Which pathophysiological response supports a client's vomiting experience?
a. Sensory input of noxious stimuli relayed to the cognitive centers is associated with disgust and
illicits vomiting.
b. Response of stimulation of the posterior oropharynx results in reverse peristalsis of the
gastrointestinal tract.
c. Spasmodic reflex of respiratory and gastric movements results from stimulation of the
chemoreceptor trigger zone.
d. Increased gastric and colonic pressures move gastrointestinal contents to the orifice of least
resistance. correct answers c. Spasmodic reflex of respiratory and gastric movements results
from stimulation of the chemoreceptor trigger zone.
Rationale: Vomiting is a reflex of spasmodic respiratory movements against the glottis causing
the forceful expulsion of the contents of the stomach through the mouth. Stimulation of the
emetic center results from afferent vagal and sympathetic nerve pathways that activate the
chemoreceptor trigger zone (CTZ).
A deficiency of intrinsic factor should alert the nurse to assess a client's history for which
condition?
a. Emphysema.
b. Hemophilia.
c. Pernicious anemia.
d. Oxalic acid toxicity. correct answers c. Pernicious anemia.
Rationale: Pernicious anemia is a type of anemia due to failure of absorption of cobalamin (Vit
B12). The most common cause is lack of intrinsic factor, a glucoprotein produced by the parietal
cells of the gastric lining.
The nurse is measuring blood pressure on all four extremities of a child with coarctation of the
aorta. Which blood pressure finding should the nurse expect to obtain?
, a. Higher on the left side.
b. Higher on the right side.
c. Lower in the arms than in the legs.
d. Lower in the legs than in the arms. correct answers d. Lower in the legs than in the arms.
Rationale: In coarctation of the aorta, a congenital constriction is found at the aorta near the
ductus arteriosus region that lies past the left subclavian arteries, which perfuses the upper
extremities. The child should have higher blood pressures in the upper extremities than in the
legs.
A middle-aged male client asks the nurse what findings from his digital rectal examination
(DRE) prompted the healthcare provider to prescribe a repeat serum prostatic surface antigen
(PSA) level. What information should the nurse provide?
a. A uniformly enlarged prostate is benign prostatic hypertrophy that occurs with aging.
b. The spongy or elastic texture of the prostate is normal and requires no further testing.
c. An infection is usually present when the prostate indents when a finger is pressed on it.
d. Stony, irregular nodules palpated on the prostate should be further evaluated. correct answers
d. Stony, irregular nodules palpated on the prostate should be further evaluated.
Rationale: PSA levels are prescribed to screen for prostatic cancer which is often detected by
DRE and manifested as small, hard, or stony, irregularly-shaped nodules on the surface of the
prostate. Although PSA levels are prescribed for routine screening, the findings suggestive of
BPH normal texture or infection do not suggest cancer of the prostate which requires further
evaluation
The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH),
which is manifested by which symptoms?
a. Loss of thirst, weight gain.
b. Dependent edema, fever.
c. Polydipsia, polyuria.
d. Hypernatremia, tachypnea. correct answers a. loss of thirst, weigh gain