Test bank for Porth's Essentials of Pathophysiology 5th Edition by Tommie Norris

TEST BANK

TEST BANK

UNIT 1 - Concepts of Health and Disease Chapter 1: Concepts of Health and Disease

UNIT 2 - Cell Function and Growth Chapter 2 : Cell and Tissue Characteristics Chapter 3 : Cellular Adaptation, Injury, and Death Chapter 4 : Genetic Control of Cell Function and Inheritance Chapter 5 : Genetic and Congenital Disorders Chapter 6 : Neoplasia

UNIT 3 - Disorders of Integrative Function Chapter 7 : Stress and Adaptation Chapter 8 : Disorders of Fluid, Electrolyte, and Acid–Base Balance

UNIT 4 - Infection, Inflammation, and Immunity Chapter 9 : Inflammation, Tissue Repair, and Wound Healing Chapter 10 : Mechanisms of Infectious Disease Chapter 11: Innate and Adaptive Immunity Chapter 12 : Disorders of the Immune Response, Including HIV/AIDS

UNIT 5 - Disorders of Neural Function Chapter 13 : Organization and Control of Neural Function Chapter 14 : Somatosensory Function, Pain, Headache, and Temperature Regulation Chapter 15 : Disorders of Motor Function Chapter 16 : Disorders of Brain Function Chapter 17 : Sleep and Sleep–Wake Disorders Chapter 18 : Disorders of Thought, Emotion, and Memory

UNIT 6 - Disorders of Special Sensory Function

Chapter 19 : Disorders of Visual Function Chapter 20 : Disorders of Hearing and Vestibular Function Chapter 21 : Blood Cells and the Hematopoietic System Chapter 22 : Disorders of Hemostasis Chapter 23 : Disorders of Red Blood Cells Chapter 24 : Disorders of White Blood Cells and Lymphoid Tissues

UNIT 8 - Disorders of Cardiovascular Function Chapter 25 : Structure and Function of the Cardiovascular System Chapter 26 : Disorders of Blood Flow and Blood Pressure Regulation Chapter 27 : Disorders of Cardiac Function, and Heart Failure and Circulatory Shock Chapter 28 : Disorders of Cardiac Conduction and Rhythm

UNIT 9 - Disorders of Respiratory Function Chapter 29 : Structure and Function of the Respiratory System Chapter 30 : Respiratory Tract Infections, Neoplasms, and Childhood Disorders Chapter 31 : Disorders of Ventilation and Gas Exchange

UNIT 10 - Disorders of Renal Function Chapter 32 : Structure and Function of the Kidney Chapter 33 : Disorders of Renal Function Chapter 34 : Acute Kidney Injury and Chronic Kidney Disease Chapter 35 : Disorders of the Bladder and Lower Urinary Tract

UNIT 11- Disorders of Gastrointestinal Function Chapter 36 : Structure and Function of the Gastrointestinal System Chapter 37 : Disorders of Gastrointestinal Function Chapter 38 : Disorders of Hepatobiliary and Exocrine Pancreas Function Chapter 39 : Alterations in Nutritional Status

UNIT 12 - Disorders of Endocrine Function Chapter 40 : Mechanisms of Endocrine Control1 Chapter 41: Disorders of Endocrine Control of Growth and Metabolism

UNIT 13 - Disorders of Genitourinary and Reproductive Function Chapter 42 : Structure and Function of the Male Genitourinary System Chapter 43 : Disorders of the Male Reproductive System Chapter 44 : Structure and Function of the Female Reproductive System Chapter 45 : Disorders of the Female Reproductive System Chapter 46 : Sexually Transmitted Infections

UNIT 14 - Disorders of Musculoskeletal Function Chapter 47 : Structure and Function of the Musculoskeletal System Chapter 48 : Disorders of Musculoskeletal Function: Trauma, Infection, Neoplasms1 Chapter 49 : Disorders of Musculoskeletal Function: Developmental and Metabolic Disorders, Activity Intolerance, and Fatigue Chapter 50 : Disorders of Musculoskeletal Function: Rheumatic Disorders

UNIT 15 - Disorders of Integumentary Function Chapter 51 : Structure and Function of the Skin Chapter 52 : Disorders of Skin Integrity and Function

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Porth's Essentials of Pathophysiology 5th Edition by Tommie L Norris ISBN-10 1975107195 ISBN-13 978-1975107192 Test Bank for Porth's Essentials of Pathophysiology 5th Edition by Tommie L Norris.

ISBN-10 1975107195 ISBN-13 978-1975107192

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Chapter 1 Concepts of Health and Disease 1. Although the basic structure of the cell plasma membrane is formed by a lipid bilayer, most of the specific membrane functions are carried out by: A) Bound and transmembrane proteins B) Complex, long carbohydrate chains C) Surface antigens and hormone receptors D) A gating system of selective ion channels Ans: A Feedback: The functions of plasma membrane depend on the presence of proteins that are bound in the lipid bilayer and some that have the ability to pass freely into and out of the cell.

Carbohydrate chains form a cell coat that surrounds the membrane and that contain surface antigens and surface hormone receptors. Some ion channels are gated and open only when the membrane potential changes significantly.

2. Which describes the function of the nucleus?

A) It is basically the site of protein synthesis in the body.

B) It contains the genetic code for the individual.

C) It is the transformer of cellular energy.

D) It initiates the process of aerobic metabolism.

Ans: B Feedback: The nucleus contains DNA, which contains the genetic code that contains the information that controls cells. Ribosomes synthesize protein. Mitochondria transform organic compounds into cellular energy. Mitochondria require oxygen for aerobic metabolism, using hydrogen and carbon combined with oxygen molecules to form carbon dioxide and water as energy is released.

3. Which of the following aspects of the function of the nucleus is performed by ribosomal RNA (rRNA)?

A) Copying and carrying DNA instructions for protein synthesis B) Carrying amino acids to the site of protein synthesis C) Providing the site where protein synthesis occurs D) Regulating and controlling protein synthesis Ans: C Feedback: There are three types of ribonucleic acid (messenger RNA, ribosomal RNA, and transfer RNA) that move to the cytoplasm and carry out the actual synthesis of proteins.

Messenger RNA (mRNA) copies and carries the DNA instructions for protein synthesis to the cytoplasm; ribosomal RNA (rRNA) is the site of protein synthesis; and transfer RNA (tRNA) transports amino acids to the site of protein synthesis for incorporation into the protein being synthesized.

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4. Which accurately explains the functions of the organelles lysosomes? They: A) Are sacs filled with enzymes that breakdown and remove foreign substances and worn-out cell parts B) Function in association with the endoplasmic reticulum to modify protein end products and package them into secretory granules or vesicles C) Are small particles of nucleoproteins that are involved in the synthesis of proteins that remain in the cell as cytoplasmic structural or functional elements D) Are a dynamic system of interconnected membranous tubes that functions as a tubular communication system for transporting various substances from one part of the cell to another Ans: A Feedback: Lysosomes are sacs that are filled with hydrolytic enzymes that aid in the processing and removal of unwanted substances within the cytoplasm. The Golgi apparatus functions in association with the endoplasmic reticulum to modify and package substances in preparation for secretion, whereas ribosomes are small particles of nucleoproteins that are involved in the synthesis of proteins. The ER is a tubular communication system for transporting various substances from one part of the cell to another.

5. Impairment in the function of peroxisomes would result in: A) Inadequate sites for protein synthesis B) An inability to transport cellular products across the cell membrane C) Insufficient energy production within a cell D) Accumulation of free radicals in the cytoplasm Ans: D Feedback: Peroxisomes function in the control of free radicals; unless degraded, these highly unstable chemical compounds damage other cytoplasmic molecules. Peroxisomes do not directly contribute to energy production, protein synthesis, or transport of cellular secretions.

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6. Although energy is not made in mitochondria, they are known as the “power plants” of the cell because they: A) Contain RNA for protein synthesis B) Utilize glycolysis for oxidative energy C) Extract energy from organic compounds D) Store calcium bonds for muscle contractions Ans: C Feedback: Mitochondria contain the enzymes needed for transforming organic compounds into energy that is easily accessible to the cell. Mitochondria contain their own DNA. Glycolysis is anaerobic metabolism and unrelated to oxidative energy. Mitochondria store phosphate bonds (such as in ATP) to power cellular functions.

7. Semen analysis indicates that the client's sperm have decreased motility. Which of the following cellular components may be defective within the client's sperm?

A) Ribosomes B) Microtubules C) Mitochondria D) Microfilaments Ans: B Feedback: Abnormalities in the structure and function of microtubules and consequent dysfunction of the flagella may contribute to impaired sperm motility. Ribosomes, microfilaments, and mitochondria do not directly contribute to movement in cells such as cilia and flagella.

8. When explaining the function of glycolysis as it relates to anaerobic metabolism, the faculty will mention which of the following key points? Select all that apply.

A) Glycolysis requires the use of oxygen to begin the process.

B) Glycolysis occurs in mitochondrion-lacking cells.

C) Glycolysis provides the majority of the body's energy needs.

D) Pyruvic acid is an end result from a series of reactions that converts glucose.

Ans: B, D Feedback: Glycolysis is the anaerobic process by which energy is liberated from glucose, and it is an important source of energy for cells that lack mitochondria. The process also provides a temporary source of energy for cells that are deprived of an adequate supply of oxygen. Glycolysis involves a sequence of reactions that converts glucose to pyruvic acid, with the concomitant production of ATP from ADP. It accounts for a small minority of the body's energy needs and results in NADH, hydrogen ions, ATP, and pyruvic acid.

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9. Aerobic metabolism, also known as oxidative metabolism, provides energy to the body by: A) Removing the phosphate bonds from ATP B) Combining hydrogen and oxygen to form water C) Activating pyruvate stored in the cytoplasm D) Breaking down glucose to form lactic acid Ans: B Feedback: Aerobic metabolism involves the combination of carbon ions from dietary nutrients, hydrogen ions, and oxygen. The result is carbon dioxide and water as energy is released, which is stored in ATP. Phosphate bonds are added (not removed from) to ADP to form ATP. Pyruvate is formed from glucose in the anaerobic process of glycolysis and is converted to lactic acid during anaerobic metabolism.

10. To effectively relay signals, cell-to-cell communication utilizes a chemical messenger system to: A) Displace surface receptor proteins B) Accumulate within cell gap junctions C) Bind to contractile microfilaments D) Release secretions into extracellular fluid Ans: D Feedback: Signals are transmitted by releasing chemical secretions into extracellular fluid.

Chemical signals move through cell-to-cell junctions to reach other cells and may attach to surface receptor proteins. The cytoplasmic contractile microfilaments are incapable of transmitting communication signals.

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11. Which identifies correctly how the G protein–linked receptors are similar?

A) Their cytosolic domain has intrinsic enzyme activity.

B) Insulin is an example of the second messenger cAMP, which binds to an enzyme-linked receptor.

C) These linked receptors are involved in rapid synaptic signaling between cardiac electrical cells.

D) They have a ligand-binding extracellular receptor component, which causes changes that activate the G protein on the cytoplasmic side of the cell membrane.

Ans: D Feedback: Although there are differences among the G protein–linked receptors, all share a number of features. They all have a ligand-binding extracellular receptor component, which recognizes a specific ligand or first messenger. Upon ligand binding, they all undergo conformational changes that activate the G protein found on the cytoplasmic side of the cell membrane. Instead of having a cytosolic domain that associates with a G protein, enzyme-linked receptors have cytosolic domain either that has intrinsic enzyme activity or that associates directly with an enzyme. The binding of the hormone to a special transmembrane receptor results in activation of the enzyme adenylyl cyclase at the intracellular portion of the receptor. This enzyme then catalyzes the formation of the second messenger cAMP, which has multiple effects on cell function. Insulin, for example, acts by binding to an enzyme-linked receptor. Ion channel–linked receptors are involved in the rapid synaptic signaling between electrically excitable cells.

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12. When working with a client who has end-stage renal disease (ESRD) and is receiving peritoneal dialysis, the concept of diffusion can be explained by which of the following statements?

A) “If your potassium level is high, then K+ particles will move from your peritoneal cavity into the dialysis solution, where the concentration of K + is lower.”

B) “You will need to give yourself a potent diuretic so that you can pull the potassium into your blood stream and filter the potassium out in your kidneys.”

C) “Your potassium molecules are lipid soluble and will dissolve in the lipid matrix of your cell membranes.”

D) “If you can get very warm in a sauna, you will heat up your K+ particles, and the kinetic movement of the particles will increase and pass through the cell membranes faster.”

Ans: A Feedback: Diffusion refers to the passive process by which molecules and other particles in a solution become widely dispersed and reach a uniform concentration because of energy created by their spontaneous kinetic movements. In the process of reaching a uniform concentration, these molecules and particles move “downhill” from an area of higher to an area of lower concentration. Lipid-soluble molecules, such as oxygen, carbon dioxide, alcohol, and fatty acids (not K+), become dissolved in the lipid matrix of the cell membrane and diffuse through the membrane in the same manner that diffusion occurs in water. Diuretics are not very effective if a person has ESRD. The rate of diffusion depends on how many particles are available for diffusion, the kinetic movement of the particles, and the number and size of the openings in the membrane through which the molecules or ions can move. The environmental temperature does not play a role in this.

13. A male client with a diagnosis of type 1 diabetes mellitus is experiencing hyperglycemia because he lacks sufficient insulin to increase the availability of glucose transporters in his cell membranes. Consequently, his cells lack intracellular glucose, and it accumulates in his blood. Which of the following processes would best allow glucose to cross his cell membranes?

A) Facilitated diffusion B) Simple diffusion C) Secondary active transport D) Endocytosis Ans: A Feedback: Transport molecules perform facilitated diffusion, in which one substance carries another substance across a cell membrane. Simple diffusion does not require a transport molecule. Glucose does not cross the cell membrane by secondary active transport or endocytosis.

