HESI RN ADVANCED PATHOPHYSIOLOGY EXAM - QUESTIONS AND ANSWERS

1. Following routine colonoscopy screening, a client is told that he had several polyps removed. The client began crying stating, “I just can't deal with cancer. I'm too young.” The nurse responds: A) “Don't worry. We have some great cancer doctors on staff. I'm sure chemo will help you fight it.” B) “Maybe if you're lucky, they have stopped it from metastasizing to your liver.” C) “A simple intestinal surgery will cure you.” D) “Most colon polyps are not cancerous. The biopsy results will direct your care. Ans: D Feedback: A polyp is a growth that projects from a mucosal surface, such as the intestine. Although the term usually implies a benign neoplasm, some malignant tumors also appear as polyps. Adenomatous polyps are considered precursors to adenocarcinomas of the colon. 2. A lung biopsy and magnetic resonance imaging have confirmed the presence of a benign lung tumor in a client. Which of the following characteristics is associated with this client's neoplasm? A) The tumor will grow by expansion and is likely encapsulated. B) The cells that constitute the tumor are undifferentiated, with atypical structure. C) If left untreated, the client's tumor is likely to metastasize. D) The tumor is likely to infiltrate the lung tissue that presently surrounds it. Ans: A Feedback: Benign neoplasms typically grow by expansion rather than invasion. As well, they are usually contained within a fibrous capsule. Malignant tumors are associated with undifferentiated cells, metastasis, and infiltration of surrounding tissue. 3. A newly diagnosed lung cancer client asks how his tumor spread (metastasized) so fast without displaying many signs/symptoms. The nurse responds that malignant tumors affect area tissues by: A) Increasing tissue blood flow B) Providing essential nutrients C) Liberating enzymes and toxins D) Forming fibrous membranes Ans: C Feedback: Malignant tumors affect area tissues by liberating enzymes and toxins that destroy tumor tissue and normal tissue. In addition, the malignant cells compress area vessels, causing ischemia and tissue necrosis. The high metabolic rate of tumor growth causes the tumor to deprive the normal tissues of essential nutrients. 4.A client had a positive Pap smear. The surgeon diagnosed “cancer in situ of the cervix.” The client asks, “What does this mean?” From the following statements, which is most appropriate in response to this question? The tumor has: A) Been walled off within a strong fibrous capsule B) Developed a distant infiltration C) Not crossed the basement membrane, so it can be surgically removed with little chance of growing back D) Grown undifferentiated cells that no longer look like the tissue from which it arose Ans: C Feedback: Cancer in situ is a localized preinvasive lesion. As an example, in breast ductal carcinoma, in situ the cells have not crossed the basement membrane. Depending on its location, an in situ lesion usually can be removed surgically or treated so that the chances of recurrence are small. For example, cancer in situ of the cervix is essentially 100% curable. 5. While studying to become chemo-certified, the nurse reviews some basic concepts about cancer cells. When a client asks about why the tumor grows so fast, the nurse will respond based on which of the following physiological principles? Select all that apply. A) Cancer cells have shorter cell cycle times than normal cells. B) Cancer cells do not die when they are programmed to die. C) Growth factors prevents cancer cells from entering resting (G0) cell cycle phase. D) Cancer cells will reach a balance between cell birth and cell death rate. E) Cancer cells never reach a flattened growth rate. Ans: B, C Feedback: One of the reasons cancerous tumors often seem to grow so rapidly relates to the size of the cell pool that is actively engaged in cycling. It has been shown that the cell cycle time of cancerous tissue cells is not necessarily shorter than that of normal cells. Rather, cancer cells do not die on schedule, and growth factors prevent cells from exiting the cell cycle and entering the G0 or noncycling phase. The ratio of dividing cells to resting cells in a tissue mass is called the growth fraction. The doubling time is the length of time it takes for the total mass of cells in a tumor to double. As the growth fraction increases, the doubling time decreases. When normal tissues reach their adult size, an equilibrium between cell birth and cell death is reached. Cancer cells, however, continue to divide until limitations in blood supply and nutrients inhibit their growth. When this occurs, the doubling time for cancer cells decreases. The initial growth rate is exponential and then tends to decrease or flatten out over time. 6. Although growth rate is variable among types of bacteria, the growth of bacteria is dependent on: A) D) Biofilm communication Individual cell motility B) Availability of nutrients C)An intact protein capsid Ans: B Feedback: Bacterial growth is dependent upon the availability of nutrients and physical growth conditions. Bacteria prefer to colonize as biofilm and communicate with other bacteria within the biofilm, but biofilm is not necessary for growth. Viruses (not bacteria) form a capsid. Although some bacteria have projections for motility, these are not necessary for growth. 