parasympathetic receptors to increase bladder tone. 42. A female client asks, “Why do I leak urine every time I cough or sneeze?” The health care worker's response is based on which physiologic principle? A) Involuntary bladder continence during filling B) A pressure difference between the urethra and bladder C) When intravesical pressure exceeds maximal urethral closure pressure D) A decrease in bladder distensibility Ans: C Feedback: Stress incontinence represents the involuntary loss of urine that occurs when, in the absence of detrusor muscle action, the intravesical pressure exceeds the maximum urethral closure pressure. Stress incontinence, which is a common problem in women of all ages, occurs as the result of weakness or disruption of pelvic floor muscles, leading to poor support of the vesicourethral sphincters. Except during the act of micturition, intraurethral pressure is normally greater than intravesical pressure. Urge incontinence and overactive bladder are associated with urgency caused by bladder infection or CNS or myogenic mechanisms. Overflow incontinence is an involuntary loss of urine that occurs when intravesical pressure exceeds the maximal urethral pressure because of bladder distention in the absence of detrusor activity. 43. The nurse is scheduled to teach a client experiencing urinary incontinence about Kegel exercises. Which of the following descriptors should the nurse include in this education? A) “Drink at least two glasses of water and then try to hold it for at least 3 hours before going to the bathroom.” B) “Contract and relax the pelvic floor muscles at least 10 times every hour while awake.” C) “After you have emptied your bladder, continue sitting on the commode and try to forcefully expel more urine.” D) “Try to start and stop urination while sitting in a bathtub full of warm soapy water.” Ans: B Feedback: Exercises for the pelvic muscles or Kegel exercises involve repetitive contraction and relaxation of the pelvic floor muscles and are an essential component of client-dependent behavioral interventions. None of the other distractors are examples of Kegel exercises. 44. An elderly client who experiences chronic pain takes opioid analgesics on a regular basis, a practice that has resulted in frequent constipation and occasional bowel obstructions. Which of the following problems may directly result from these gastrointestinal disorders? A) Urinary tract infections B) Overflow urinary incontinence C) Bladder cancer D) Neurogenic bladder Ans: B Feedback: Fecal impaction occurs when a large bolus of stool forms in the rectum, which can push against the urethra causing obstruction that results in overflow incontinence. This does not constitute a risk factor for bladder cancer or neurogenic bladder, and although a urinary tract infection (UTI) may result, this is an indirect consequence of the bowel obstruction. 45. Many factors contribute to the incontinence that is common among the elderly. A major factor is increased: A) Detrusor muscle function B) Intake of liquids and water C) Urethral closing pressure D) Use of multiple medications Ans: D Feedback: Use of multiple medications for other health problems can affect bladder function, especially diuretics. Drugs such as hypnotics, tranquilizers, and sedatives can interfere with the conscious inhibition of voiding, leading to urge incontinence. Detrusor muscle function and urethral closing pressure are decreased in the elderly, causing incontinence. Decreased fluid and water intake causes problems of bowel impaction and urinary tract infection. 46. A major factor in the development of hepatic encephalopathy is: A) Hypersplenism B) High sodium level C) Neurotoxin accumulation D) Steroid hormone deficiency Ans: C Feedback: Although the cause of hepatic encephalopathy is unknown, the accumulation of neurotoxins, which appear in the blood because the liver has lost its detoxifying capacity, is believed to be a factor. The liver metabolizes the steroid hormones; therefore, these hormones are often elevated in persons with liver failure and cause feminization (rather than encephalopathy) of male clients. Hypersplenism associated with liver failure is a factor in the development of anemia, thrombocytopenia, and leukopenia. Although the mechanisms responsible for the development of ascites are not completely understood, several factors seem to contribute to fluid accumulation, including salt and water retention by the kidney and increase in capillary pressure due to portal hypertension and obstruction of venous flow through the liver. 