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14. The client asks the health care provider to explain phagocytosis. The provider will respond, “Phagocytosis: A) Is a cotransport system that helps with the absorption of the medication.”

B) Is the movement of particles from an area of higher concentration to one of lower concentration.”

C) Uses proteins to form an open channel through which the drug can move into the cell.”

D) Is a process where microorganisms are engulfed and subsequently degraded or killed.”

Ans: D Feedback: Phagocytosis, which means “cell eating,” involves the engulfment and subsequent killing or degradation of microorganisms and other particulate matter. Certain cells, such as macrophages and neutrophils, are adept at engulfing and disposing of invading organisms, damaged cells, and unneeded extracellular constituents. An example of cotransport occurs in the intestine, where the absorption of glucose and amino acids is coupled with sodium transport. The process of diffusion describes particle movement from an area of higher concentration to an area of lower concentration, resulting in an equal distribution of permeable substances across the cell membrane. Ion channels are integral proteins that span the width of the membrane and are normally composed of several polypeptides or protein subunits that form a gating system. Specific stimuli cause the protein subunits to undergo conformational changes to form an open channel or gate through which the ions can move.

15. Exocytosis allows granular content to be released into extracellular fluid by: A) Engulfing and ingesting fluid and proteins for transport B) Killing, degrading, and dissolving harmful microorganisms C) Removing cellular debris and releasing synthesized substances like hormones D) Destruction of particles by lysosomal enzymes for secretion Ans: C Feedback: In exocytosis, a secretory granule fuses to the inner cell membrane to form an opening, allowing granule contents to be released. The granule contains cellular debris and synthesized substances such as hormones, which it releases into the extracellular fluid.

Phagocytosis and pinocytosis—types of endocytosis—function to engulf, kill, and present particles to lysosomal enzymes for degradation.

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16. The process responsible for generating and conducting membrane potentials is: A) Diffusion of current-carrying ions B) Millivoltage of electrical potential C) Polarization of charged particles D) Ion channel neurotransmission Ans: A Feedback: Membrane potentials rely on the permeability of the cell membrane and the diffusion of electrically charged ions. Charged particles are polarized (positive charge on one side of the membrane and negative charge on the opposite side of the membrane), but membrane potential exists when the charges are unbalanced on the two sides. Ion channel neurotransmitters are involved with opening protein channels for purposes of cell-to-cell communication.

17. Epithelial tissues are classified according to the shape of the cells and the number of layers. Which of the following is a correctly matched description and type of epithelial tissue?

A) Simple epithelium: cells in contact with the intercellular matrix; some do not extend to surface.

B) Stratified epithelium: single layer of cells; all cells rest on the basement membrane.

C) Glandular epithelium: arises from surface epithelia and underlying connective tissue.

D) Pseudostratified epithelium: multiple layers of cells; the deepest layer rests on the basement membrane.

Ans: C Feedback: Glandular epithelial tissue is formed by cells to produce fluid and arises from surface epithelium, involving connective tissue. Simple epithelium is a single layer of cells resting on the basement membrane; stratified epithelium has more than one layer, with the deepest layer resting on the basement membrane. Pseudostratified epithelium is in contact with the intercellular matrix and may not extend to the surface.

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18. Which body tissue exhibits the highest rate of turnover and renewal?

A) The squamous epithelial cells of the skin B) The connective tissue supporting blood vessels C) The skeletal muscle that facilitates movement D) The nervous tissue that constitutes the central nervous system Ans: A Feedback: Cells making up the epithelial tissues generally exhibit a high rate of turnover, which is related to their location and function. Renewal of connective and muscle tissue takes place at a much slower pace, whereas nervous tissue is incapable of postnatal regeneration.

19. While explaining to a post–surgical knee client about the various forms and function of connective tissue, the nurse gives the example of the client's surgical repair of a torn anterior cruciate ligament (ACL), which is due to: A) A reticular fiber problem that interrupted the framework for capillaries B) A dense regular connective tissue tear that is usually rich in collagen fibers that allows ligaments to join bone to bone C) An irregular, dense connective tissue tear of loose connective tissue that is located in the perichondrium D) Irregular filling of spaces between tissues to facilitate keeping of joints and tendons in their proper place Ans: B Feedback: Dense regular connective tissues are rich in collagen fibers and form the tendons and aponeuroses that join muscles to bone or other muscles and the ligaments that join bone to bone. Dense irregular connective tissue consists of the same components found in loose connective tissue but exhibits a predominance of collagen fibers and fewer cells.

This type of tissue can be found in the fibrous sheaths of cartilage (i.e., perichondrium) and bone (i.e., periosteum). Fibroblasts, the most abundant loose connective tissue cells, synthesize the gel-like substance and collagen, elastin, and reticular fibers. Reticular fibers provide a fibrous framework for capillaries. Adipose tissue helps to fill spaces between tissues and keep organs in place.

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20. A student asks the instructor what it means when the book states, skeletal muscles are syncytial or multinucleated? The instructor responds: A) “Each of the skeletal muscle cells has an apical, lateral, and basal surface.”

B) “They are closely apposed and are joined by cell-to-cell adhesion molecules.”

C) “This means that these muscles exhibit cross-striations formed by alternating segments of thick and thin protein filaments, with muscle cells having a branched appearance.”

D) “If a skeletal muscle is injured and a portion dies, the adjacent sections of that same skeletal muscle fiber do not die because they have their own nuclear material.”

Ans: D Feedback: Skeletal muscles are syncytial or multinucleated structures, meaning there are no true cell boundaries within a skeletal muscle fiber. The multinucleated arrangement is important in pathologic states where focal necrosis (death) of a portion of skeletal muscle fibers does not result in necrosis death of the adjacent sections of that same skeletal muscle fiber, because those adjacent sections have their own nuclear material.

Cardiac muscle exhibits cross-striations formed by alternating segments of thick and thin protein filaments. In contrast to skeletal muscle, cardiac muscle cells may be branched instead of linear and longitudinal. The other noted qualities are associated with epithelial, not skeletal muscle, cells.

21. With skeletal muscle contraction, what prevent the development of cross-bridges between the actin and myosin? Select all that apply.

A) Tropomyosin attaches globular heads to the myosin filament.

B) Troponin covers the tropomyosin-binding sites and prevents the formation of cross-bridges.

C) ATP actually plays a role in the positioning of the myosin filaments and actin.

D) The concentration of calcium around the myofibrils will prevent the cross-bridges from being formed.

Ans: A, B Feedback: Associated with each actin filament are the two regulatory proteins: tropomyosin and troponin. Tropomyosin, which lies in grooves of the actin strand, provides the site for attachment of the globular heads of the myosin filament. In the noncontracted state, troponin covers the tropomyosin-binding sites and prevents formation of cross-bridges between the actin and myosin. Energy from ATP is used to break the actin and myosin cross-bridges, stopping the muscle contraction. The binding of calcium to troponin uncovers the tropomyosin-binding sites such that the myosin heads can attach and form cross-bridges.

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22. Which of the following statements about how smooth muscle differs from skeletal or cardiac muscle are accurate? Smooth muscle: Select all that apply.

A) Has dense bodies attached to actin filaments B) Contains sarcomeres between Z lines and M bands C) Contracts more rapidly than skeletal muscles D) Has one centrally located nucleus Ans: A, D Feedback: Smooth muscle cells are spindle shaped and smaller than skeletal muscle fibers. Each smooth muscle cell has one centrally positioned nucleus. Smooth muscle contains dense bodies that are attached to the membrane, dispersed in the cell, and attached to actin filaments. Smooth muscle has slow contractions and no cross-striations. Sarcomeres are the functional units of cardiac and skeletal muscle only. The sarcomeres extend between Z lines and M bands.

23. A client with a pathophysiologic condition that affects the desmosomes is most likely to exhibit: A) Impaired contraction of skeletal and smooth muscle B) Weakness of the collagen and elastin fibers in the extracellular space C) Impaired communication between neurons and effector organs D) Separation at the junctions between epithelial cells Ans: D Feedback: Desmosomes are a type of cell junction common in epithelium. Failure of epithelial desmosomes results in the inappropriate separation of adjacent cells. Desmosomes do not contribute to muscle contraction, communication between neurons and effector organs, or the structure of collagen and elastin.

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24. When exercising outside on an extremely warm day, the client can feel his heart pounding very rapidly. Thinking in terms of the ability of the aorta to stretch to accommodate more blood circulating during exercise and the warm environment, this is an example of the function of which fibrous protein?

A) Collagen B) Reticular C) Elastin D) Ligaments Ans: C Feedback: Three types of fibers are found in the extracellular space: collagen, elastin, and reticular fibers. Elastin acts like a rubber band; it can be stretched and then returns to its original form. Elastin fibers are abundant in structures subjected to frequent stretching, such as the aorta and some ligaments. Collagen is the most common protein in the body. It is a tough, nonliving, white fiber that serves as the structural framework for skin, ligaments, tendons, and many other structures. Reticular fibers are extremely thin fibers that create a flexible network in organs subjected to changes in form or volume, such as the spleen, liver, uterus, or intestinal muscle layer.

25. While caring for a client who has just been diagnosed with leukocyte adhesion deficiency (LAD), the client asks why he is always sick with an infection. The nurse responds, “LAD is a rare autosomal recessive disorder that results in recurrent infections because of the lack of transmigration. This means: A) Your body doesn't make enough white blood cells.”

B) Your white blood cells are not able to leave the blood vessels and move into the area of infection.”

C) I don't really understand this, but it sounds like a good question to ask your physician.”

D) Your bone marrow is damaged and can't put out enough white blood cells to fight off your infections.”

Ans: B Feedback: Leukocyte adhesion deficiency (LAD) is a rare autosomal recessive disorder characterized by immunodeficiency, resulting in recurrent infections. A WBC differential will reveal extremely elevated levels of neutrophils (on the order of 6–10 times normal) because they are unable to leave the blood vessels. Certain integrins play an important role in allowing white blood cells to pass through the vessel wall, a process called transmigration.

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Chapter 2 Cell and Tissue Characteristics 1. Which of the following clients would be an example of cellular atrophy?

A) A middle-aged female experiencing menopause due to loss of estrogen stimulation B) A postnephrectomy client whose remaining kidney enlarges to compensate for the loss C) A hypertensive, noncompliant client who has developed a progressive increase in left ventricular mass D) A female client with the change in uterine size as a result of pregnancy Ans: A Feedback: In women, the loss of estrogen stimulation during menopause results in atrophic changes in the reproductive organs. Compensatory hypertrophy is the enlargement of a remaining organ or tissue after a portion has been surgically removed or rendered inactive. For instance, if one kidney is removed, the remaining kidney enlarges to compensate for the loss. In hypertension, for example, the increased workload required to pump blood against an elevated arterial pressure results in a progressive increase in left ventricular muscle mass and need for coronary blood flow. The pregnant uterus undergoes both hypertrophy and hyperplasia as a result of estrogen stimulation.

2. A client has experienced significant decreases in mobility and stamina during a 3-week hospital stay for the treatment of a femoral head fracture. Which of the following phenomena most likely accounts for the client's decrease in muscle function?

A) Impaired muscle cell metabolism resulting from metaplasia B) Dysplasia as a consequence of inflammation during bone remodeling C) Disuse atrophy of muscle cells during a prolonged period of immobility D) Ischemic atrophy resulting from vascular changes while on bedrest Ans: C Feedback: Disuse atrophy frequently occurs as a consequence of prolonged periods of muscle inactivity. Metaplasia and dysplasia are not common consequences of immobility and muscle disuse. Similarly, infrequent muscle use does not typically cause vascular changes that result in ischemic atrophy.

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3. The client is found to have liver disease, resulting in the removal of a lobe of his liver.

Adaptation to the reduced size of the liver leads to which phenomenon in the remaining liver cells?

A) Metaplasia B) Organ atrophy C) Compensatory hyperplasia D) Physiologic hypertrophy Ans: C Feedback: Compensatory hyperplasia can be stimulated in response to loss of vital tissue that is capable of regeneration, such as liver cells. Metaplasia involves replacement of one existing cell type with another fully differentiated cell type. Organ atrophy is caused by irreversible loss of cells. Physiologic hypertrophy is increased size of existing cells resulting from increased workload.

4. A client presents for a scheduled Papanicolaou (Pap) smear. The clinician who will interpret the smear will examine cell samples for evidence of: A) Changes in cell shape, size, and organization B) The presence of unexpected cell types C) Ischemic changes in cell samples D) Abnormally high numbers of cells in a specified field Ans: A Feedback: A Pap smear is an example of a diagnostic procedure that tests for the presence of cell dysplasia, that is, deranged cell growth of a specific tissue that results in cells that vary in size, shape, and organization. Unexpected cell types are evidence of metaplasia, whereas ischemic changes are associated with cell hypertrophy. Increases in the number of cells are characterized as hyperplasia.

5. When performing an assessment on a school-aged child, the nurse notes that the mucous membranes along the gum margins have a noticeable blue-colored line. At this point, the nurse should ask the parents about possible: A) Liver problems as an infant B) Congenital heart problems C) Exposure to lead D) Second-hand smoke exposure Ans: C Feedback: The formation of a blue lead line along the margins of the gum is one of the diagnostic features of lead poisoning. Liver problems are usually displayed as jaundice (yellowing of the skin/sclera). Congenital heart problems may exhibit cyanosis, but this would not be just in the gum margins. Second-hand smoke exposure may cause accumulation in the lungs.

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6. An elderly client asks her health care provider if the reason she has developed aortic stenosis is because she drank so much milk as a child growing up on a farm. Which of the following responses is most accurate?

A) “Drinking lots of real milk as a child may have contributed to the damage in your valve.”

B) “Atherosclerosis is a long process that eventually results in calcification of heart valves.”

C) “This calcification of your aortic valve is more than likely due to an undiagnosed thyroid problem.”

D) “More than likely, calcium has left your bones and collected on your aortic valve.”