7. Which of the following outpatients are at a greater risk for developing Treponema pallidum, the cause of syphilis? Select all that apply. A) A homeless adolescent female performing oral sex for money B) A male who frequents clubs catering to exotic dancers and sexual favors C) A homosexual male couple who have had a monogamous relationship for the past 20 years D) An older adult female living in a condominium who regularly has sex with three to four different men/week Ans: A, B, D Feedback: Treponema pallidum is a sexually transmitted infection that is spread by direct physical contact. The Borrelia type of spirochete is spread from animals to humans through lice or tick bites. Leptospira spirochetes spread from animals to humans through contact with infected animal urine. Spirochetes are anaerobic; therefore, they would not invade the host through oxygen-filled aerobic lungs. 8. Chlamydiaceae have characteristics of both viruses and bacteria and are a rather common sexually transmitted infectious organism. After entry into the host, they transform into a reticulate body. The health care provider should monitor which of the following clients for this possible infection? Select all that apply. A) An adult male who raises a number of exotic birds in his home B) A drug abuser looking to share needles/syringes C) A newborn with a noticeable eye infection D) A teenager who swims in the lake regularly Ans: A, B, C Feedback: Chlamydiaceae are in the form of an elementary body when infectious and outside of the host cell. Once an organism enters the cell, it transforms into a large reticulate body. This undergoes active replication into multiple elementary bodies, which are then shed into the extracellular environment to initiate another infectious cycle. Chlamydial diseases of humans include sexually transmitted genital infections (Chlamydophila trachomatis); ocular infections and pneumonia of newborns (C. trachomatis); upper and lower respiratory tract infections in children, adolescents, and young adults (Chlamydophila pneumoniae); and respiratory disease acquired from infected birds (Chlamydophila psittaci). 9. A client has been diagnosed with Coxiella burnetii infection. She asked the health care provider how she could have gotten this disease. The health care provider's best response is: A) “Probably while walking outside without your shoes on.” B) “While swimming in an unsanitary pond.” C) “Drinking contaminated milk.” D) “Eating undercooked fish.” Ans: C Feedback: In humans, Coxiella infection produces a disease called Q fever, characterized by a nonspecific febrile illness often accompanied by headache, chills, arthralgias, and mild pneumonia. The organism produces a highly resistant sporelike stage that is transmitted to humans when contaminated animal tissue is aerosolized (e.g., during meat processing) or by ingestion of contaminated milk. 10. A teenage male develops a severe case of “athlete's foot.” He asks, “How did I get this?” The health care worker explains that certain fungi become infectious (called dermatophytes) and exhibit which of the following characteristics? A) Prefer to grow in warm environments like shoes/socks B) Like a moist environment C) Limited to cooler cutaneous surfaces D) Need higher blood flow to survive Ans: C Feedback: Dermatophytes are not able to grow at core body temperature, preferring the cooler surface skin areas instead of moist skin folds. Diseases caused by these organisms, including ringworm, athlete's foot, and jock itch, are collectively called superficial mycoses. 11. A male client with a history of angina has presented to the emergency department with uncharacteristic chest pain, and his subsequent ECG reveals T-wave elevation. This finding suggests an abnormality with which of the following aspects of the cardiac cycle? A) Atrial depolarization B) Ventricular depolarization C) Ventricular repolarization D) Depolarization of the AV node Ans: C Feedback: The T wave on electrocardiography (ECG) corresponds to ventricular repolarization. Atrial depolarization is represented by the P wave and ventricular depolarization by the QRS complex. The isoelectric or zero line between the P wave and the Q wave represents depolarization of the AV node, bundle branches, and Purkinje system. 