47. Hepatocellular cancer usually has a poor prognosis due in part to which of the following factors? A) Surgical options do not exist because removal of all or part of the liver is a threat to health. B) Liver cancer typically metastasizes at a much earlier stage than other cancers. C) Liver tumors are poorly differentiated due to the low density of hepatic tissue. D) The nonspecific symptomatology of liver cancer leads to a diagnosis at a late stage. Ans: D Feedback: Primary cancers of the liver are often far advanced at the time of diagnosis. This is partly due to the fact that the manifestations are often insidious in onset and masked by those related to cirrhosis or chronic hepatitis. Surgical options exist, and metastasis does not occur earlier than in other types of cancer, although the liver is a common site of secondary cancer. Liver tumors do not lack differentiation. 48. An ultrasound (US) of a client with intermittent pain reveals gallbladder sludge. Which of the following client history items are likely factors in the US result? Select all that apply. A) Had lap band surgery 2 years ago and lost 100 pounds B) Recent pregnancy with a 6-month-old child at home C) Current prescription for a medicine to lower cholesterol D) A runner training for a marathon E) Works in surgery with long periods of standing in one place Ans: A, B, C Feedback: Three factors contribute to the formation of gallstones: abnormalities in the composition of bile, stasis of bile (rather than rapid elimination), and inflammation of the gallbladder. The formation of cholesterol stones is associated with obesity and occurs more frequently in women, especially women who have had multiple pregnancies or who are taking oral contraceptives. All of these factors cause the liver to excrete more cholesterol into the bile. Estrogen reduces the synthesis of bile acid in women. Gallbladder sludge (thickened gallbladder mucoprotein with tiny trapped cholesterol crystals) is thought to be a precursor of gallstones. Sludge frequently occurs with pregnancy, starvation, and rapid weight loss. Drugs that lower serum cholesterol levels, such as clofibrate, also cause increased cholesterol excretion into the bile. 49. Which of the following factors is most strongly associated with the pathogenesis of gallstones? A) Excess serum ammonia and urea levels B) Portal hypertension C) Abnormalities or stasis of bile D) High-cholesterol diet Ans: C Feedback: Three factors contribute to the formation of gallstones: abnormalities in the composition of bile, stasis of bile, and inflammation of the gallbladder. Portal hypertension, a high- cholesterol diet, and excess ammonia and/or urea are not causative factors of cholelithiasis. 50. Which of the following signs and symptoms is most suggestive of acute cholecystitis? A) Upper right quadrant or epigastric pain B) Fever and sudden abdominal distention C) Appearance of undigested fat in feces D) Nausea resulting in greenish vomitus Ans: A Feedback: Persons with acute cholecystitis usually experience an acute onset of upper right quadrant or epigastric pain. Nausea and vomiting are also common, although these are not specific to cholecystitis. Abdominal distention and steatorrhea are not key signs of acute cholecystitis. 51. The signs and symptoms of abrupt cessation of pharmacologic glucocorticoids closely resemble those of: A) Addison disease B) Cushing disease C) Cushing syndrome D) Graves disease Ans: A Feedback: Although the etiology differs, the adrenal cortical insufficiency resulting from the abrupt cessation of glucocorticoids is nearly identical to Addison disease in terms of physiologic effects. 52. Which of the following pathophysiologic phenomena may result in a diagnosis of Cushing disease? A) Hypopituitarism B) Excess ACTH production by a pituitary tumor C) Autoimmune destruction of the adrenal cortex D) Malfunction of the HPA system Ans: B Feedback: Three important forms of Cushing syndrome result from excess glucocorticoid production by the body. One is a pituitary form, which results from excessive production of ACTH by a tumor of the pituitary gland. Hypopituitarism and destruction of the adrenal cortex are associated with Addison disease. Disruption of the HPA system is not implicated in the etiology of Cushing disease. 