Ans: B Feedback: Dystrophic calcification represents the macroscopic deposition of calcium salts in injured tissue. Dystrophic calcification is commonly seen in atheromatous lesions of advanced atherosclerosis, in areas of injury in the aorta and large blood vessels, and in damaged heart valves. For example, calcification of the aortic valve is a frequent cause of aortic stenosis in the elderly. Drinking milk, undiagnosed thyroid problems, and calcium loss from bone causing osteoporosis do not cause damaged heart valves.

7. Which of the following pathophysiologic processes is most likely to result in metastatic calcification?

A) Benign prostatic hyperplasia B) Liver cirrhosis C) Impaired glycogen metabolism D) Hyperparathyroidism Ans: D Feedback: Metastatic calcification is a result of markedly increased serum calcium levels. Because the parathyroid gland is responsible for the regulation of serum calcium levels, hyperparathyroidism creates a risk for hypercalcemia and consequent metastatic calcification. Benign prostatic hypertrophy, cirrhosis, and impaired glycogen metabolism are not implicated in cases of metastatic calcification.

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8. Despite the low levels of radiation used in contemporary radiologic imaging, a radiology technician is aware of the need to minimize her exposure to ionizing radiation.

What is the primary rationale for the technician's precautions? Radiation: A) Stimulates pathologic cell hypertrophy and hyperplasia B) Results in the accumulation of endogenous waste products in the cytoplasm C) Interferes with DNA synthesis and mitosis D) Decreases the action potential of rapidly dividing cells Ans: C Feedback: Radiation has a damaging effect on DNA synthesis and mitosis, a process that is especially harmful to rapidly dividing cells. Radiation does not directly influence the action potential of cells or the accumulation of endogenous waste products. Cell changes such as hypertrophy or hyperplasia may result from radiation exposure, but such changes are secondary to interference with DNA synthesis and mitosis.

9. A mother rushes her 4-year-old child to the emergency department after she found an empty Tylenol (acetaminophen) bottle beside her child. The nurse is trying to explain why it is so important to give the child Ipecac to induce vomiting in order to prevent: A) Renal failure B) Seizures C) Liver failure D) Hemorrhage Ans: C Feedback: Acetaminophen, a commonly used over-the-counter analgesic drug, is detoxified in the liver, where small amounts of the drug are converted to a highly toxic metabolite. This metabolite is detoxified by a metabolic pathway that uses a substance normally present in the liver. When large amounts of the drug are ingested, this pathway becomes overwhelmed and toxic metabolites accumulate, causing massive liver necrosis.

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10. The parents of a 4-year-old girl have sought care because their daughter has admitted to chewing and swallowing imported toy figurines that have been determined to be made of lead. Which of the following blood tests should the care team prioritize?

A) White blood cell levels with differential B) Red blood cell levels and morphology C) Urea and creatinine levels D) Liver function panel Ans: B Feedback: Anemia is a cardinal sign of lead toxicity. Consequently, assessment of the quantity and morphology of RBCs is paramount in cases of suspected lead toxicity. White blood cell and liver studies are not central to the care of this client. Lead is indeed nephrotoxic, and urea and creatinine levels are relevant to assessment, but the priority blood test is assessment of the RBCs.

11. A pregnant client is attending a nutrition class for first-time moms. During the class, the instructor stressed that they should avoid consumption of which food that may cause brain damage from methyl mercury exposure?

A) Tuna B) Raw hamburger C) Fresh milk D) Beets Ans: A Feedback: The main source of methyl mercury exposure is from consumption of long-lived fish, such as tuna and swordfish. Fish concentrate mercury from sediment in the water.

Because the developing brain is more susceptible to mercury-induced damage, it is recommended that young children and pregnant and nursing women should avoid consumption of fish known to contain high mercury content. None of the other foods listed pose a threat of mercury toxicity.

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12. A client has been diagnosed with a gram-negative bacillus in his blood cultures. The health care providers know these bacteria may produce clinical manifestations such as high temperature, high respiratory rate, and low blood pressure. These manifestations are primarily caused by: A) Disrupting the sodium/potassium ATPase pump B) Interrupting oxidative metabolism processes C) The outer layer of the bacterial membrane acting as an endotoxin D) The bacteria causing a decrease in protein synthesis and function Ans: C Feedback: Bacteria and viruses can replicate within a cell, thus perpetuating the injuries.

Gram-negative bacilli have unique characteristics in the structure of the outer membrane. The outer leaflet of the membrane has a lipid portion that acts as an endotoxin. If this bacillus enters the circulatory system, it causes a toxic reaction, with the sufferer developing a high temperature, high respiration rate, and low blood pressure. Other agents that are injurious to cells are unable to replicate in the cell, but they may disrupt the sodium/potassium pump, interrupt oxidative metabolism, or decrease protein synthesis.

13. Which of the following diseases would be considered to be caused by a lack of a specific vitamin or mineral?

A) Anorexia nervosa B) Scurvy C) Sickle cell anemia D) Atherosclerosis Ans: B Feedback: Dietary deficiencies can occur because of a selective deficiency of a single nutrient. Iron deficiency anemia, scurvy, beriberi, and pellagra are examples of injury caused by a lack of specific vitamins or minerals. Anorexia nervosa, sickle cell anemia, and atherosclerosis are not caused by lack of a vitamin/mineral.

14. Free radicals damage cells by: A) Destroying phospholipids in the cell membrane B) Altering the immune response of the cell C) Disrupting calcium storage in the cell D) Inactivation of enzymes and mitochondria Ans: A Feedback: Free radicals are highly reactive and can damage cells in several ways. One way is by destroying lipids, which results in a loss of cell membrane integrity. Free radicals modify proteins but do not affect the immune function, calcium storage, or intracellular enzymes of cells.

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15. A 70-year-old male client has been admitted to a hospital for the treatment of a recent hemorrhagic stroke that has left him with numerous motor and sensory deficits. These deficits are most likely the result of which of the following mechanisms of cell injury?

A) Free radical injury B) Hypoxia and ATP depletion C) Interference with DNA synthesis D) Impaired calcium homeostasis Ans: B Feedback: Stroke is characterized by impaired cerebral circulation and consequent death of neurons from cellular hypoxia. Free radical injury, abnormal DNA synthesis, and impaired calcium homeostasis are not direct consequences of lack of blood flow to body cells.

16. An elderly client has experienced some hypoxia as a result of chronic respiratory problems. Knowing that oxygen -deprived cells result in an accumulation of lactic acid in the cells, physiologically, the client may experience: A) An increase in fat load B) Altered cell membrane permeability C) Retention of lysosomal enzymes D) Cellular shrinkage and dehydration Ans: B Feedback: Altered membrane permeability impairs the balance, allowing too much of some and not enough of other substances to flow in and out of the cell. The altered permeability, lack of ATP, and loss of functional surface receptors make it difficult for glucose to enter the cell. Excess fat accumulates because it is unable to move through the damaged membrane. Injury to the lysosomal membranes results in the leakage (not retention) of destructive lysosomal enzymes into the cytoplasm and enzymatic digestion of cell components.

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17. Injured cells become very swollen as a result of: A) Increased cell protein synthesis B) Altered cell volume regulation C) Passive entry of potassium into the cell D) Bleb formation in the plasma membrane Ans: B Feedback: Altered cell volume regulation, caused by the impaired permeability of the cell membrane, leads to sodium retention and substance accumulation within the cell.

Sodium attracts water, and the cell swells even more. Protein synthesis is decreased in injured cells. Potassium has difficulty entering the cell and accumulates in the serum, due to loss of the ATPase sodium/potassium pump. Bleb formation occurs in the cell that is already swollen and ready to burst.

18. Ischemia and other toxic injuries increase the accumulation of intracellular calcium as a result of: A) Release of stored calcium from the mitochondria B) Improved intracellular volume regulation C) Decreased influx across the cell membrane D) Attraction of calcium to fatty infiltrates Ans: A Feedback: Disruption of the normal intracellular functions causes the impaired mitochondria to release stored calcium. Cell injury disrupts intracellular volume regulation, allowing excessive influx of substances across the impaired cell membrane. Fatty infiltrate is an ominous sign of cell damage and does not interact with calcium.

19. Which of the following processes associated with cellular injury is most likely to be reversible?

A) Cell damage resulting from accumulation of fat in the cytoplasm B) Cellular changes as a result of ionizing radiation C) Cell damage resulting from accumulation of free radicals D) Apoptosis Ans: A Feedback: Intracellular accumulation of fat leads to serious cell damage, but this is a potentially reversible effect. Ionizing radiation and damage from free radicals are more likely to be permanent, whereas apoptosis is defined as the permanent removal of injured and aged cells.

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20. A client with diabetes has impaired sensation, circulation, and oxygenation of his feet.

He steps on a piece of glass, the wound does not heal, and the tissue area becomes necrotic. The necrotic cell death is characterized by: A) Rapid apoptosis B) Cellular breakage C) Shrinkage and collapse D) Chronic inflammation Ans: B Feedback: Apoptosis is a programmed cell death, unrelated to cell injury, and occurs in a controlled, organized manner. Necrosis is an unorganized death of cells that initiates the acute inflammatory response with intracellular swelling and resulting cellular breakage (rupture).

21. A client has been diagnosed with gram-negative pneumonia of the lower lobe. Knowing that gram-negative bacteria have a lipopolysaccharide endotoxin on their outer cell membrane, the health care provider should be assessing the client for which pathophysiological end result?

A) Damage to cellular mitochondria B) Increased ATP levels C) Activation of the p53 protein D) Apoptosis Ans: D Feedback: The extrinsic pathway of apoptosis involves extracellular signaling proteins that bind to cell surface molecules called death receptors and trigger apoptosis. The end result includes activation of endonucleases that cause fragmentation of DNA and cell death. In addition to TNF and Fas ligand, primary signaling molecules known to activate the extrinsic pathway include TNF-related apoptosis-inducing ligand (TRAIL); the cytokine interleukin-1 (IL-1); and lipopolysaccharide (LPS), the endotoxin found in the outer cell membrane of gram-negative bacteria. DNA damage, activation of the p53 protein, and decreased ATP levels are associated with the intrinsic pathway.

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22. A person eating peanuts starts choking and collapses. His airway obstruction is partially cleared, but he remains hypoxic until he reaches the hospital. The health care providers will be assessing this client for which of the following physiological events? Select all that apply.

A) Cerebral infarction B) Coagulation necrosis C) Rapid phagocytosis D) Protein p53 deficiency Ans: A, B Feedback: Tissue infarction is caused by prolonged oxygen deprivation, and the resulting large group of dead cells coagulates in the damaged area. During coagulation necrosis, acidosis develops and denatures the enzymatic and structural proteins of the cell.

Phagocytosis occurs rapidly during apoptosis, so it does not elicit an inflammatory response. Protein p53 activation initiates apoptosis.

23. A client with diabetes and severe peripheral vascular disease has developed signs of dry gangrene on the great toe of one foot. The client asks, “How this can happen?” Which of the following pathophysiologic processes should the nurse explain to this client? “More than likely, your gangrene is caused by: A) Inappropriate activation of apoptosis, which means death of your cells.”

B) Bacterial invasion into the foot and toe.”

C) Impaired arterial blood supply to your toe.”

D) Metaplastic cellular changes in your toe.”

Ans: C Feedback: Dry gangrene is often a result of impaired arterial blood supply to the extremities. A bacterial etiology is more common in wet gangrene, whereas neither metaplasia nor activation of apoptosis is implicated in cases of dry gangrene.

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24. A group of elderly residents were commenting on how many cell functions decline with age. One resident commented that many of his friends who lived under large electromagnetic towers seemed to experience aging at an accelerated rate in comparison with residents who lived nearby in lakefront housing. This observation is the basis for which theory on aging?

A) Theories of genetic influences B) Programmed cell receptor theories C) Insufficient telomerase enzyme theory D) Error theory associated with DNA damage Ans: D Feedback: Error theory suggests that aging results from DNA mutation or faulty repair. Another group of theories of aging focuses on programmed cell changes with genetic influences that systematically cause cell senescence. Elimination of receptor sites is not part of aging theory. Telomerase enzyme is thought to reduce the shortening of the chromosomes and loss of telomere DNA with each cell replication.

25. Which of the following facts underlies the concept of replicative senescence?

A) Genes controlling longevity are present or absent in varying quantities among different individuals.

B) Telomeres become progressively shorter in successive generations of a cell.

C) The damaging influence of free radicals increases exponentially in later generations of a cell.

D) Aging produces mutations in DNA and deficits in DNA repair.

Ans: B Feedback: Replicative senescence implies that cells have limited capacity for reproduction, largely as a result of the shortening of telomeres and consequent chromosomal damage. Genetic theories, the influence of free radicals, and DNA mutation are not central to the concept of replicative senescence.

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1. Chapter 3 A client with poor arterial circulation in the lower limbs has developed areas of inflammation and “weeping” clear serous exudate. Since chronic inflammation lasts for a long time, it has been associated with which of the following changes in physiological response? Select all that apply.

A) Formation and development of new blood vessels B) The death of one or more cells in the body within a localized area C) Release of a number of potent inflammatory mediators, altering adhesive properties D) Regulation and modulation of the immune response through synthesis and release of inflammatory mediators E) Release of scavenger cells capable of engulfing bacteria through phagocytosis Ans: A, B Feedback: Chronic inflammation is of a longer duration, lasting for days to years, and is often associated with the proliferation of blood vessels (angiogenesis), tissue necrosis, and fibrosis (scarring). Endothelial cells are also key players in the inflammatory response.

They regulate leukocyte extravasation by expression of adhesion molecules and receptor activation and contribute to the regulation and modulation of immune responses through synthesis and release of inflammatory mediators. Activated platelets also release a number of potent inflammatory mediators, thereby increasing vascular permeability and altering the chemotactic, adhesive, and proteolytic properties of the endothelial cells.