12. During ventricular systole, closure of the atrioventricular (AV) valves coincides with: A) Atrial chamber filling B) Aortic valve opening C) Isovolumetric contraction D) Semilunar valves opening Ans: C Feedback: Ventricular systole is divided into two parts: isovolumetric contraction when the AV valves close and ventricles fill; and the ejection period, when the semilunar valves open and blood is ejected through the aortic valve into circulation. Immediately after closure of the AV valves, there is a 0.02- to 0.03-second period during which the pulmonic and aortic valves remain closed. During this period, the ventricular volume remains the same while the ventricles contract, producing an abrupt increase in pressure. At the end of systole, the ventricles relax, causing a precipitous fall in intraventricular pressures. As this occurs, blood from the large arteries flows back toward the ventricles, causing the aortic and pulmonic valves to snap shut—an event marked by the second heart sound. 13. A heart failure client has an echocardiogram performed revealing an ejection fraction (EF) of 40%. The nurse knows this EF is below normal and explains to the client: A) “This means you have a lot of pressure built-up inside your heart.” B) “This means your heart is not pumping as much blood out of the heart with each beat.” C) “You need to increase the amount of exercise you do to get your heart muscle back in shape.” D) “Your ventricular muscle is getting too stiff to beat normally.” Ans: B Feedback: Ejection fraction is the percentage of diastolic volume ejected from the heart [left ventricle] during systole. Stroke volume is determined by the difference between end-diastolic and end-systolic volumes. Cardiac output is determined by stroke volume and heart rate. Cardiac reserve refers to the maximum percentage of increase in cardiac output that can be achieved above the normal resting level. 14. A client with a history of heart failure has been referred for an echocardiogram. Results of this diagnostic test reveal the following findings: heart rate 80 beats/minute; end-diastolic volume 120 mL; and end-systolic volume 60 mL. What is this client's ejection fraction? A) 200 mL B) 50% C) 0.80 D) 180 mL Ans: B Feedback: Ejection fraction = stroke volume ÷ end-diastolic volume, whereas stroke volume equals the difference between end-diastolic and end-systolic volume. Therefore, EF = 60 ÷ 120, or 50%. 15. Preload represents the volume work of the heart and is largely determined by: A) Venous blood return B) Vascular resistance C) Force of contraction D) Ventricular emptying Ans: A Feedback: Preload represents the amount of blood the heart must pump with each beat and represents the volume of blood stretching the ventricular muscle fibers at the end of diastole. Pressure (resistance), contraction, and ventricular emptying relate to afterload. 16. Which of the following clients coming to a small free clinic are at high risk for malnutrition? Select all that apply. A) An 88-year-old senior citizen on a fixed budget B) A 60-year-old homeless Vietnam veteran complaining of pain C) A 4-year-old child who lives with a single mom in a rooming house D) A 17-year-old female who thinks she might have been exposed to syphilis E) A 32-year-old construction working having muscle spasms in his back Ans: A, B, C Feedback: Among the many causes of malnutrition are poverty and lack of knowledge, acute and chronic illness, and self-imposed dietary restrictions. Homeless people, the elderly, and the children of the poor often demonstrate the effects of protein and energy malnutrition, as well as vitamin and mineral deficiencies. Sexually active teenagers and working young adults are not usually at high risk for malnutrition. 17. Which of the following characteristics distinguishes kwashiorkor from marasmus? A) Impairment of immune function B) Lack of dietary fat intake C) High intake of carbohydrates D) Impaired pigment synthesis Ans: C Feedback: Kwashiorkor is a protein deficiency coupled with a high-carbohydrate diet; marasmus is a deficiency in both calories and protein. Both forms of malnutrition impair immune function and pigment synthesis, and each is normally accompanied by inadequate intake of dietary fats. 18. A child has been diagnosed with marasmus due to the fact that the parents have both lost their jobs and have very limited funds for food. Which of the following clinical manifestations would the school nurse assess that would confirm this diagnosis? Select all that apply. A) Discolored hair B) Bradycardia C) Enlarged liver D) Pitting edema E) Stunted growth pattern Ans: B, E Feedback: Inadequate food intake, with equal deficiencies of calories and protein, is the cause of marasmus, which is characterized by low heart rate, blood pressure, and body temperature; dull hair; and an emaciated appearance. Hair discoloration, enlarged liver, and pitting edema are manifestations of kwashiorkor, which is a severe protein deficiency. 