NURS 319 Exam 1 Questions With Complete Solutions

1. While assessing a client with liver cirrhosis, the nurse observes that the client has asterixis. What is the reason for this condition of the client? - ANSWER encephalopathy 2. asterixis - ANSWER tremor of the hand when the wrist is extended 3. The nurse is caring for multiple clients in an acute care setting. Which client does the nurse identify as being at risk for nonalcoholic fatty liver disease (NAFLD)? A. The client being treated for hepatitis B B. The client with exposure to isoniazid C. The client who follows a strict vegetarian diet D. The client with cell-mediated immunity - ANSWER C. The client who follows a strict vegetarian diet Lack of proteins in the diet leads to a deficiency of amino acids that are needed by the liver for the conversion of fat to phospholipids, lipoproteins, and transportation of fat/cholesterol from the cells. This can cause fat accumulation in the liver, resulting in NAFLD. 4. The nurse is reviewing the pathophysiology of NAFLD with staff nurses. Which statement made by an attending nurse indicates understanding? A. NAFLD is linked to metabolic syndrome B. Exposure to vinyl chloride can cause NAFLD C. Increased level of adiponectin is associated with NAFLD D. NAFLD is caused by accumulation of fat in the adipose tissue - ANSWER A. NAFLD is linked to metabolic syndrome Metabolic syndrome is characterized by insulin resistance, obesity, and hyperlipidemia. It can lead to excess fat accumulation in the liver. Therefore, NAFLD is linked to metabolic syndrome. 5. A physical examination of a client exhibits Cullen sign and Grey Turner sign. Which condition should the nurse suspect in the client? - ANSWER acute pancreatitis 6. Which factors may lead to an acute inflammation of the pancreas? - ANSWER both excessive alcohol intake and high triglyceride levels 7. A nurse instructor is teaching a group of nursing students about the pathophysiology of cholecystitis. The nursing instructor asks, "What happens during chronic cholecystitis?" Which statement of a student nurse indicates effective learning? A. The gallbladder is filled with purulent effusion B. Perforation and gangrene are developed on the wall of the gallbladder C. The gallstone passes from the cystic duct into the common bile duct D. The gallbladder becomes thickened and functions poorly - ANSWER D. The gallbladder becomes thickened and functions poorly 8. List 4 common risk factors for forming gallstones: - ANSWER - estrogen level - obesity - oral contraceptives - liver enzymes 9. Which conditions show an elevated level of WBCs? Select all that apply. A. Appendicitis B. Constipation C. Diverticular disease D. Large bowel obstruction E. Irritable bowel syndrome - ANSWER A. Appendicitis C. Diverticular disease D. Large bowel obstruction 10. A client has been diagnosed with Ehlers-Danlos Syndrome. The nurse would expect to see which assessment findings? - ANSWER highly elastic skin and hypermobile joints 11. A client is in the late stages of Huntington's disease. The nurse would expect to find which assessment findings? - ANSWER dysarthria and dysphagia 12. 13. dysarthria - ANSWER slurred speech A client's wound healed by tertiary intention. The nurse understands that this means _____. A. the recovery should be complete in 7-10 days B. the client is at a lower risk of infection C. the client will need physical therapy to recover D. scaring will likely occur at the site of the wound - ANSWER D. scaring will likely occur at the site of the wound 14. The nurse determines which client will be at risk for delayed wound healing? SELECT ALL THAT APPLY: A. a client who is underweight B. a client diagnosed with depression C. a client who is receiving chemotherapy for cancer D. a client who is over the age of 65 E. a client who is under the age of 1 year old - ANSWER A, C, D 15. A client with a large abdominal incision just started vomiting. The nurse is concerned with _____ following this action. - ANSWER wound dehiscence 16. Histamine release results in which clinical manifestations following a sprained ankle? SELECT ALL THAT APPLY: A. edema B. warmth C. hypertension D. bradycardia E. fever - ANSWER A, B 17. A client presents with fever, pain, lymphadenopathy, anorexia, and lethargy. Which substance is responsible for these symptoms? - ANSWER prostaglandins 18. Failure to follow sterile technique when inserting an intravenous catheter could result in _____. - ANSWER septicemia 19. septicemia - ANSWER aka sepsis infection in the blood 20. 21. 22. Tetanus is caused by _____. - ANSWER a bacterial infection During the prodromal phase of infection, the client is _____. A. highly contagious B. not displaying symptoms C. recovering from symptoms D. unable to function - ANSWER A. highly contagious A client has been diagnosed with GABHS pharyngitis following a throat culture. The client states they do not believe in taking antibiotics and prefer to allow the body to heal itself. The nurse educates the client that the consequence of this action could result in _____. A. rheumatic heart disease B. an upper respiratory infection C. a stronger immunity D. respiratory complications - ANSWER A. rheumatic heart disease 23. A positive Kernig's sign is indicative of _____. - ANSWER bacterial meningitis 24. While caring for a client with an autoimmune skin disorder, the nurse observes a red butterfly-patterned lesion over the client's nose and cheeks. After reviewing the skin biopsy reports, the nurse also finds deposits of immunoglobulin M (IgM) in the lesions. Which skin disorder does the nurse expect to find in the medical record of this client? - ANSWER systemic lupus erythematosus SLE is an inflammatory autoimmune disease that is characterized by a red, plaque like, asymmetric, butterfly-patterned lesion over the nose and cheeks. Deposits of immunoglobulins, especially IgM, in the lesions are identified in the skin biopsy Conjunctivitis is a bacterial or viral infection that results in red, swollen eyes. It spreads easily through contact with contaminated objects. 