Neutrophils are scavenger cells capable of engulfing bacteria and other cellular debris through phagocytosis.

2. During a lecture on inflammation, the physiology instructor discusses the major cellular components involved in the inflammation response. The instructor asks, “Which of the following cells arrives early in great numbers?” The student with the correct response is: A) Basophils B) Lymphocytes C) Neutrophils D) Monocytes Ans: C Feedback: Neutrophils are the primary early arrival cells and are signified by an elevated neutrophil count that includes mature (PMNs) and immature (bands) cell forms.

Basophils respond later. Lymphocytes have a slower arrival and stay longer. The half-life of circulating monocytes is about a day, after which they begin to migrate to the site of injury and mature into larger macrophages, which have a longer half-life and greater phagocytic ability than do blood monocytes.

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3. A diabetic client has injured his foot while walking barefoot on the lawn. On admission, which of the following assessment findings would be considered a localized cardinal sign of acute inflammation?

A) Temperature of 101°F B) Fatigue with listlessness C) Redness and edema at the injured site D) Urine output of less than 500 mL/24 hours (low) Ans: C Feedback: Localized manifestations include redness, swelling, and heat. Fever and fatigue are systemic manifestations of acute inflammation. Low urine output is not a localized sign but could be a systemic manifestation if the client goes into septic shock.

4. An older adult client has just sheared the skin on her elbow while attempting to boost herself up in bed, an event that has precipitated acute inflammation in the region surrounding the wound. Which of the following events will occur during the vascular stage of the client's inflammation?

A) Outpouring of exudate into interstitial spaces B) Chemotaxis C) Accumulation of leukocytes along the epithelium D) Phagocytosis of cellular debris Ans: A Feedback: The vascular stage of acute inflammation includes the outpouring of exudate into the extravascular spaces. Margination (epithelial accumulation of leukocytes), chemotaxis, and phagocytosis take place during the cellular stage.

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5. A client cuts herself with a sharp knife while cooking dinner. The client describes how the wound started bleeding and had a red appearance almost immediately. The nurse knows that in the vascular stage of acute inflammation, the vessels: A) Bleed profusely until the body can compensate and start to send fibrinogen to the wound B) Vasodilate causing the area to become congested causing the red color and warmth C) Constrict as a result of “fight/flight” hormone release resulting in pale-colored skin D) Swell to the point of compromising circulation causing the limb to become cool to touch Ans: B Feedback: Vasodilation allows more blood and fluid into the area of injury, resulting in congestion, redness, and warmth. Vasodilation is quickly followed by increased permeability of the microvasculature. The loss of fluid results in an increased concentration of blood constituents (red blood cells, leukocytes, platelets, and clotting factors), stagnation of flow, and clotting of blood at the site of injury. This aids in limiting the spread of infectious microorganisms. The loss of plasma proteins increases fluid movement from the vascular compartment into the tissue space and producing the swelling, pain, and impaired function that are the cardinal signs of acute inflammation.

6. A group of teenagers spent an entire day on the beach without using sunscreen. The first night, their skin was reddened and painful to touch. The second day, they awoke to find large fluid-filled blisters over several body areas. The nurse recognizes the development of blisters as which type of inflammatory response?

A) Cellular response B) Immediate transient response C) Continuous response D) Delayed response Ans: D Feedback: The first pattern is an immediate transient response, which occurs with minor injury. It develops rapidly after injury and is usually reversible and of short duration (15 to 30 minutes). The second pattern is an immediate sustained response. The third pattern is a delayed response, in which the increased permeability begins after a delay of 2 to 12 hours, lasts for several hours or even days, and involves venules as well as capillaries. A delayed response often accompanies injuries due to radiation, such as sunburn. The cellular stage of acute inflammation is marked by changes in the endothelial cells lining the vasculature and movement of phagocytic leukocytes into the area of injury or infection.

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7. During lecture on wound care, the instructor mentions the final stage of the cellular response of acute inflammation. Of the following statements, which describes what physiologically occurs in the final stage?

A) Leukocytes accumulate and begin migration to the site of injury.

B) Chemokines direct the trafficking of leukocytes.

C) Mediators are transformed into inactive metabolites.

D) Neutrophils, monocytes, and macrophages engulf and degrade the bacteria/cellular debris.

Ans: D Feedback: During the final stage of the cellular response, neutrophils, monocytes, and tissue macrophages are activated to engulf and degrade the bacteria and cellular debris in a process called phagocytosis. During the early stages of the inflammatory response, signaling between blood leukocytes and the endothelial cells defines the inflammatory event and ensures arrest of the leukocytes along the endothelium. This process of leukocyte accumulation is called margination. Once leukocytes exit the capillary, they crawl through the tissue guided by a gradient of secreted chemoattractants, such as chemokines, bacterial and cellular debris, and fragments generated from activation of the complement system. Chemokines are small proteins that direct the trafficking of leukocytes during the early stages of inflammation or injury. Once activated and released from the cell, most mediators are short-lived. They may be transformed into inactive metabolites, inactivated by enzymes, or otherwise scavenged or degraded.

8. A client presents to the clinic with a swollen, painful “hang nail” on the index finger.

There is a large pustule over the site that needs to be lanced. The health care worker knows that which mediator of inflammation causes this increase in capillary permeability and pain?

A) Serotonin B) Histamine C) Bradykinin D) Nitric oxide Ans: C Feedback: Bradykinin causes increased capillary permeability and pain. Serotonin and histamine are released by the mast cell degranulation. Histamine causes arteriole dilation and increased permeability of venules. Serotonin has actions similar to those of histamine.

Nitric oxide relaxes smooth muscle and reduces platelet aggregation and adhesion.

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9. A client has an abscess in the mouth with a profuse amount of thick creamy white exudate. The nurse knows that this wound with necrotic cells is classified as: A) Serous B) Fibrinous C) Suppurative D) Membranous Ans: D Feedback: Membranous or pseudomembranous exudates develop on mucous membrane surfaces. It is an acute inflammatory response to a powerful necrotizing toxin with formation on a mucosal surface, of a false membrane composed of precipitated fibrin, necrotic epithelium, and inflammatory white cells. Serous exudate is a watery fluid. Fibrinous exudates contain fibrinogen and form a thick sticky meshwork. Suppurative exudate contains pus.

10. In contrast to acute inflammation, chronic inflammation is characterized by which of the following phenomena?

A) Profuse fibrinous exudation B) A “shift to the left” of granulocytes C) Metabolic and respiratory alkalosis D) Lymphocytosis and activated macrophages Ans: D Feedback: Chronic inflammation requires lymphocytes and macrophages to remain in large numbers for the high use of immune cells. Chronic inflammation is associated with fibroblast proliferation instead of exudations. A “shift to the left” is characteristic of acute inflammation with a high neutrophil count. Inflammation, with continued cell injury, is a source of metabolic and respiratory (if the lungs are the site of inflammation) acidosis.

11. Which of the following individuals most likely has the highest risk of experiencing chronic inflammation? A client who: A) Has recently been diagnosed with type 2 diabetes B) Is a carrier of an antibiotic-resistant organism C) Is taking oral antibiotics for an upper respiratory infection D) Is morbidly obese and who has a sedentary lifestyle Ans: D Feedback: Obesity has been linked to chronic inflammation. Acute infections, diabetes, and being a carrier of a microorganism are not circumstances that are noted to cause chronic inflammation.

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12. The nurse notes the client has developed a systemic response of inflammation based on assessment findings. Which of the following clinical manifestations support this diagnosis? Select all that apply.

A) Temperature of 100.9°F, lethargy B) Pulse rate 130 beats/minute (high) C) Generalized achiness D) Low urine output E) Pounding, throbbing headache Ans: A, B, C Feedback: Manifestations of the acute-phase response include fever, increased heart rate, anorexia, somnolence, and malaise. Low urine output and throbbing headache are not an acute response.

13. Which of the following lab results confirm the client has developed an acute-phase inflammatory response? Select all that apply.

A) Erythrocyte sedimentation rate (ESR) 175 mm/h (high).

B) Red blood cell count (RBC) 3.11 cells/L (low).

C) Leukocytes (WBC) 18.7 cells/L (high).

D) C-reactive protein (CRP) 10.0 mg/L (high).

E) Fibrinogen level 1.5 g/L (normal).

Ans: A, C, D Feedback: During the acute-phase response, the liver dramatically increases the synthesis of acute-phase proteins such as fibrinogen, C-reactive protein (CRP), and serum amyloid A protein (SAA) that serve several different defense functions. The synthesis of these proteins is stimulated by cytokines, especially TNF-, IL-1 (for SAA), and IL-6 (for fibrinogen and CRP). The accelerated erythrocyte sedimentation rate (ESR) that occurs in disease conditions is characterized by the systemic inflammatory response.

Leukocytosis, or the increase in white blood cells, is a frequent sign of an inflammatory response, especially those caused by bacterial infection. In acute inflammatory conditions, the white blood cell count commonly increases from a normal value of 4000 to 10,000 cells/L.

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14. A client asks why his temperature is always below 98.6°F. The nurse responds: A) Some people maintain a core body temperature of 41°C and that is normal for them.

B) Normal core temperature varies between individuals within the range of 97.0°F to 99.5°F. C) A person's highest point of core temperature is usually first thing in the morning.

D) The best way to bring your body temperature up to normal is to live in a warmer climate.

Ans: B Feedback: Core temperature is normally maintained within a range of 36.0°C to 37.5°C (97.0°F to 99.5°F). A core temperature greater than 41°C (105.8°F) or less than 34°C (93.2°F) usually indicates that the body's thermoregulatory ability is impaired. Body heat is generated in the tissues of the body, transferred to the skin surface by the blood, and then released into the environment surrounding the body. The thermoregulatory center regulates the temperature of the deep body tissues, or “core” of the body, rather than the surface temperature. Internal core temperatures reach their highest point in late afternoon and evening and their lowest point in the early morning hours.

15. A postsurgical client who is recovering in the postanesthetic recovery unit states that she is “freezing cold.” Which of the following measures is likely to be initiated in the client's hypothalamus in an effort to reduce heat loss?

A) Opening of arteriovenous (AV) shunts B) Reduced exhalation of warmed air C) Contraction of pilomotor muscles D) Decreased urine production Ans: C Feedback: Contraction of the pilomotor muscles reduces the surface area available for heat loss.

Opening of the AV shunts exacerbates heat loss. The body does not normally adjust urine production or decrease exhalation in response to heat loss.

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16. An elderly client is dressed only in a hospital gown and complains of a draft in her room. Consequently, she has requested a warm blanket while she sits in her wheelchair.

Which of the following mechanisms of heat loss is most likely the primary cause of her request?

A) Evaporation and conduction B) Radiation and convection C) Conduction and convection D) Convection and evaporation Ans: B Feedback: Approximately 60% of heat loss typically occurs through radiation to the surrounding air. Convection is heat loss related to air currents, such as those in a drafty room.

17. Which of the following clients have a pathophysiologic process capable of causing fever by inducing the production of pyrogens? Select all that apply.

A) A farmer who cut his arm while sharpening his tools coming to clinic because of acute inflammation signs like fever and redness B) A middle-aged obese client complaining of “knees hurting and swelling by the end of the day” C) An older adult recuperating following a myocardial infarction D) A newly diagnosed Hodgkin lymphoma client E) A 30-year-old end-stage renal failure client receiving hemodialysis three times per week Ans: A, C, D Feedback: Inflammation, myocardial infarction, and malignancies are all processes that result in the production and release of pyrogens. Obesity and renal failure are not noted to directly result in pyrogen production and consequent fever.

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18. Exogenous pyrogens (interleukin-1) and the presence of bacteria in the blood lead to the release of endogenous pyrogens that: A) Stabilize thermal control in the brain B) Produce leukocytosis and shivering C) Block viral replication in cells D) Inhibit prostaglandin release Ans: B Feedback: Exogenous pyrogens induce host cells, such as blood leukocytes and tissue macrophages, to produce fever-producing mediators called endogenous pyrogens (e.g., IL-1). For example, the breakdown products of phagocytosed bacteria that are present in the blood lead to the release of endogenous pyrogens. The endogenous pyrogens are thought to increase the set point of the hypothalamic thermoregulatory center through the action of prostaglandin E2 (PGE2). In response to the sudden increase in set point, the hypothalamus initiates heat production behaviors (shivering and vasoconstriction) that increase the core body temperature to the new set point, and fever is established.

Pyrogens are not capable of blocking viral replication or prostaglandin release.

19. Which of the following clients is most likely to be susceptible to developing a neurogenic fever? A client who has: A) Stage II Alzheimer disease B) Sustained a head injury in a bicycle crash C) Become delirious after the administration of a benzodiazepine D) Begun taking a selective serotonin reuptake inhibitor (SSRI) for the treatment of depression Ans: B Feedback: Neurogenic fever is the result of damage to the hypothalamus caused by central nervous system trauma, intracerebral bleeding, or an increase in intracranial pressure. All these problems may be precipitated by a head injury. Alzheimer disease and drug administration are not typical causes of a neurogenic fever.

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20. A client has sought care because of recent malaise and high fever. Upon assessment, the client states that his current fever began 2 days earlier, although he states that for the last 2 weeks he is in a cycle of high fever for a couple of days followed by a day or two of normal temperature. Which of the following fever patterns is this client experiencing?

A) Recurrent fever B) Remittent fever C) Sustained fever D) Intermittent fever Ans: D Feedback: A recurrent or relapsing fever pattern is one in which there is one or more episodes of fever, each lasting as long as several days, with one or more days of normal temperature between episodes. An intermittent fever is one in which temperature returns to normal at least once every 24 hours, whereas sustained and remittent fevers do not involve a return to normal temperature range.

21. Which assessment findings of a client with an elevated temperature would be considered a “normal” finding? Select all that apply.