19. A school nurse has identified a student with noticeable loss of lean tissues and muscle mass. More than likely, this is caused by protein–calorie malnutrition. The nurse should ask the student if he is experiencing which of the following clinical manifestations that helps confirm this diagnosis? A) Respiratory muscle stimulation B) Excessive blood cell production C) Diarrhea D) Increased cardiac contractility Ans: C Feedback: Protein–calorie malnutrition results in skeletal muscle loss and diarrhea. This type of malnutrition is also characterized by respiratory muscle weakness and blood cell loss that impairs the immune response. 20. A homeless client asks, “Why can't I get this wound on my foot to heal?” Knowing that the client is not receiving good nutrition on a regular basis, the nurse will reply: A) “Maybe if you could come to the clinic every day, we can help you change your dressing.” B) “Right now your immune system is decreased because you are not eating a balanced diet.” C) “Maybe if you could find a place to sleep that is cleaner than where you usually sleep that will help.” D) “We just need to make sure you are getting the right antibiotics.” Ans: B Feedback: As protein is lost from the liver, hepatic synthesis of proteins declines, and plasma protein levels decrease. There also is a decrease in immune cells. Wound healing is poor, and the body is unable to fight off infection because of multiple immunologic malfunctions throughout the body. 21. At the cellular level, cardiac muscle cells respond to an increase in ventricular volume to the point of overload by: Select all that apply. A) Elongating the cardiac muscle cells B) Thickening of the individual myocytes C) Replicating the myofibrils D) Decreasing the ventricular wall thickness E) Symmetrically widening and lengthening the hypertrophy Ans: A, D Feedback: At the cellular level, cardiac muscle cells respond to stimuli from stress placed on the ventricular wall by pressure and volume overload by initiating several different processes that lead to hypertrophy. With ventricular volume overload, the increase in wall stress leads to replication of myofibrils in series, elongation of the cardiac muscle cells, and eccentric hypertrophy. Eccentric hypertrophy leads to a decrease in ventricular wall thickness or thinning of the wall with an increase in diastolic volume and wall tension. Production of a symmetric hypertrophy occurs with a proportionate increase in muscle length and width, as occurs in athletes; concentric hypertrophy with an increase in wall thickness, as occurs in hypertension; and eccentric hypertrophy with a disproportionate increase in muscle length, as occurs in dilated cardiomyopathy. When the primary stimulus for hypertrophy is pressure overload, the increase in wall stress leads to parallel replication of myofibrils, thickening of the individual myocytes, and concentric hypertrophy. Concentric hypertrophy may preserve systolic function for a time, but eventually the work performed by the ventricle exceeds the vascular reserve, predisposing to ischemia. 22. From the following clients, who are at high risk for developing heart failure as a result of diastolic dysfunction? Select all that apply. A) A 48-year-old client with uncontrolled hypertension B) A marathon runner with history of chronic bradycardia whose pulse rate is 46 C) A 57-year-old client with history of ischemic heart disease D) A 70-year-old with enlarged left ventricle due to myocardial hypertrophy Ans: A, D Feedback: Conditions that reduce the heart's ability to adequately fill during diastole, such as myocardial hypertrophy and tachycardia, can lead to heart failure. Hypertension remains the leading cause of diastolic dysfunction. Ischemic heart disease is associated with systolic heart failure, or impaired contractile performance. It is normal for athletes, like marathon runners, to have slow pulses. 