NURS 241- Exam 1 Psychosis, electrolytes, fluid balance, &
HF Questions With Complete Solutions
1) What disorder causes narrowed arteries in the heart from
plaques?
2) What disorder causes stiff, unresponsive vessels?
*both gradually leave the heart too weak or stiff to fill & pump
effieciently Correct Answers 1) atheroscelorisis
2) arteriosclerosis
*heart muscle can change thickness as a response to chronic
disease/inflammation & that can impact filling and squeezing
A 20-year-old male patient diagnosed with chronic
schizophrenia is placed on an antipsychotic, 20 mg twice a day.
At the evening medication time, he expresses that he is not
feeling well. The nurse assesses the patient and finds the
following symptoms: oral temperature 103° F (39.4° C), pulse
110 beats/min, and respirations 24 breaths/min. The patient is
diaphoretic and appears rigid. This patient is most likely
suffering from which of the following?
A) Tardive dyskinesia
B) Pneumonia
C)Neuroleptic malignant syndrome
D) Pseudoparkinsonism Correct Answers C)Neuroleptic
malignant syndrome
*The symptoms are consistent with neuroleptic malignant
syndrome, which is an adverse reaction to antipsychotic
medication. While the other conditions listed in answers A and
D may also be side effects of antipsychotic medication, the
,symptoms presented are not indicative of these conditions.
Pneumonia may present with these vital signs; however, the
diaphoresis and muscular rigidity are not.
A 25-year-old man is admitted to the psychiatric unit after being
found by the police walking naked down the middle of the street
at 3:00 AM. He insists that he is the real Santa Claus. Which of
the following nursing interventions should the nurse implement
when working with this patient?
A) Consistently use the patient's name.
B) Point out to the patient why he cannot be Santa Claus.
C) Agree that he is Santa Claus so as not to upset him further.
D)Provide medication as needed (PRN).
*The patient needs continuous reality-based orientation, so his
name should be used in all interactions with the nurse and other
staff. The nurse should not reinforce the delusion by agreeing
with the patient. Logical arguments and PRN medication are not
likely to change his thinking. Correct Answers A) Consistently
use the patient's name.
*The patient needs continuous reality-based orientation, so his
name should be used in all interactions with the nurse and other
staff. The nurse should not reinforce the delusion by agreeing
with the patient. Logical arguments and PRN medication are not
likely to change his thinking.
A client admitted for heart failure has a priority problem of
hypervolemia related to compromised regulatory mechanisms.
Which assessment result obtained the day after admission is the
best indicator that the treatment has been effective?
a) The client has diuresis of 400 mL in 24 hours.
,b) The client's blood pressure is 122/84 mm Hg.
c) The client has an apical pulse of 82 beats/min.
d) The client's weight decreases by 2.5 kg. Correct Answers d)
The client's weight decreases by 2.5 kg.
*The best indicator that treatment is effective on a client with
heart failure and problems of hypervolemia is the client's weight
decreased by 5.5 pounds (2.5 kg) in one day. The best indicator
of fluid volume gain or loss is daily weight. Because each
kilogram represents approximately 1 liter, this client has lost
approximately 2500 mL of fluid.Diuresis of 400 mL in 24 hours
represents oliguria. Although a blood pressure of 122/84 mm Hg
is a normal finding, alone it is not significant for relief of
hypervolemia. Although an apical pulse of 82 beats/min is a
normal finding, alone it is not significant to determine whether
hypervolemia is relieved.
A client begins therapy with lisinopril (Prinivil, Zestril). What
does the nurse consider at the start of therapy with this
medication?
a) The client's ability to understand medication teaching
b) The risk for hypotension
c) The potential for bradycardia
d) Liver function tests Correct Answers b) The risk for
hypotension
*At the start of therapy with lisinopril, the nurse needs to
consider the risk for hypotension. Angiotensin-converting
enzyme (ACE) inhibitors like lisinopril are associated with first-
dose hypotension and orthostatic hypotension, which are more
likely in those older than 75 years.Although desirable, ability to
, understand teaching is not essential. ACE inhibitors are
vasodilators and do not affect heart rate. Renal function, not
liver function, may be altered by ACE inhibitors.
A client develops fluid overload while in the intensive care unit.
Which nursing intervention does the nurse perform first?
a) Places the extremities in a dependent position
b) Puts the client in a side-lying position
c) Elevates the head of the bed
d) Draws blood for laboratory tests Correct Answers c)
Elevates the head of the bed
*The nurse first needs to elevate the client's head of bed when
caring for a client with fluid overload. Remember to follow the
ABC's and perform interventions that promote lung expansion
and oxygenation to relieve symptoms of fluid overload.
Drawing blood for laboratory tests may be indicated, but would
not be performed first. Placing the extremities in a dependent
position increases peripheral edema, and positioning the client in
a side-lying position increases the work of breathing.
A client is diagnosed with right-sided heart failure. Which
assessment findings will the nurse expect the client to have?
(Select all that apply.)
a. Peripheral edema
b. Crackles in both lungs
c. Increased abdominal girth
d. Ascites
e. Tachypnea
*Peripheral edema, increased abdominal girth, ascites, and
tachypnea are all symptoms associated with right-sided heart
HF Questions With Complete Solutions
1) What disorder causes narrowed arteries in the heart from
plaques?