A) Flushed skin B) White, cheesy patches on oral mucous membranes C) Pain when moving joints to sit up in bed D) Unusual fatigue and drowsiness E) Complaining of “spots before the eyes” Ans: A, C, D Feedback: Common manifestations of fever are anorexia, myalgia, arthralgia, and fatigue. These discomforts are worse when the temperature rises rapidly or exceeds 39.5°C (103.1°F).

Respiration is increased, and the heart rate usually is elevated. Dehydration occurs because of sweating and the increased vapor losses caused by the rapid respiratory rate.

White, cheesy patches in the mouth are usually associated with a fungal infection. Spots before one's eyes are unrelated to fever.

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22. While sponging a client who has a high temperature, the nurse observes the client begins to shiver. At this point, the priority nursing intervention would be to: A) Administer an extra dose of aspirin B) Stop sponging the client and retake a set of vital signs C) Increase the room temperature by turning off the air conditioner and continue sponging the client with warmer water D) Place a heated electric blanket on the client's bed Ans: B Feedback: Modification of the environment ensures that the environmental temperature facilitates heat transfer away from the body. Sponge baths with cool water or an alcohol solution can be used to increase evaporative heat losses. More profound cooling can be accomplished through the use of a cooling blanket or mattress, which facilitates the conduction of heat from the body into the coolant solution that circulates through the mattress. Care must be taken so that cooling methods do not produce vasoconstriction and shivering that decrease heat loss and increase heat production.

23. A client arrived in the emergency department following 2 days of general malaise. The temperature is 103.8°F. The nurse administers the prescribed aspirin, an antipyretic.

Which of the following statements relates to the rationale for this action?

A) Temperatures in excess of 37.5°C (99.5° F) can result in seizure activity.

B) Lower temperatures inhibit the protein synthesis of bacteria.

C) These medications protect vulnerable organs, such as the brain, from extreme temperature elevation.

D) Most common antipyretics have been shown to have little effect on core temperature.

Ans: C Feedback: There is little research to support the belief that fever is harmful unless the temperature rises to extreme levels; it has been shown that small elevations in temperature, such as those that occur with fever, enhance immune function. Antipyretics are effective in lowering core body temperature.

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24. A febrile, 3-week-old infant has been brought to the emergency department by his parents and is currently undergoing a diagnostic workup to determine the cause of his fever. Which of the following statements best conveys the rationale for this careful examination?

A) The immature hypothalamus is unable to perform normal thermoregulation.

B) Infants are susceptible to serious infections because of their decreased immune function.

C) Commonly used antipyretics often have no effect on the core temperature of infants.

D) Fever in neonates is often evidence of a congenital disorder rather than an infection.

Ans: B Feedback: Younger children have decreased immunologic function and are more commonly infected with virulent organisms. Neonates are at particularly high risk for serious bacterial infections that can cause bacteremia or meningitis. Neonates are capable of thermoregulation, and fever is not necessarily indicative of a congenital disorder.

Antipyretics are effective in the treatment of fever in infants.

25. An 84-year-old client's blood cultures have come back positive, despite the fact that his oral temperature has remained within normal range. Which of the following phenomena underlies the alterations in fever response that occur in the elderly?

A) Disturbance in the functioning of the thermoregulatory center B) Increased heat loss by evaporation C) The presence of comorbidities that is associated with lowered core temperature D) Persistent closure of arteriovenous shunts Ans: A Feedback: The probable mechanisms for the blunted fever response in older adults include a disturbance in sensing of temperature by the thermoregulatory center in the hypothalamus. Heat loss by evaporation tends to decrease with age, and the closure of AV shunts results in increased core temperature. The presence of comorbidities is not noted to contribute to reduced fever response in older adults.

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1. Chapter 4 During a discussion of different cell types in the body, the instructor mentions that which types of cells renew themselves continuously throughout life?

A) Liver cells B) Neurons C) Cells lining the GI tract D) Osteoblasts Ans: C Feedback: The process of differentiation is regulated by a combination of internal processes involving the expression of specific genes and external stimuli provided by neighboring cells, the ECM, and a variety of growth factors. The process occurs in orderly steps, with each progressive step being exchanged for a loss of ability to develop different cell characteristics. As a cell becomes more highly specialized, the stimuli that are able to induce mitosis become more limited. Neurons, which are highly specialized cells, lose their ability to proliferate once development of the nervous system is complete. In other, less specialized tissues, such as the skin and mucosal lining of the gastrointestinal tract, a high degree of cell renewal continues throughout life. Liver cells and osteoblasts (bone-forming cells) do not renew throughout life.

2. Which of the following cells will likely stay in a permanent resting state known as G0, unless there is a change in nutrients, growth factors, or hormones that trigger cell renewal?

A) Stratified squamous epithelium of the skin B) Cells lining the esophagus and intestines C) Neurons D) Cancerous cells Ans: C Feedback: When environmental conditions are adverse, such as nutrient or growth factor unavailability, or cells become terminally differentiated (i.e., highly specialized), cells may exit the cell cycle, becoming mitotically quiescent and reside in a special resting state known as G0. Cells in G0 may reenter the cell cycle in response to extracellular nutrients, growth factors, hormones, and other signals such as blood loss or tissue injury that trigger cell renewal. Highly specialized and terminally differentiated cells, such as neurons, may permanently stay in G0. The skin, cells lining the GI tract, and cancer cells are continuously dividing and going through the cell cycle.

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3. A mutation has occurred during mitosis of an individual's bone marrow cell. This event may be the result of the failure of which of the following?

A) Progenitor cells B) Fibroblasts C) Stem cells D) Cyclins Ans: D Feedback: The cyclins are a family of proteins that control the entry and progression of cells through the cell cycle, the failure or absence of which may result in mutations.

Fibroblasts do not contribute to the cell cycle, and neither progenitor cells nor stem cells are likely to directly contribute to mutation.

4. A client has arrived in the emergency department with massive blood loss from a lacerated liver. Knowing the physiological principles behind the capacity for cells to regenerate, the client's body will likely: A) Pull fluid from the tissues to maintain a reasonable blood pressure B) Stimulate rapid proliferation of RBCs by the blood-forming progenitor cells of the bone marrow C) Activate the tissue cells to start producing stem cells D) Begin a cell cycle so stem cells can undergo numerous mitotic divisions Ans: B Feedback: Continuously dividing tissues are those in which the cells continue to divide and replicate throughout life, replacing cells that are continually being destroyed. These tissues can readily regenerate after injury as long as a pool of stem cells is preserved.

Bleeding, for example, stimulates the rapid proliferation of replacement cells by the blood-forming progenitor cells of the bone marrow. Another type of tissue cell, called a stem cell, remains incompletely differentiated throughout life. As mature cells die, the tissue is replenished by the differentiation of cells generated from stem cells.

5. A client has experienced a myocardial infarction with accompanying necrosis of cardiac muscle, a permanent tissue. What are the ramifications of the fact that cardiac muscle is a permanent tissue?

A) The cardiac muscle cells will remain perpetually in the G1 stage of mitosis.

B) Regeneration of the client's cardiac muscle will be exceptionally slow.

C) The necrotic cells will be replaced with muscle cells that have limited metabolism.

D) The cells will not proliferate and will be replaced with scar tissue.

Ans: D Feedback: The cells in permanent tissues do not proliferate and, if destroyed, are replaced with fibrous scar tissue. The G0 stage of mitosis, not the G1 stage, involves quiescence.

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6. A couple has chosen to pay for the harvesting and storage of umbilical cord blood after the delivery of their child to secure a future source of embryonic stem cells. What is the most likely rationale for the couple's decision?

A) The stem cells may be able to produce a wide range of body cells.

B) The embryonic stem cells allow stable and permanent tissues to enter mitosis.

C) The stem cells can change the proliferative capacity of other cells.

D) The embryonic stem cells remove cyclin-dependent kinase inhibitors from the body.

Ans: A Feedback: Embryonic stem cells hold the potential for broad differentiation. They do not change the proliferative capacity of existing cells and they do not foster mitosis by removing CKIs.

7. A client with a complete tear of the rotator cuff in the right shoulder was given the choice between surgery and stem cell transplant. The client chose to try the stem cell injection. The client asked the health care provider, “How does this work on my shoulder?” The best response would be: A) Bone marrow stem cells have been shown to generate cartilage, bone, and muscle when injected directly into the injured site.

B) The stem cells will circulate through your arterial system and come to rest in any area that is inflamed and in need of repair.

C) Stem cell injection is similar to a blood transfusion in that the cells will bring more oxygen and nutrients to the damaged tissue.

D) In addition to stem cells, the physician will give you some growth factor to help your body build more muscle mass.

Ans: A Feedback: Whether adult stem cells have a differentiation capacity similar to that of embryonic stem cells remains the subject of current debate and research. Thus far, bone marrow stem cells have been shown to have very broad differentiation capabilities, being able to generate not only blood cells but also fat, cartilage, bone, endothelial, and muscle cells.

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8. The physiology instructor asks the students, “How does growth factor affect cell proliferation?” Which students have the most accurate responses? Growth factors: Select all that apply.

A) Regulate the inflammatory process B) Act as a chemoattractant for many cells like neutrophils and macrophages C) Inhibit the beginning stages of cell changes that can result in cancer D) Stimulate new blood vessel growth E) Inhibit cell proliferation Ans: A, B, D Feedback: The term growth factor is generally applied to small proteins that increase cell size and cell division. In addition to cell proliferation, most growth factors have other effects.

They assist in regulating the inflammatory process; serve as chemoattractants for neutrophils, monocytes (macrophages), fibroblasts, keratinocytes, and epithelial cells; stimulate angiogenesis; and contribute to the generation of the ECM.

9. The basement membrane surrounding a client's foot wound remains intact, a fact that bodes well for the wound-healing process. Which types of substances/cells are responsible for the synthesis of collagen and elastic fibers?

A) Prostaglandins B) Fibroblasts C) Lymphocytes D) Glycoproteins Ans: B Feedback: Fibroblasts are responsible for the synthesis of collagen, elastic, and reticular fibers.

Prostagladins are inflammatory mediators. Lymphocytes are the smallest of the leukocytes, the major cellular components of the inflammatory response. Glycoproteins are responsible for maintaining the cell membrane.

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10. A client with a history of several previous abdominal surgeries has been admitted to the hospital with several abdominal pains. Knowing that fibrous strands of collagen can form following abdominal surgery resulting in adhesions, the nurse should assess the client for: A) Excess fluid in the abdomen B) Intestinal obstruction causing constipation C) Peritoneal fluid leaking from the umbilicus D) Tight, rigid abdomen caused by bleeding from old surgical sites Ans: B Feedback: If fibrosis occurs in any tissue space occupied by an inflammatory exudate, it is called organization. It occurs in serous cavities such as the pericardium and peritoneal cavities.

Fibrous strands sometimes become organized within the peritoneal cavity following abdominal surgery or peritonitis. These strands of collagen, called adhesions, can trap loops of bowel and cause obstruction. Adhesions do not cause ascites (fluid in abdomen), leakage of serum from the umbilicus, or bleeding from old surgical scars.

11. A nursing student is cleaning and changing the dressing on a client's sacral ulcer. The student has vigorously cleansed the wound bed to remove all traces of the beefy, red tissue that existed in the wound bed. The student has most likely removed: A) Necrotic tissue B) Granulation tissue C) Stem cells D) The extracellular matrix Ans: B Feedback: Granulation tissue is a glistening red, moist connective tissue that fills the injured area while necrotic debris is removed. Stem cells will not exist in a wound bed and necrotic tissue would not be bright red. The student has likely done the client a disservice by cleansing aggressively.

12. A 12-year-old boy's severe wound that he received from a dog bite has begun to heal and currently shows no signs of infection. Which of the following processes occurred first during this process of repair by connective tissue deposition?

A) Reorganization of fibrous tissue B) Angiogenesis C) Emigration of fibroblasts to the wound site D) Deposition of the extracellular matrix Ans: B Feedback: During the process of tissue repair by connective tissue deposition, angiogenesis precedes the emigration of fibroblasts, deposition of the extracellular matrix (ECM), and reorganization of the fibrous tissue.

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13. Which of the following wounds is most likely to heal by secondary intention?

A) A finger laceration that a cook received while cutting up onions B) A boy's “road rash” that he got by falling off his bicycle C) A needle stick injury that a nurse received when injecting a client's medication D) The incision from a teenager's open appendectomy Ans: B Feedback: Incisions, cuts, and puncture wounds are likely to heal by primary intention, whereas larger wounds with loss of tissue and contamination (such as may be experienced in a bicycle crash) are likely to heal by secondary intention.

14. A client has been brought to the emergency department with a large, gaping wound from a farming accident. The client is critically ill and has required blood products and surgery to clean and close the wound. Sharing with a student nurse the steps in wound healing, the nurse discusses the inflammatory phase, stating macrophages: Select all that apply.

A) Release growth factors that stimulate epithelial cell growth B) Facilitate the body's ability to grow new vessels in the injured area C) Remove debris from the wound D) Synthesize and secrete collagen E) Proliferate to form the granulation tissue to serve as a foundation for scar tissue to form Ans: A, B, C Feedback: Within 24 to 48 hours, macrophages, which are larger phagocytic cells, enter the wound area and remain for an extended period. These cells, arising from blood monocytes, are essential to the healing process. Their functions include phagocytosis and release of growth factors that stimulate epithelial cell growth, angiogenesis, and attraction of fibroblasts. When a large wound occurs in deeper tissues, neutrophils and macrophages are required to remove the debris and facilitate closure. Although a wound may heal in the absence of neutrophils, it cannot heal in the absence of macrophages. In the proliferative phase, the fibroblasts synthesize and secrete collagen and other intercellular elements needed for wound healing. Fibroblasts also produce numerous growth factors that induce angiogenesis and endothelial cell proliferation and migration.

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15. A client underwent an open cholecystectomy 4 days ago, and her incision is now in the proliferative phase of healing. What is the dominant cellular process that characterizes this phase of the client's healing?