53. A lung cancer client with small cell carcinoma may secrete an excess of which hormone causing an ectopic form of Cushing syndrome due to a nonpituitary tumor? A) GH B) TSH C) DHEA D) ACTH Ans: D Feedback: The third form (of Cushing syndrome) is ectopic Cushing syndrome, caused by a nonpituitary ACTH-secreting tumor. Certain extra pituitary malignant tumors such as small cell carcinoma of the lung may secrete ACTH or, rarely, CRH and produce Cushing syndrome. The adrenal sex hormone dehydroepiandrosterone (DHEA) contributes to the pubertal growth of body hair, particularly pubic and axillary hair in women. Thyroid-stimulating hormone (TSH) levels are used to differentiate between primary and secondary thyroid disorders. Although secretion of growth hormone (GH) has diurnal variations over a 24-hour period, with nocturnal sleep bursts occurring 1 to 4 hours after onset of sleep, it is unrelated to ACTH and/or CRH secretion. 54. The iatrogenic form of Cushing syndrome is caused by: A) Long-term cortisone therapy B) Pituitary tumor secreting ACTH C) Benign or malignant adrenal tumor D) Ectopic ACTH-secreting lung tumor Ans: A Feedback: Three important forms of Cushing syndrome result from excess glucocorticoid production by the body. One is a pituitary form, which results from excessive production of ACTH by a tumor of the pituitary gland, called Cushing disease. The second form is the adrenal form, caused by a benign or malignant adrenal tumor. The third form is ectopic Cushing syndrome, caused by a nonpituitary ACTH-secreting tumor, often carcinoma of the lung. Iatrogenic Cushing syndrome results from long-term therapy with one of the potent pharmacologic preparations of glucocorticoids. 55. Which of the following clinical manifestations would support 57. A client with chronic low back pain presents to the clinic. In addition to a detailed pain assessment, which of the following questions would be appropriate to ask? Select all that apply. A) “Do you have trouble making water?” the medical diagnosis of Cushing syndrome? Select all that apply. B) “Can you financially afford your medicine?” A) Excessive facial hair growth C) “What kind of stressors are you experiencing?” B) Muscle hypertrophy D) “Do you consider yourself a good driver?” C) Blood glucose level in 200 mg/dL range E) “Are you having trouble sleeping?” D) “Buffalo hump” on back Ans: B, C, E E) Blood pressure reading less than 90/70 Feedback: Ans: A, C, D Unlike acute pain that serves as a warning system, persistent Feedback: The major manifestations of Cushing syndrome represent an exaggeration of the many actions of cortisol. There is muscle weakness, and the extremities are thin. Derangements in glucose metabolism are found in approximately 75% of clients, with clinically overt diabetes mellitus occurring in approximately 20% of clients. The glucocorticoids possess mineralocorticoid properties; this causes fluid retention and hypertension resulting from sodium retention, water retention, and hypervolemia. An increase in androgen levels causes hirsutism. Altered fat metabolism causes a peculiar deposition of fat characterized by a protruding abdomen; subclavicular fat pads or “buffalo hump” on the back; and a round, plethoric “moon face.” 56. When lecturing about heart attacks (myocardial infarctions), the instructor will emphasize the client may present with: Select all that apply. A) Substernal chest pain B) Neck pain C) Umbilicus pain D) Deep, right-sided abdominal pain E) Pain that radiates to the left arm Ans: A, B, E Feedback: Referred pain is perceived at a site different from the location of its point of origin but innervated by the same spinal segment. The sites of referred pain are determined embryologically with the development of visceral and somatic structures that share the same site for entry of sensory information into the central nervous system (CNS) and then move to more distant locations. Pain that originates in the abdominal or thoracic viscera is diffuse and poorly localized and is often perceived at a site far removed from the affected area. For example, the pain associated with myocardial infarction commonly is referred to the left arm, neck, and chest, which may delay diagnosis and treatment of a potentially life-threatening condition. chronic pain usually serves no useful function. To the contrary, it imposes physiologic, psychological, interpersonal, and economic stresses and may exhaust a person's resources. It is often associated with loss of appetite, sleep disturbances, and depression, which commonly is relieved once the pain is removed. Trouble urinating (dysuria) is usually not associated with chronic pain syndrome (unless this is a preexisting condition like BPH). A person's ability to drive is not a priority question asked of a client with chronic pain. 58. A client with a diagnosis of lung cancer has developed bone metastases resulting in severe and protracted pain. Which of the following assessment components should the nurse prioritize when assessing the client's pain? A) The appearance of grimacing, guarding, or wincing B) The presence of changes in vital signs that correspond to pain C) The client's subjective report of the character and severity of pain D) The results of a detailed neurologic assessment Ans: C Feedback: Although objective signs of pain may or may not be evident, the priority component of any pain assessment is the client's self- report. 