23. The most common causes of left-sided heart failure include: A) Acute myocardial infarction B) Chronic pulmonary disease C) Impaired renal blood flow D) Tricuspid valve regurgitation Ans: A Feedback: The most common causes of left-sided heart failure are acute myocardial infarction and hypertension. Acute or chronic pulmonary disease can cause right heart failure, referred to as cor pulmonale. The causes of right-sided heart failure include stenosis or regurgitation of the tricuspid or pulmonic valves, right ventricular infarction, and cardiomyopathy. Manifestations (rather than causes) of heart failure reflect the physiologic effects of the impaired pumping ability of the heart, including decreased renal blood flow. 24. Assessment of an elderly female client reveals the presence of bilateral pitting edema of the client's feet and ankles and pedal pulses that are difficult to palpate. Auscultation of the client's lungs reveals clear air entry to bases, and the client's oxygen saturation level is 93%, and vital signs are within reference ranges. What is this client's most likely health problem? A) Right-sided heart failure B) Pericarditis C) Cardiogenic shock D) Cor pulmonale Ans: A Feedback: A major effect of right-sided heart failure is the development of peripheral edema. A client who is in shock would not have stable vital signs. Cor pulmonale would be accompanied by manifestations of lung disease. Pericarditis is an inflammation of the pericardium exhibited by fever, precordial pain, dyspnea, and palpitations. 25. While teaching a client with new-onset right-sided heart failure, the nurse should educate the client to monitor for fluid accumulation by: A) Weighing every day at the same time with same type of clothing B) Measuring all of the client's urine output daily to check for a decrease in output C) Listening to the breath sound with a stethoscope every morning D) Take blood pressure daily and call doctor if it is decreased Ans: A Feedback: When the right heart fails, a damming back of blood occurs, leading to its accumulation in the systemic venous system, causing an increase in right atrial, right ventricular end-diastolic, and systemic venous pressures. The accumulation of fluid (edema) is evidenced by a gain in weight (i.e., 1 pint of accumulated fluid results in a 1-pound weight gain). Shortness of breath due to congestion of the pulmonary circulation is one of the major manifestations of left-sided heart failure. It is unrealistic to expect clients to listen to their own breath sounds. BP measurement could be an intervention; however, it is not a primary indicator of edema from right-sided heart failure. With impairment of left heart function, there is a decrease in cardiac output, with resulting decreased renal perfusion and output. 26. A client with a history of emphysema is experiencing hypoxemia after a taxing physical therapy appointment. Which of the following physiologic phenomena will occur as a consequence of hypoxemia? A) Peripheral vasodilation B) Necrosis C) Hypoventilation D) Increased heart rate Ans: D Feedback: Consequences of hypoxemia include peripheral vasoconstriction, hyperventilation, and increased heart rate. Mild to moderate hypoxemia does not result in cell death and necrosis. 27. An elderly client who has been restricted to bed by numerous comorbidities for several weeks has been diagnosed with a large pleural effusion. Which of the following treatment modalities is most likely to resolve the client's most recent health problem? A) Thoracentesis B) Supplementary oxygen therapy C) Administration of corticosteroids D) Administration of bronchodilators Ans: A Feedback: With large effusions, thoracentesis may be used to remove fluid from the intrapleural space and allow for reexpansion of the lung. 28. Pleuritic chest pain associated with respiratory movements is usually described as: A) Bilateral B) Localized C) Continuous D) Substernal Ans: B Feedback: Pleuritis is usually unilateral and tends to be localized to the lower and lateral part of the chest; pain worsens with chest movements, such as deep breathing and coughing that accentuate pressure changes in the pleural cavity and increase movement of the inflamed or injured pleural surfaces. Musculoskeletal pain usually is bilateral and may occur as the result of frequent, forceful coughing. The pain associated with irritation of the bronchi usually is substernal and dull. Myocardial pain usually is located in the substernal area and is not affected by respiratory movements. 29. A man sustained a puncture injury to his chest that caused a tension pneumothorax to form. This is a life-threatening condition because: A) Expired air exits the bleeding wound. B) Trapped, inspired air collapses the lung. C) The opposite lung hyperinflates. D) Blebs on the lung surface rupture. Ans: B Feedback: Tension pneumothorax occurs when the intrapleural pressure exceeds atmospheric pressure. It is a life-threatening condition and occurs when injury to the chest or respiratory structures permits air to enter but not leave the pleural space. Spontaneous pneumothorax occurs when an air-filled bleb, or blister, on the lung surface ruptures. Rupture of these blebs allows atmospheric air from the airways to enter the pleural cavity. This results in a rapid increase in pressure in the chest with a compression atelectasis of the unaffected lung. ......