A) Hemostasis and vasoconstriction B) Keloid formation C) Collagen secretion by fibroblasts D) Phagocytosis by neutrophils Ans: C Feedback: The proliferative phase of wound healing is characterized by the action of fibroblasts.

Hemostasis, vasoconstriction, and phagocytosis are characteristic of the inflammatory phase, whereas keloid formation is an abnormality in the remodeling phase.

16. Epithelialization, the first component of the proliferative phase of wound healing, is delayed in open wounds until what type of tissue has formed?

A) Granulation tissue B) Fibrinous meshwork C) Capillary circulation D) Collagenous layers Ans: A Feedback: Epithelialization cannot occur until granulation tissue has formed in the wound area.

Collagen is part of the remodeling phase, after epithelialization is complete. Fibroblasts are active during the remodeling phase, to synthesize collagen. New capillaries are not formed as part of the wound-healing process.

17. A client states, “I heard that my healed wound tissue is stronger than my normal tissue.

Is that true?” The nurse responds that roughly 3 months after a wound; the wound tensile strength is approximately what percentage from normal?

A) 10% of normal B) 30% of normal C) 50% of normal D) 70% of normal Ans: D Feedback: Tensile strength increases rapidly over the weeks and then slows, reaching a plateau of approximately 70% to 80% of the tensile strength of unwounded skin at the end of 3 months.

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18. Which of the following clients, who have undergone a major surgery to repair a “leaking” colon with associated peritonitis, is most likely to experience enhanced wound healing as a result of his or her presurgery diet history? A client who: A) Eats a high-calorie diet and large amounts of red meat B) Is a vegetarian and who eats organic foods when possible C) Practices carefully calorie control and who avoids animal fats D) Is receiving total parenteral nutrition due to recurrent nausea Ans: A Feedback: Protein is important for many aspects of wound healing, including control of the inflammatory phase, fibroblast function, collagen and protein matrix synthesis, angiogenesis, and wound remodeling. A diet that is high in both calories and protein is known to enhance wound healing.

19. Which of the following clients would be considered a good candidate for hyperbaric oxygen therapy?

A) A middle-aged adult who got in a fight and received a laceration above the eye B) A motorcycle accident client with lots of “road rash” requiring scrubbing of the wounds with a brush to remove all the debris C) An older adult with history of diabetes and intermittent claudication (poor circulation in the legs) who received a laceration while on the lawnmower D) A fifth grade student who fell on the playground and broke his femur and developed large hematoma over the injured leg Ans: C Feedback: Hyperbaric oxygen therapy delivers 100% oxygen at two to three times the normal atmospheric pressure at sea level. The goal of hyperbaric oxygen therapy is to increase oxygen delivery to tissues by increasing the partial pressure of oxygen dissolved in the plasma. Hyperbaric oxygen is currently reserved for the treatment of problem wounds in which hypoxia and infection interfere with healing.

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20. Which of the following clients is most likely to experience impaired wound healing?

A) A client with a diagnosis of type 1 diabetes and a history of poor blood sugar control B) A child whose severe cleft lip and palate have required a series of surgeries over several months C) A client who takes nebulized bronchodilators several times daily to treat chronic obstructive pulmonary disease D) A client with persistent hypertension who takes a -adrenergic blocker and a potassium-wasting diuretic daily Ans: A Feedback: Diabetes mellitus is a significant barrier to wound healing. Serial surgeries, chronic obstructive pulmonary disease (COPD), hypertension, and related medications are not directly linked to impaired wound healing.

21. A client who had an implantable cardioverter–defibrillator (ICD) returns the next week with a fever, chills, and elevated WBC. The physician suspects the wound is infected. If this wound does not respond to antibiotic therapy, the nurse can anticipate the client will undergo: A) Debridement B) Skin grafting C) Removal of device D) Whirlpool therapy Ans: C Feedback: Wound infections are of special concern in persons with implantation of foreign bodies such as orthopedic devices (e.g., pins, stabilization devices), cardiac pacemakers, and shunt catheters. These infections are difficult to treat and may require removal of the device.

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1. Chapter 5 When explaining genetic coding to a group of students, the instructor discusses gene activation and deactivation. It was stressed that inactivation of a gene requires which of the following processes?

A) Methylation of histone amino acid B) Acetylation of histone amino acid C) Release of endonucleases D) Protein-synthesizing apparatus of mitochondrial DNA Ans: A Feedback: Although solving the structural problem of how to fit a huge amount of DNA into the nucleus, the chromatin fiber, when complexed with histones and packaged into various levels of compaction, makes the DNA inaccessible during the processes of replication and gene expression. Several chemical interactions are now known to affect this process. One of these involves the acetylation of a histone amino acid group that is linked to opening of the chromatin fiber and gene activation. Another important chemical modification involves the methylation of histone amino acids, which is correlated with gene inactivation. Several repair mechanisms exist, and each depends on specific enzymes called endonucleases that recognize distortions of the DNA helix, cleave the abnormal chain, and remove the distorted region. Replication of mtDNA depends on enzymes encoded by nuclear DNA. Thus, the protein-synthesizing apparatus and molecular components for oxidative metabolism are jointly derived from nuclear and mitochondrial genes.

2. When an infant is born with gene mutations in his cells, the nurse explains to the parents that accidental errors may be a result of: Select all that apply.

A) Loss of one or more base pairs B) Substitution of one base pair for another C) Induction of chromatin to change its structure D) Rearrangement of the base pairs Ans: A, B, D Feedback: Genetic mutations occur in germ cells (inherited errors) or somatic cells. Germ cell mutations can be spontaneous or an error of base pair deletion, substitution of one pair for a different pair, or rearrangement of the sequence of base pairs. Somatic cell mutations affect a cell line that differentiates into tissue types. Although solving the structural problem of how to fit a huge amount of DNA into the nucleus, the chromatin fiber, when complexed with histones and packaged into various levels of compaction, makes the DNA inaccessible during the processes of replication and gene expression.

To accommodate these processes, chromatin must be induced to change its structure, a process called chromatin remodeling.

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3. Which of the following statements is true of genetic mutations?

A) Errors in DNA duplication are normally irreparable.

B) Mutations that occur in somatic cells are inheritable.

C) Mutations may result from environmental agents.

D) Errors in DNA replication are most often fatal.

Ans: C Feedback: In addition to random errors, extrinsic factors such as environmental agents, chemicals, and radiation can induce errors in DNA duplication. DNA repair mechanisms resolve the majority of mutations. As a result, most mutations are corrected and do not result in pathology or death. Only those DNA changes that occur in germ cells can be inherited.

4. While explaining the individual differences in physical traits in the family group, the health care provider states this is usually a result of: A) An enzyme interfering with DNA sequence B) An environmental chemical exposure C) Small DNA sequence variation D) Ischemia within the cell wall Ans: C Feedback: It is the small DNA sequence variation (1 in every 1000 base pairs) that is thought to account for the individual differences in physical traits, behaviors, and disease susceptibility. Enzyme interference, chemical exposure, and ischemia are not believed to be responsible for these differences.

5. Which genetic disorders (body system) have a high requirement for oxidative metabolism associated with mitochondrial DNA? A) Cardiac dysrhythmias B) Neuromuscular disorders C) Renal abnormalities D) Facial deformities Ans: B Feedback: In addition to nuclear DNA, part of the DNA of a cell resides in the mitochondria.

Mitochondrial DNA (mtDNA) is inherited from the mother by her offspring. Genetic disorders of mitochondrial DNA commonly affect tissues such as those of the neuromuscular system that have a high requirement for oxidative metabolism.

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6. Which of the following statements is true of messenger RNA (mRNA)?

A) mRNA is produced in the nucleolus.

B) mRNA provides the template for protein synthesis.

C) Each mRNA molecule has two recognition sites.

D) mRNA delivers the activated form of an amino acid to the protein being synthesized.

Ans: B Feedback: mRNA is a long molecule containing several hundred to several thousand nucleotides and is the template for the process of protein synthesis. rRNA, not mRNA, is produced in the nucleolus, whereas tRNA has two specific recognition sites and delivers an activated form of an amino acid to a protein being synthesized.

7. When comparing and contrasting the various forms of RNA, the pathophysiology instructor identifies that ribosomal RNA (rRNA) is unique in that it: A) Is produced in the nucleolus B) Delivers activated amino acids C) Is formed by transcription D) Coordinates RNA translation Ans: A Feedback: Ribosomal RNA (rRNA) is produced in the nucleolus and combines with ribosomal proteins in the nucleus to produce the ribosome. Transfer RNA (tRNA) delivers the activated form of amino acids to protein molecules in the ribosome. Messenger RNA (mRNA) is formed by the transcription process. Translation (protein synthesis) requires the coordinated actions of mRNA, tRNA, and rRNA.

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8. A physiology instructor asks the students about the purpose of the promoter region on a DNA strand. Which student response is most accurate?

A) Contains amino acids that the RNA polymerase recognized and binds to, thus starting the replication process B) Location for protein-coding regions of the mRNA sequences C) Delivers activated amino acids to begin mitosis D) Reverses redundant base pairs Ans: A Feedback: During transcription, RNA polymerase recognizes the start sequence of a gene and attaches to the DNA. It is initiated by the assembly of a transcription complex composed of RNA polymerase and other associated factors. This complex binds to the double-stranded DNA at a specific site called the promoter region. Within the promoter region is the so-called “TATA box,” which contains the crucial thymine–adenine– thymine–adenine sequence that RNA polymerase recognizes and binds to, starting the replication process. Exons are RNA sequences retained on the original RNA during splicing. tRNA delivers activated amino acids to proteins in the ribosome. When several triplet codons encode the same amino acid, the genetic code is said to be redundant.

9. Splicing of mRNA during processing permits a cell to: A) Form different proteins B) Increase DNA content C) Stop copying DNA onto RNA D) Add nucleic acid end pieces Ans: A Feedback: Splicing permits a cell to produce a variety of mRNA molecules from a single gene, thus reducing how much DNA must be contained in the genome. Stop codes signal the end of a protein molecule, and RNA strands are then processed. Processing involves addition of certain nucleic acids to the RNA; splicing involves removing segments of RNA.

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10. A genetic test result returns noting that the specimen (client) has inclusion bodies in the sample. The health care provider can associate this result with the development of which pathologic disease process? Select all that apply.

A) Alzheimer disease B) Parkinson disease C) Myasthenia gravis D) Multiple myeloma Ans: A, B Feedback: Disruption of chaperoning mechanisms causes intracellular molecules to become denatured and insoluble. These denatured proteins tend to stick to one another, precipitate, and form inclusion bodies. The development of inclusion bodies is a common pathologic process in Parkinson, Alzheimer, and Huntington diseases.

11. Which of the following would be an example of gene expression? Select all that apply.

A) Control of insulin expression so it gives a signal for blood glucose regulation B) Induction by an external influence to facilitate having a male child C) Increasing the amount of UV light exposure to end up with darker skin D) Activation of growth control genes by injecting growth hormone into a small for age male child Ans: A, C Feedback: The degree to which a gene or particular group of genes is active is called gene expression. A phenomenon termed induction is an important process by which gene expression is increased. Gene repression is a process by which a regulatory gene acts to reduce or prevent gene expression. Activator and repressor sites commonly monitor levels of the synthesized product and regulate gene transcription through a negative feedback mechanism. Whenever product levels decrease, gene transcription is increased, and when product levels increase, gene transcription is repressed. Control of insulin expression so it gives a signal for blood glucose regulation and increases the amount of UV light exposure to end up with darker skin are examples of the negative feedback system.

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12. Identifying the genetic sex of a child is based on finding intracellular Barr bodies that consist of: A) Inactive chromatin material B) Male-specific chromosomes C) Homologous chromosomes D) Excess autosomal material Ans: A Feedback: Barr bodies are present only when there is more than one X in each cell, signifying a female. The extra X is inactivated and stored as chromatin material that can be visualized in epithelial cells. Genetically normal males have one X and one Y chromosome, so a Barr body is not present. Male-specific encoding is on the Y chromosome only. The maternal and paternal chromosomes of a pair are called homologous chromosomes (homologs).

13. Prenatal genetic testing that counts the number of Barr bodies in a chromosome is able to determine: A) The genetic sex of a child B) Susceptibility to hemophilia B C) The presence of fragile X syndrome D) Fetal viability Ans: A Feedback: The genetic sex of a child can be determined by microscopic study of cell or tissue samples because the total number of X chromosomes (which determine sex) is equal to the number of Barr bodies plus one. Genetic testing can reveal the presence of inherited disorders such as fragile X syndrome and hemophilia, but the focus of such testing is not the Barr bodies. Similarly, overall fetal viability is not ascertained from identifying Barr bodies.

14. Crossing-over of chromatid segments during meiosis division 1 results in: A) Spontaneous gene mutations B) Initial DNA synthesis C) Bivalent X and Y genes D) New gene combinations Ans: D Feedback: Crossing-over of chromatid segments allows for new gene combinations and increased genetic variability. It is unrelated to mutations. DNA synthesis occurs only during or after meiosis division 2. Because X and Y chromosomes are not homologs, they do not pair up to form bivalents during meiosis division 1.

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15. When discussing upcoming chromosome studies, a client asks, “What kind of sample are they going to take to do these tests?” The nurse replies, “The most common cells used for this purpose are: A) From lymph nodes from your underarm.”

B) Lymphocytes from a venous blood specimen.”

C) Skin scrapings from your back.”

D) From a bone marrow biopsy.”

Ans: B Feedback: Chromosome studies can be done on any tissue or cell that grows and divides in culture.

Lymphocytes from venous blood are frequently used for this purpose.

16. While lecturing on inheritance patterns, a student asks, “My mother has blue eyes and my father has brown eyes. All my siblings have brown eyes except me. How can this happen?” Which of the following is the most accurate response?

A) Phenotypically, the brown-eyed persons are the same, but genotypically they are different.