2) What disorder causes stiff, unresponsive vessels?
*both gradually leave the heart too weak or stiff to fill & pump
effieciently Correct Answers 1) atheroscelorisis
2) arteriosclerosis
*heart muscle can change thickness as a response to chronic
disease/inflammation & that can impact filling and squeezing
A 20-year-old male patient diagnosed with chronic
schizophrenia is placed on an antipsychotic, 20 mg twice a day.
At the evening medication time, he expresses that he is not
feeling well. The nurse assesses the patient and finds the
following symptoms: oral temperature 103° F (39.4° C), pulse
110 beats/min, and respirations 24 breaths/min. The patient is
diaphoretic and appears rigid. This patient is most likely
suffering from which of the following?
A) Tardive dyskinesia
B) Pneumonia
C)Neuroleptic malignant syndrome
D) Pseudoparkinsonism Correct Answers C)Neuroleptic
malignant syndrome
*The symptoms are consistent with neuroleptic malignant
syndrome, which is an adverse reaction to antipsychotic
medication. While the other conditions listed in answers A and
D may also be side effects of antipsychotic medication, the
,symptoms presented are not indicative of these conditions.
Pneumonia may present with these vital signs; however, the
diaphoresis and muscular rigidity are not.
A 25-year-old man is admitted to the psychiatric unit after being
found by the police walking naked down the middle of the street
at 3:00 AM. He insists that he is the real Santa Claus. Which of
the following nursing interventions should the nurse implement
when working with this patient?
A) Consistently use the patient's name.
B) Point out to the patient why he cannot be Santa Claus.
C) Agree that he is Santa Claus so as not to upset him further.
D)Provide medication as needed (PRN).
*The patient needs continuous reality-based orientation, so his
name should be used in all interactions with the nurse and other
staff. The nurse should not reinforce the delusion by agreeing
with the patient. Logical arguments and PRN medication are not
likely to change his thinking. Correct Answers A) Consistently
use the patient's name.
*The patient needs continuous reality-based orientation, so his
name should be used in all interactions with the nurse and other
staff. The nurse should not reinforce the delusion by agreeing
with the patient. Logical arguments and PRN medication are not
likely to change his thinking.
A client admitted for heart failure has a priority problem of
hypervolemia related to compromised regulatory mechanisms.
Which assessment result obtained the day after admission is the
best indicator that the treatment has been effective?
a) The client has diuresis of 400 mL in 24 hours.
,b) The client's blood pressure is 122/84 mm Hg.
c) The client has an apical pulse of 82 beats/min.
d) The client's weight decreases by 2.5 kg. Correct Answers d)
The client's weight decreases by 2.5 kg.
*The best indicator that treatment is effective on a client with
heart failure and problems of hypervolemia is the client's weight
decreased by 5.5 pounds (2.5 kg) in one day. The best indicator
of fluid volume gain or loss is daily weight. Because each
kilogram represents approximately 1 liter, this client has lost
approximately 2500 mL of fluid.Diuresis of 400 mL in 24 hours
represents oliguria. Although a blood pressure of 122/84 mm Hg
is a normal finding, alone it is not significant for relief of
hypervolemia. Although an apical pulse of 82 beats/min is a
normal finding, alone it is not significant to determine whether
hypervolemia is relieved.
A client begins therapy with lisinopril (Prinivil, Zestril). What
does the nurse consider at the start of therapy with this
medication?
a) The client's ability to understand medication teaching
b) The risk for hypotension
c) The potential for bradycardia
d) Liver function tests Correct Answers b) The risk for
hypotension
*At the start of therapy with lisinopril, the nurse needs to
consider the risk for hypotension. Angiotensin-converting
enzyme (ACE) inhibitors like lisinopril are associated with first-
dose hypotension and orthostatic hypotension, which are more
likely in those older than 75 years.Although desirable, ability to
, understand teaching is not essential. ACE inhibitors are
vasodilators and do not affect heart rate. Renal function, not
liver function, may be altered by ACE inhibitors.
A client develops fluid overload while in the intensive care unit.
Which nursing intervention does the nurse perform first?
a) Places the extremities in a dependent position
b) Puts the client in a side-lying position
c) Elevates the head of the bed
d) Draws blood for laboratory tests Correct Answers c)
Elevates the head of the bed
*The nurse first needs to elevate the client's head of bed when
caring for a client with fluid overload. Remember to follow the
ABC's and perform interventions that promote lung expansion
and oxygenation to relieve symptoms of fluid overload.
Drawing blood for laboratory tests may be indicated, but would
not be performed first. Placing the extremities in a dependent
position increases peripheral edema, and positioning the client in
a side-lying position increases the work of breathing.
A client is diagnosed with right-sided heart failure. Which
assessment findings will the nurse expect the client to have?
(Select all that apply.)
a. Peripheral edema
b. Crackles in both lungs
c. Increased abdominal girth
d. Ascites
e. Tachypnea
*Peripheral edema, increased abdominal girth, ascites, and
tachypnea are all symptoms associated with right-sided heart