59. Which of the following interventions would be considered a nonpharmacologic method of pain control? Select all that apply. A) Distraction by knitting B) Guided imagery C) Biofeedback D) OTC acetaminophen Ans: A, B, C Feedback: A number of nonpharmacologic methods of pain control are used in pain management. These include cognitive–behavioral interventions (e.g., relaxation, distraction, imagery, and biofeedback), physical agents (e.g., heat and cold), electroanalgesia (transcutaneous electrical nerve stimulation [TENS]), and acupuncture. Even though acetaminophen is an over-the-counter pain medication, it is still a pharmacologic intervention. 60. A hospital client has been reluctant to accept morphine sulfate despite visible signs of pain. Upon questioning, the client reveals that he is afraid of becoming addicted to the drug. How can a member of the care team best respond to the client's concern? A) “You might become addicted, but there are excellent resources available in the hospital to deal with that development.” B) “You should likely prioritize the control of your pain over any fears of addiction that you have.” C) “If you start needing higher doses to control your pain, then we'll address those concerns.” D) “There's only a minute chance that you will become addicted to these painkillers.” Ans: D Feedback: Although long-term treatment with opioids can result in opioid tolerance (i.e., increasingly greater drug dosages being needed to achieve the same effect) and physical dependence, this should not be confused with addiction. Long-term drug-seeking behavior is rare in persons who are treated with opioids only during the time that they require pain relief. 61. Which of the following pathophysiologic processes occurs in cases of bacterial meningitis? A) Infection in the cerebrospinal fluid causes vasoconstriction and cerebral hypoxia. B) Trauma introduces skin-borne pathogens to the cerebrospinal fluid. C) Infection in the cerebrospinal fluid causes spinal cord compression and neurologic deficits. D) Inflammation allows pathogens to cross into the cerebrospinal fluid. Ans: D Feedback: In the pathophysiologic process of bacterial meningitis, the bacterial organisms replicate and undergo lysis in the CSF, releasing endotoxins or cell wall fragments. These substances initiate the release of inflammatory mediators, which set off a complex sequence of events permitting pathogens, neutrophils, and albumin to move across the capillary wall into the CSF. Cerebral hypoxia does not result directly from meningitis, and the causative pathogens are not introduced from the skin nor is trauma an initiating event. Spinal cord compression is not an expected consequence of meningitis. 62. Common manifestations of acute meningococcal meningitis, a highly contagious and lethal form of meningitis, include: A) Diplopia B) Petechiae C) Papilledema D) Focal paralysis Ans: B Feedback: Meningococcal meningitis causes a petechial rash with palpable purpura in most people. The most common manifestations of acute bacterial meningitis are fever and chills; headache; stiff neck (nuchal rigidity) and back; abdominal and extremity pains; and nausea and vomiting. Other signs include seizures, cranial nerve damage (especially the eighth nerve, with resulting deafness), and focal cerebral signs. General signs and symptoms of brain tumor include headache, papilledema, nausea, vomiting, mental changes, visual disturbances (e.g., diplopia), alterations in sensory and motor function, and seizures. Like meningitis, encephalitis is characterized by fever, headache, and nuchal rigidity, but more often clients also experience neurologic disturbances, such as focal paralysis, lethargy, disorientation, seizures, delirium, and coma. 63. A family brings a client to the emergency department with increasing lethargy and disorientation. They think the client had a seizure on the drive over to the hospital. The client has been sick with a “cold virus” for the last few days. On admission, the clients' temperature is 102°F. Which other