B) This is known as penetrance, where a gene has its ability to express its function.

C) Expressivity is when a gene is expressed in the phenotype.

D) Blue sclera is a genetic mutation.

Ans: A Feedback: More than one genotype may have the same phenotype. Some brown-eyed persons carry one copy of the gene that codes for blue eyes, and other brown-eyed persons do not.

Phenotypically, these two types of brown-eyed persons are the same, but genotypically they are different. Expressivity refers to the manner in which the gene is expressed in the phenotype, which can range from mild to severe. Penetrance represents the ability of a gene to express its function. Seventy-five percent penetrance means 75% of persons of a particular genotype present with a recognizable phenotype. Blue sclera is a genetic mutation but not relative in this example.

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17. The gene responsible for a particular congenital cardiac anomaly is said to have complete penetrance. What are the clinical implications of this fact?

A) The anomaly is a result of polygenetic inheritance.

B) The heart defect does not result from any other gene.

C) Multiple alleles contribute to the defect.

D) All the individuals who possess the gene will exhibit the anomaly.

Ans: D Feedback: Penetrance represents the ability of a gene to express its function, with complete, or 100%, penetrance, ensuring that all individuals possessing the gene will experience the phenotype in question. The disorder is not necessarily the result of multiple alleles or polygenetic inheritance, and complete penetrance does not mean that the disorder is a single-gene trait.

18. A pregnant female has been told she is a carrier for fragile X syndrome. She asks, “What does that mean?” The health care provider explains that she is heterozygous for fragile X recessive trait, but this will only be a problem if: A) The expressed pairing becomes homozygous.

B) The expressed pairing switches to a dominant trait.

C) Her mate also is a carrier of the recessive fragile X trait.

D) She does not receive a blood transfusion from a non–fragile X donor prior to pregnancy.

Ans: A Feedback: Offspring in whom the two alleles of a given pair are the same are called homozygotes.

For example, a plant may have two alleles for wrinkled peas. Heterozygotes have different alleles at a gene locus. All offspring with a dominant allele manifest that trait.

In human genetics, a carrier is a person who is heterozygous for a recessive trait and does not manifest the trait. For example, the gene for the genetic disorder cystic fibrosis is recessive. Therefore, only persons with a genotype having two alleles for cystic fibrosis have the disease. In most cases, neither parent manifests the disease; however, both must be carriers. A blood transfusion will not fix the problem.

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19. A child with cystic fibrosis (CF) asks the nurse why he has this disease, but his parents are perfectly healthy. The nurse explains: A) Environmental conditions affect on alleles and therefore who get CF B) Both parents are carriers and have a recessive genotype with alleles for CF. C) One of your parents may have a mild recessive form of CF. D) Both parents have homozygous pairing of two alleles for CF. Ans: B Feedback: Both multifactorial inheritance and polygenic inheritance involve multiple genes at different loci. Multifactorial is different because it involves the effects of the environment on genes also. Unlike Mendel law, multifactorial inheritance and polygenic inheritance are unpredictable. Homozygous pairing of alleles is characteristic of recessive traits. The gene for the genetic disorder cystic fibrosis is recessive. Therefore, only persons with a genotype having two alleles for cystic fibrosis have the disease. In most cases, neither parent manifests the disease; however, both must be carriers.

20. When discussing linkage studies, the instructor mentions that colorblindness is found in a small section of the X chromosome and has been linked to development of which of the following diseases? Select all that apply.

A) Early-onset Alzheimer disease B) Hemophilia A C) Adrenal hyperplasia D) Down syndrome Ans: B, C Feedback: When two inherited traits occur together at a rate greater than would occur by chance alone, they are said to be linked. Color blindness has been linked to classic hemophilia A (i.e., lack of factor VIII) in some pedigrees; hemophilia A has been linked to glucose-6-phosphate dehydrogenase deficiency in others; and color blindness has been linked to glucose-6-phosphate dehydrogenase deficiency in still others. Because the gene for color blindness is found on the X chromosome, all three genes must be found in a small section of the X chromosome. Alzheimer disease and Down syndrome have not been associated with a linkage disorder.

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21. A client diagnosed with a cancer has been prescribed monoclonal antibodies as a treatment option. He asks the health care provider, “What are you talking about? I've never heard of this treatment. Is it experimental?” The health care provider explains somatic cell hybridization to the client by explaining that: A) Researchers inject mice with an antigen from human cancer cells. They then harvest the antibody-producing cells from the mice and individually fuse them with a cancerous cell.

B) Short sequences of base pairs can be synthesized, radioactively labeled, and subsequently used to identify their complementary sequence.

C) The DNA molecule is cut apart using a bacterial enzyme, called a restriction enzyme, that binds to DNA wherever a particular short sequence of base pairs is found and cleaves the molecule at a specific nucleotide site.

D) The restrictive fragments of DNA can often be replicated through insertion into a unicellular organism, such as a bacterium.

Ans: A Feedback: Somatic cell hybridization involves the fusion of human somatic cells with those of a different species (typically, the mouse) to yield a cell containing the chromosomes of both species. Because these hybrid cells are unstable, they begin to lose chromosomes of both species during subsequent cell divisions. In situ hybridization involves the use of specific sequences of DNA or RNA to locate genes that do not express themselves in cell culture. DNA and RNA can be chemically tagged with radioactive or fluorescent markers. Gene mapping that is performed using dosage studies involves measuring enzyme activity. The restrictive fragments of DNA can often be replicated through insertion into a unicellular organism, such as a bacterium. In cloning, the restrictive fragments of DNA can often be replicated through insertion into a unicellular organism, such as a bacterium.

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22. From the following list, which medications have been developed utilizing recombinant DNA technology? Select all that apply.

A) Insulin, for clients with diabetes B) Coumadin, a blood thinner for irregular heartbeats C) Erythropoietin to help the body generate more RBCs D) Tissue plasminogen activator (tPA) to dissolve a clot in the brain E) Zyrtec, for allergies Ans: A, C, D Feedback: Recombinant DNA technology has also made it possible to produce proteins that have therapeutic properties. One of the first products to be produced was human insulin.

More complex proteins are produced in mammalian cell culture using recombinant DNA techniques. These include erythropoietin, which is used to stimulate red blood cell production; factor VIII, which is used to treat hemophilia; and tissue plasminogen activator (tPA), which is frequently administered after a heart attack to dissolve the thrombi that are obstructing coronary blood flow. Coumadin and Zyrtec are not manufactured using recombinant DNA technology.

23. When a client with a kidney transplant develops graft versus host disease, a suicide gene transfer can be accomplished by: A) Giving a blood transfusion from the donor B) Infusion of donor lymphocytes C) Increasing the dose of corticosteroids D) Administering radioactive tracer cells Ans: B Feedback: To date, gene therapy has been used successfully to treat children with severe combined immunodeficiency disease and in a suicide gene transfer to facilitate treatment of graft versus host disease after donor lymphocyte infusion. One of the main approaches to gene therapy is the transferring of genes to replace or selectively inhibit defective ones.

Giving a blood transfusion, increasing the steroid dose, or administering a radioactive tracer will assist in the treatment of graft versus host disease.

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24. Which of the following facts underlies the application of RNA interference in the treatment of disease?

A) Restriction enzymes are able to cleave genetic molecules at predictable sites.

B) It is possible to produce proteins that have therapeutic properties.

C) Faulty gene activity that produces unwanted proteins can sometimes be stopped.

D) Individual differences are attributable to a very small percentage of the genes in the human body.

Ans: C Feedback: RNAi is premised on the fact that several genetic disorders are not due to missing genes, but due to faulty gene activity. RNAi can sometimes be used to stop genes from making unwanted disease proteins. Restriction enzymes underlie gene isolation and cloning. The existence of a haplotype and the ability to produce therapeutic proteins are not central to RNAi.

25. Which of the following is an application of recombinant DNA technology?

A) Production of human insulin B) DNA fingerprinting C) Gene dosage studies D) Somatic cell hybridization Ans: A Feedback: Recombinant DNA technology can be used to direct cells to produce proteins they would not otherwise produce, such as human insulin. DNA fingerprinting does not utilize recombinant DNA technology, whereas gene dosage studies and somatic cell hybridization are genetic mapping methods.

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1. Chapter 6 Genetic disorders that involve a single-gene trait are characterized by: A) Multifactorial gene mutations B) Chromosome rearrangements C) Mendelian patterns of transmission D) Abnormal numbers of chromosomes Ans: C Feedback: Single-gene disorders are characterized by patterns of transmission that follow the Mendelian patterns of inheritance. Multifactorial inheritance involves more than one gene mutation, rearrangement of groups of genes, and uneven numbers of some chromosomes in each cell.

2. In one family, a son was born with polydactyly toes while his sister had polydactyly fingers. In explaining this phenomenon in genetic terms to the parents, which concept should be addressed?

A) Aneuploidy of genes in all cells B) Deficiencies in enzyme synthesis C) Heterozygote dominant trait D) Variable expressivity of a gene Ans: D Feedback: Autosomal dominant disorders are characterized by variable gene penetrance (degree to which the trait is displayed) and expression (differences in how the trait is displayed).

Aneuploidy is not a single-gene disorder and does not follow the Mendelian pattern of inheritance. Deficiencies of enzyme synthesis are common in autosomal recessive disorders. X-linked inheritance can be dominant or recessive, but it is not autosomal.

3. A woman who is a carrier for which of the following diseases possesses the greatest likelihood of passing the disease to her future children when heterozygous pairing exists?

A) Phenylketonuria (PKU) B) Tay-Sachs disease C) Neurofibromatosis D) Cystic fibrosis Ans: C Feedback: Neurofibromatosis is an autosomal dominant genetic disorder with a consequent 50% chance of passing the disease to offspring. Tay-Sachs disease, PKU, and cystic fibrosis are autosomal recessive disorders and are manifested only when both members of the gene pair are affected.

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4. A 16-year-old male presents to the clinic complaining of headaches, trouble hearing the teacher in the front of the classroom, and ringing in the ears. He also revealed that every time he goes swimming underwater, he gets disorientated (which never happened when he was younger). Given these manifestations, the health care provider is going to start testing for: A) Deafness B) Neurofibromas C) Tay-Sachs disease D) Fragile X syndrome Ans: B Feedback: NF-2, which is characterized by tumors of the acoustic nerve and multiple meningiomas, is much less common than NF-1. The disorder is often asymptomatic through the first 15 years of life. The most frequent symptoms are headaches, hearing loss, and tinnitus. Infants with Tay-Sachs disease appear normal at birth but begin to manifest progressive weakness, muscle flaccidity, and decreased attentiveness at approximately 6 to 10 months of age. Fragile X syndrome, an abnormality in the X chromosome, is the common cause of inherited intellectual disability.

5. Which of the following statements is true of autosomal recessive disorders?

A) Onset is typically late in childhood or early in adulthood.

B) Symptomatology is less uniform than with autosomal dominant disorders.

C) Mitochondrial DNA is normally the site of genetic alteration.

D) Effects are typically the result of alterations in enzyme function.

Ans: D Feedback: With autosomal recessive disorders, the age of onset is frequently early in life; the symptomatology tends to be more uniform than with autosomal dominant disorders; and the disorders are characteristically caused by loss-of-function mutations, many of which impair or eliminate the function of an enzyme. Mutations typically occur in nuclear, rather than mitochondrial, DNA.

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6. Following routine newborn testing, an infant has been diagnosed with an elevated phenylalanine level. The nurse teaches the parents to follow a strict low-protein diet to prevent which of the following major complications for the infant?

A) Kidney failure B) Impaired brain development C) Thyroid metabolism errors D) Cardiac valvular disorders Ans: B Feedback: Infants and children with classic and mild PKU require dietary protein restrictions to prevent mental retardation, microcephaly, and other signs of impaired neurologic development. Affected infants are normal at birth but within a few weeks begin to develop a rising phenylalanine level and signs of impaired brain development. Seizures, other neurologic abnormalities, decreased pigmentation of the hair and skin, and eczema often accompany the mental retardation in untreated infants.

7. When a male child inherits an X-linked disorder from his heterozygous carrier mother: A) His sons will be carriers.

B) His father has the disorder.

C) Some of his sisters will be carriers.

D) His daughters will have the disorder.

Ans: C Feedback: A male who has a recessive X-linked disorder will have daughters who are carriers and sons who are unaffected. Male children of a carrier mother have a 50% risk of having the disorder and cannot be carriers. Female children of a carrier mother have a 50% risk of being carriers and are not affected by the disorder.

8. When quizzing obstetrical nursing students regarding tissues affected by mitochondrial DNA mutations, the instructor accepts which of the following responses? Select all that apply.

A) Retinal degeneration B) Deafness C) Cardiac valve abnormalities D) Absent testes E) Palatal abnormalities Ans: A, B Feedback: Mitochondrial DNA mutations generally affect tissues and organs that are highly dependent on oxidative phosphorylation to meet their high needs for metabolic energy.

Thus, mitochondrial diseases frequently affect the brain and neuromuscular system and produce encephalomyopathies, retinal degeneration, loss of extraocular muscle function, lactic acidosis, and deafness.

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9. Which of the following statements about multifactorial inheritance disorders are accurate to share with a family of a child born with a cleft lip and palate? Multifactorial inheritance disorders: Select all that apply.

A) Can be predicted with the same degree of accuracy as Mendelian single-gene mutations B) Usually involve more than a single organ or tissue C) Carry the same risk for recurrence with future pregnancies D) Have an increased risk among first-degree relatives of the affected person E) Carry no additional risk with increasing incidence of the defect among relatives Ans: C, D Feedback: Although multifactorial traits cannot be predicted with the same degree of accuracy as Mendelian single-gene mutations, characteristic patterns exist. First, multifactorial congenital malformations tend to involve a single organ or tissue. Second, the risk of recurrence in future pregnancies is for the same or a similar defect. This means that parents of a child with a cleft palate defect have an increased risk of having another child with a cleft palate. Third, the increased risk (compared with the general population) among first-degree relatives of the affected person is 2% to 7%. The risk increases with increasing incidence of the defect among relatives. This means that the risk is greatly increased when a second child with the defect is born to a couple.