25. Which vision impairment is associated with elongation of the eyeball? - ANSWER myopia aka nearsightedness 26. While assessing a client with glaucoma, the nurse uses a tonometry instrument. Which clinical information does the nurse document from this instrument? - ANSWER measurement of intraocular pressure Glaucoma is a condition of optical nerve damage associated with an increase in intraocular pressure. A tonometry instrument is a handheld device that helps to assess intraocular pressure, the pressure within the eye. 27. Which eye disorder is associated with irregular clumping of proteinaceous substances within the lens? - ANSWER cataract formation Cataract is an eye disorder associated with clumping of excessive proteinaceous layers within the cornea or lens. 28. 29. Select the infections that are caused by bacteria: A. measles B. gas gangrene C. mononucleosis D. legionnaire's disease E. botulism F. tetanus G. lyme disease H. influenza A I. whooping cough J. polio - ANSWER B, D, E, F, G, I A 23 year old patient is concerned with osteoporosis following her grandmother sustaining a hip fracture. Identify factors that would prevent bone demineralization for this patient. SELECT ALL THAT APPLY: A. increase dietary calcium intake to mg a day B. regularly engage in weight bearing exercises, such as jogging C. incorporate swimming into your daily routine D. increase vitamins and minerals in your diet, particularly vitamin D E. ensure blood pressure remains well controlled as you age - ANSWER A, B, D 30. Four patients have sustained a musculoskeletal injury. Which patient is your priority to intervene with? A. a patient presenting with a swollen ankle after tripping while jogging B. a patient in an arm cast whose hand is cool to the touch and has no palpable pulse C. a patient who is experiencing severe hip pain following a fall While reviewing the medical record of a client with a skin disorder, the nurse finds the term "lichenification" in the record. Which symptom does the nurse anticipate when assessing this client? A. a scratch that breaks the skin's surface B. an irregular, elevated scar tissue C. a hardening or thickening of the skin with markings D. a crack in the skin that breaks through keratin - ANSWER C. a hardening or thickening of the skin with markings Lichenification is the hardening or thickening of the skin with markings. It occurs from repeated trauma, such as scratching. 31. A school-age client diagnosed with Stevens-Johnson syndrome is admitted to the hospital. Which symptom does the nurse find in this client? - ANSWER a red, painful rash, and blistering 32. Senile angiomas - ANSWER a disorder of the skin's blood vessels characterized by a small group of asymptomatic, cherry red, dome-shaped papules that appear on the trunk The nurse is providing care for a client after a recent skin biopsy is positive for melanoma. The health-care provider prescribes chest x-ray, CT, MRI of the brain, and ultrasound testing of lymph nodes. Which explanation does the nurse give the client regarding the extensive testing? - ANSWER the tests are necessary to look for any evidence of metastases The nurse is preparing teaching material for a community presentation about the prevention of skin cancer. Which factor presents a dilemma for the nurse regarding conflicting information? A. The most common risks to skin cancer B. Danger of overexposure outdoors C. Vitamin D production D. Use of tanning beds - ANSWER C. Vitamin D production The nurse's dilemma over conflicting information is related to the fact that the skin being exposed to sunlight is a major factor in vitamin D synthesis. Vitamin D is essential for good health. The Dilemma is that too much sun exposure can cause skin cancer, specifically melanoma. Prevention of skin cancer involves the use of sunscreens, hats, and/or protective clothing. While reviewing the medical record of a client with a skin disorder, the nurse finds the term "plaque" int he client's record. Which manifestation does the nurse expect to find? A. raised, flat-topped lesion greater than 2 cm in diameter B. solid lump greater than 0.5 cm in diameter C. raised, well-defined lesion less than 0.5 cm in diameter D. large blister greater than 0.5 cm in diamter - ANSWER A. raised, flat topped lesion greater than 2 cm in diameter Which disorders are precursors to malignant melanoma? SELECT ALL THAT APPLY: A. keloid formation B. lentigo maligna C. psoriatic plaques D. benign nevus E. dysplastic nevus - ANSWER B, E lentigo maligna can become malignant melanoma Dysplastic nevi have an irregular shape, vary in color, and are prone to change into skin cancers. Therefore, they are precursors to malignant melanoma. You are turning your bed-bound patient to assess the skin on his back, when you notice non-blanchable redness to the sacrum with a small opening of the skin in the middle of the skin lesion. How would you document this finding? - ANSWER stage 2 pressure ulcer A client reports difficulty hearing. The nurse finds that the client's external ear exhibits a cause for the altered function. Which finding in the client supports the nurse's finding? A. The auditory ossicles do not move B. There are balance problems C. The eardrum is inflamed D. There is pain with swallowing - ANSWER C. The eardrum is inflamed The external ear includes the tympanic membrane or eardrum; therefore, inflammation of the eardrum is indicative of possible infection and altered function A client reports difficulty with hearing. The nurse performs a hearing test and discovers the client cannot hear any sounds softer than 44 dB. Which type of hearing loss does the nurse record on the client's chart. - ANSWER moderate hearing loss