clinical manifestations may lead to the diagnosis of encephalitis? A) Petechia over entire body B) BP 100/72 C) Impaired neck flexion resulting from muscle spasm D) Appearance of red-purple discolorations on the skin that do not blanch on applying pressure Ans: C Feedback: Like meningitis, encephalitis is characterized by fever, headache, and nuchal rigidity (impaired neck flexion resulting from muscle spasm), but more often clients also experience neurologic disturbances, such as lethargy, disorientation, seizures, focal paralysis, delirium, and coma. Meningococcal meningitis is characterized by a petechial (petite hemorrhagic spots) rash with palpable purpura (red- purple discolorations on the skin that do not blanch on applying pressure) in most people. This BP is within normal range. 64. Which of the following individuals has the highest chance of having a medulloblastoma? A) An 88-year-old man who has begun displaying signs and symptoms of increased ICP B) A 60-year-old woman who is soon to begin radiation therapy for the treatment of breast cancer C) A 4-year-old child who has become uncoordinated in recent months D) A 68-year-old man who is a smoker and has a family history of cancer Ans: C Feedback: Tumors of neuronal origin (e.g., medulloblastoma) usually occur during infancy and childhood. This is due to the fact that a cell must be capable of replication to undergo neoplastic transformation. 65. Following surgery for a large malignant brain tumor, the nurse should anticipate discussing which further treatment option with the family that may ensure that any remaining cancer cells will be killed? A) Chemotherapy B) Immunotherapy C) Gamma knife radiation D) Stem cell transplant Ans: C Feedback: Most malignant brain tumors respond to external irradiation. Irradiation can increase longevity and sometimes can allay symptoms when tumors recur. The treatment dose depends on the tumor's histologic type, responsiveness to radiation, and anatomic site and on the level of tolerance of the surrounding tissue. A newer technique called gamma knife combines stereotactic localization of the tumor with radiosurgery, allowing delivery of high-dose radiation to deep tumors while sparing the surrounding brain. 66. Which of the following clients is at greatest risk for developing balanitis xerotica obliterans? A) A homosexual male with a monogamous partner B) A client who has had their pituitary gland removed due to cancer C) A male who has an uncircumcised penis D) A middle-aged male with history of chronic prostatitis Ans: C Feedback: Balanitis xerotica obliterans is a chronic, sclerosing, atrophic process of the glans penis that occurs solely in uncircumcised men. As such, the uncircumcised state supersedes the influence of sexual behavior, prostatitis, or hormonal effects of not having a pituitary gland. 67. Which of the following clinical manifestations are characteristic for clients with Peyronie disease? Select all that apply. A) Painful erection B) Thick, yellow discharge from the penis C) Presence of a hard mass on the tunica albuginea of the penis D) Papillary lesions on penis filled with serous-colored fluid E) Thick, nonretractable foreskin of uncircumcised male Ans: A, C Feedback: Peyronie disease involves a localized and progressive fibrosis of unknown origin that affects the tunica albuginea (i.e., the tough, fibrous sheath that surrounds the corpora cavernosa) of the penis. The manifestations of Peyronie disease include painful erection, bent erection, and the presence of a hard mass at the site of fibrosis. Approximately two thirds of men complain of pain as a symptom. Discharge and lesions from the penis is usually caused from infections or STDs. Thick, nonretractable foreskin of uncircumcised male is associated with balanitis xerotica obliterans. 68. From the following list of clients, which ones are at high risk for developing priapism? Select all that apply. A) A teenage cocaine abuser who has been “high” for the past 72 hours B) An uncircumcised male with poor hygiene habits C) A sixth grade male returning to school following sickle cell crisis D) A college student with complete spinal cord injury at T12 level following auto accident E) A middle-aged adult male with recent history of myocardial infarction Ans: C, D Feedback: Priapism is due to impaired blood flow in the corpora cavernosa of the penis. Priapism is classified as primary (idiopathic) or secondary to a disease or drug effect. Secondary causes include hematologic conditions (e.g., leukemia, sickle cell disease, polycythemia), neurologic conditions (e.g., stroke, spinal cord injury), and renal failure. Two mechanisms for priapism have been proposed: low-flow (ischemic) priapism, in which there is stasis of blood flow in the corpora cavernosa with a resultant failure of detumescence (diminution of swelling or erection), and Peyronie disease, which involves a localized and progressive fibrosis of unknown origin that affects the tunica albuginea (i.e., the tough, fibrous sheath that surrounds the corpora cavernosa) of the penis. Circumcision trauma to the penis and abnormal tightening of foreskin are external penile problems associated with phimosis rather than the internal vascular problem of priapism. 69. Squamous cell cancer of the penis is characterized by which of the following clinical manifestations? A) Erectile dysfunction with prolonged erection B) Herpes ulcerations on the penile shaft C) Painless lump on the inner surface of the prepuce D) Smegma accumulation in uncircumcised male requiring regular reminders about hygiene Ans: C Feedback: The cause of penile cancer is unknown. Invasive squamous cell carcinoma of the penis usually begins as a small lump or ulcer on the glans or inner surface of the prepuce. Several risk factors have been suggested, including poor hygiene, human papillomavirus infections (rather than herpes simplex virus infections), ultraviolet radiation exposure, and immunodeficiency states. There is an association between penile cancer and poor genital hygiene and phimosis. Circumcision confers protection, and hence cancer of the penis is extremely rare in men circumcised at birth. It is thought that circumcision is associated with better genital hygiene, which, in turn, reduces exposure to carcinogens that may accumulate in smegma and decreases the likelihood of potentially oncogenic strains of HPV. Erectile dysfunction can be the result of depression, androgen level imbalance, systemic medications, or arterial insufficiency that are unrelated to squamous cell tissue changes. 70. During a visit to the health care provider, a client complains of swelling in the scrotum. The health care worker suspects a hydrocele and performs an exam by shining a light through the scrotum. If the hydrocele is dense, the health care worker should: A) Continue to monitor the client every 6 months to see if there is a change in size. B) Prescribe diuretics like Lasix to help remove excess fluid. C) Order an ultrasound or biopsy to rule out testicular cancer. D) Gently try to express the fluid out of the scrotal sac. Ans: C Feedback: Hydroceles are palpated as cystic masses that may attain massive proportions. If there is enough fluid, the mass may be mistaken for a solid tumor. Transillumination of the scrotum (i.e., shining a light through the scrotum to visualize its internal structures) or ultrasonography can help to determine whether the mass is solid or cystic and whether the testicle is normal. A dense hydrocele that does not illuminate should be differentiated from a testicular tumor. The fluid cannot be removed by diuretics or by trying to express the fluid out of the scrotum. 71. Men whose sexual partners have been diagnosed with Trichomonas vaginalis will likely exhibit: A) No symptoms of infection B) Copious amounts of frothy discharge from the penis C) Numerous pustules on the penal shaft D) Redness and pain at the urethral meatus Ans: A Feedback: Men harbor the Trichomonas vaginalis in the urethra and prostate and are largely asymptomatic. Chlamydia, gonorrhea, and syphilis cause active infection and symptoms in both men and women. 72. A client presents to the out-client clinic complaining of gray discharge that has a fishy odor. The health care provider sees “clue cells” on wet-mount microscopic exam. This would most likely lead to the diagnosis of: A) Trichomonas vaginalis B) Chlamydial C) Bacterial vaginosis D) Syphilis Ans: C Feedback: The diagnosis of bacterial vaginosis is made when at least three of the following signs or symptoms are present: abnormal gray discharge, vaginal pH above 4.5 (usually 5.0–6.0), positive fishy odor of vaginal discharge on addition of 10% potassium hydroxide, and appearance of characteristic “clue cells” on wet-mount microscopic studies. T. vaginalis is an anaerobic protozoan that is shaped like a turnip and has three or four anterior flagella. Chlamydia exists in two morphologically distinct forms during its unique life—a small infectious elementary body and a large noninfectious reticulate body. The diagnosis of syphilis can be made rapidly by dark-field microscopic examination of the exudate from skin lesions. However