10. The parents of a newborn infant are relieved that their baby was born healthy, with the exception of a cleft lip that will be surgically corrected in 10 or 12 weeks. Which of the nurse's following statements to the parent's best conveys the probable cause of the infant's cleft lip?

A) “Though you are both healthy, you likely both carry the gene for a cleft lip.”

B) “Provided one of you had the gene for a cleft lip, your baby likely faced a 50/50 chance of having one.”

C) “Your child's cleft lip likely results from the interplay between environment and genes.”

D) “A cleft lip can sometimes result from taking prescription drugs, even when they're taken as ordered.”

Ans: C Feedback: A cleft lip is considered to be a multifactorial disorder, in which both environment and genes contribute to the condition. It does not depend solely on Mendelian patterns of inheritance and is not known to result from teratogenic drugs.

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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).

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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.

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16. A teratogenic environmental agent can cause birth defects when: A) Inherited as a recessive trait B) Intense exposure occurs at birth C) Disjunction occurs during meiosis D) Exposed during early pregnancy Ans: D Feedback: Teratogenic environmental agents cause birth defects when the fetus is exposed directly during fetal development. Recessive single-gene disorders are inherited from carriers or affected parents and are not affected by toxic agent exposures. Exposure to teratogenic agents at birth will not cause genetic defects in that infant. Disjunction during first or second meiosis is characteristic of aneuploidy disorders such as trisomy 21, Down syndrome, and is unrelated to maternal environment or in utero exposures.

17. Which of the following variables determine the extent of teratogenic drug effects?

Select all that apply.

A) Maternal health history B) Molecular weight of the drug C) Stage of pregnancy when the drug was taken D) Duration of drug exposure E) Fetal blood type Ans: B, C, D Feedback: The nature and extent of teratogenic effects are the result of numerous factors, including the timing and molecular weight of the drug and the gestational age of the embryo or fetus. Fetal blood type and the health history of the mother are not key variables.

18. Fetal alcohol syndrome (FAS) is unlike other teratogens in that the harmful effects on the fetus: A) Directly result in liver damage B) Extend throughout the pregnancy C) Are most noticeable in adulthood D) Cause death in early childhood Ans: B Feedback: Unlike other teratogenic exposures that cause abnormalities during a short period of time during fetal development (usually in the early weeks), fetal alcohol (FAS) damages the chromosomes of the developing fetus as long as alcohol continues to circulate through the fetal bloodstream. FAS is diagnosed by the presence of three findings that do not include liver abnormalities and are not life threatening. Facial features characteristic of FAS are most noticeable during childhood.

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19. A woman who has just learned that she is pregnant for the first time has sought advice from her health care provider about the safe use of alcohol during pregnancy. What advice should the clinician provide to the woman?

A) “It's likely best to eliminate alcohol from your diet while you're pregnant.”

B) “Moderation in alcohol use is critical while you are pregnant.”

C) “You should limit yourself to a maximum of one drink daily while you're pregnant.”

D) “You should drink no alcohol until you are in your second trimester.”

Ans: A Feedback: Safe intake levels of alcohol during pregnancy are unknown. Even small amounts of alcohol consumed during critical periods of fetal development may be teratogenic. As a result, it is best for pregnant women to forego alcohol use throughout pregnancy.

20. A newly pregnant female is worried about her baby. She recently returned from a mission trip to Africa. She was told there was a rubella outbreak in the next village. She has been given a TORCH screening test. If she has exposed her fetus to rubella, the nurse would expect the infant to display which of the following possible birth defects?

A) Blindness B) Missing limbs C) Hydrocephalus D) Encephalitis Ans: A Feedback: The acronym TORCH stands for toxoplasmosis, other, rubella (i.e., German measles), cytomegalovirus, and herpes, which are the agents most frequently implicated in fetal anomalies. The TORCH screening test examines the infant's serum for the presence of antibodies to these agents. Although rubella has virtually been eliminated, it remains endemic in many developing countries, where it is the major preventable cause of hearing impairment, blindness, and adverse neurodevelopmental outcome.

21. Which of the following meals would be considered high in folic acid intake?

A) Deep-fried mushrooms with creamy horseradish sauce, hot dogs without bun, and potato salad B) Fried chicken, mashed potatoes with gravy, and corn on the cob C) Green leafy salad, beef and bean burrito on whole-wheat shell D) Steak, baked potato with sour cream, and cheesecake Ans: C Feedback: To achieve an adequate intake of folic acid, pregnant women should couple a diet that contains folate-rich foods (e.g., orange juice; dark, leafy green vegetables; and legumes) with sources of synthetic folic acid, such as fortified food products.

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22. A first-time pregnant mother asks, “Why do I need an ultrasound? I'm worried that my insurance won't cover it.” The nurse responds that an ultrasonography can diagnose prenatal abnormalities like which of the following? Select all that apply.

A) Cytogenic abnormalities B) Skeletal defects like facial structural problems C) Chromosomal deficits D) Abnormal levels of -fetoprotein E) Congenital heart defects Ans: B, E Feedback: Ultrasonography is the primary method for assessing fetal size and screen for structural abnormalities that include the heart, skeleton, face, diaphragm, and gastrointestinal tract.

Cytogenic studies and chromosomal analysis require amniocentesis, chorionic villus sampling, or umbilical cord blood. -Fetoprotein (AFP) requires a maternal blood sample that is analyzed for serum markers associated with neural tube defects.

23. A pregnant client's -fetoprotein (AFP) returns elevated. The couple ask the health care worker to explain what this means. Which of the following is the best response?

A) “This means you need to decrease your protein intake to prevent renal problems in your baby.”

B) “Elevated levels means your baby is at risk of having a neural tube defect like spina bifida (an opening in the spine).”

C) “This means your baby has Down syndrome. We won't know how severe until after you give birth.”

D) “This is normal. The problem is if it is low, that means your baby will be born with trisomy 18 and will be retarded.”

Ans: B Feedback: Maternal and amniotic fluid levels of AFP are elevated in pregnancies where the fetus has a neural tube defect (i.e., anencephaly and open spina bifida) or certain other malformations such as an anterior abdominal wall defect in which the fetal integument is not intact. Screening of maternal blood samples usually is done between weeks 16 and 18 of gestation. Although neural tube defects have been associated with elevated levels of AFP, decreased levels have been associated with Down syndrome.

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24. An older mother (age 41) is worried about having a baby with birth defects. She wants to get tested so she can be prepared for the outcome. Which of the following tests should the clinic nurse prepare the client for? Select all that apply.

A) A blood test (circulating cell-free DNA) will tell if the baby is mentally retarded.

B) Abdominal x-ray can detect skeletal abnormalities.

C) Withdrawing a sample of amniotic fluid will reveal any chromosomal defects.

D) Ultrasonography will reveal any single-gene disorders like fragile X syndrome.

E) PET scanning to see if there are any areas of accelerated growth of tissue.

Ans: A, C Feedback: During pregnancy, there are cf-DNA fragments from both the mother and fetus in maternal circulation. It is possible to analyze cf-DNA from maternal blood to detect common fetal trisomies such as Down syndrome as early as 10 weeks. Amniocentesis involves the withdrawal of a sample of amniotic fluid from the pregnant uterus. The procedure is useful in women older than 35 years of age, who have an increased risk of giving birth to an infant with Down syndrome, and in parents who have another child with chromosomal abnormalities. Ultrasonography allows the visualization of body structures, revealing such defects as skeletal malformations. It is only able to identify chromosomal disorders, genetic disorders, and neural tube defects by way of their anatomic effects. PET scanning is used to assess for cancer metastasis or inflammatory diseases. It is not used in pregnancy testing.

25. A pregnant mother (16 weeks' gestation) forgot and emptied her cat's litter box without gloves. She is extremely anxious and wants tested right away. Which test would the nurse prepare her for that would give rapid cytogenic analysis?

A) Ultrasonography B) Fetal biopsy C) Chorionic villus sampling D) Percutaneous umbilical cord blood sampling Ans: D Feedback: Percutaneous umbilical cord blood sampling involves the transcutaneous insertion of a needle through the uterine wall and into the umbilical artery. It is used for prenatal diagnosis of hemoglobinopathies, coagulation disorders, metabolic and cytogenetic disorders, and immunodeficiencies. Fetal infections such as rubella and toxoplasmosis can be detected through measurement of immunoglobulin M antibodies or direct blood cultures. Results from cytogenetic studies usually are available within 48 to 72 hours.

Fetal biopsy is used to detect certain genetic skin defects that cannot be diagnosed with DNA analysis. The tissue that is obtained following sampling of the chorionic villi can be used for fetal chromosome studies, DNA analysis, and biochemical studies.

Ultrasonography makes possible the in utero diagnosis of hydrocephalus, spina bifida, facial defects, congenital heart defects, congenital diaphragmatic hernias, disorders of the gastrointestinal tract, and skeletal anomalies. Cardiovascular abnormalities are the most commonly missed malformation.

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1. Chapter 7 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.

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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.

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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.

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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.

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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. Genetic screening may be indicated for individuals who have a family history of which of the following neoplasms?

A) Liver cancer B) Multiple myeloma C) Leukemia D) Breast cancer Ans: D Feedback: The hereditary component of cancer is well identified, although it is implicated in varying degrees in different types of cancer. Breast cancer has an identified genetic component, and screening is often recommended for women with a family history of breast cancer.

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12. A public health nurse has cited a reduction in cancer risk among the many benefits of maintaining a healthy body mass index. Which of the following facts underlies the relationship between obesity and cancer?

A) Obesity can cause inflammation and hormonal changes that are associated with cancer.

B) Adipose tissue is more susceptible to malignancy than other types of connective tissue.

C) Increased cardiac workload and tissue hypoxia can interfere with normal cell differentiation.

D) Increased numbers of body cells increase the statistical chances of neoplastic cell changes.

Ans: A Feedback: Obesity has a complex interplay with the development of cancer that is thought to result from the influence of hormonal changes and inflammation. It is not thought to be due to the increased number of cells in the body or to any particular susceptibility of adipose tissue. Increased cardiac workload and hypoxia are not known to cause neoplastic changes.

13. Which of the following dietary guidelines should a nurse provide to a group of older adults to possibly decrease their risks of developing colon cancer?

A) “As much as possible, try to eat organic foods.”

B) “Regular vitamin supplements and a low-carbohydrate diet are beneficial.”

C) “Try to minimize fat and maximize fiber when you're planning your meals.”

D) “Eat enough fiber in your diet that you have bowel movement at least once daily.”

Ans: C Feedback: A low-fat, high-fiber diet is thought to provide some protection from colon cancer.

Organic foods, vitamin supplements, and avoidance of large amounts of complex carbohydrates may be components of a healthy diet, but their relationship to the risk of colon cancer is not noted.

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14. A 40-year-old female has been diagnosed with hepatocellular carcinoma. When asked what causes this cancer, the physician looks at the history and responds, “I see in your history, you have had: A) Hepatitis B related to IV drug use as a teenager.”

B) Numerous admissions for COPD exacerbations requiring steroids.”

C) Three miscarriages with no live births.”

D) Your uterus and ovaries removed for endometriosis.”

Ans: A Feedback: There is strong epidemiologic evidence linking chronic HBV and hepatitis C virus (HCV) infection with hepatocellular carcinoma. It has been estimated that 70% to 85% of hepatocellular cancers worldwide are due to infection with HBV or HCV. COPD, steroidal use, miscarriages, or endometriosis is not associated as a risk factor for hepatocellular carcinoma.

15. A male client with a diagnosis of liver cancer has been recently admitted to a palliative care unit following his recent development of bone metastases. His family shares with the nurse that even though he is usually a “big eater,” he just isn't interested in food.

This has resulted in a loss of muscle mass. Which of the following factors may underlie the client's change in nutritional status?

A) The action of cytokines and persistent inflammation B) Loss of appetite due to fatigue and pain C) Changes in peptide hormone levels D) Production of onconeural antigens by cancerous cells Ans: A Feedback: Cancer anorexia–cachexia syndrome is thought to result from a persistent inflammatory response in conjunction with production of specific cytokines and catabolic factors by the tumor. The weight loss often supersedes the effects of fatigue and reduced food intake. The production of onconeural antigens and changes in peptide hormone levels occur in some clients with cancer, but these pathophysiologic processes do not contribute directly to cancer anorexia–cachexia syndrome.

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16. Although clinical manifestations vary with the type of cancer and organs involved, the oncology nurses have observed that the most frequent side effects clients with cancer experience are: Select all that apply.

A) Copious lymph flow B) Sleep disturbances C) Involuntary weight gain D) Visceral organ expansion E) Lack of energy Ans: B, E Feedback: Neoplasia is nearly always accompanied by sleep disturbances and fatigue.

Cancer-related fatigue is characterized by feelings of tiredness, weakness, and lack of energy and is distinct from the normal tiredness experienced by healthy individuals in that it is not relieved by rest or sleep. Tissue growth often compresses and obstructs lymph flow and compresses visceral organs and adjacent structures. The cachexia of cancer is associated with unplanned rapid weight loss and wasting of body fat as tumor growth demands more caloric energy than the body can supply.

17. Paraneoplastic syndromes are manifestations of cancer that often result from: A) Radiation and chemotherapy B) Compression of area vessels C) Tumor-related tissue necrosis D) Inappropriate hormone release Ans: D Feedback: Paraneoplastic syndromes are manifestations in sites that are not directly affected by the disease; many are caused by excessive or inappropriate peptide hormone synthesis and release by cancer cells. Radiation and chemotherapy are cancer treatments that cause side effects unrelated to the paraneoplastic syndromes. Area vessel compression is a direct result of the tumor's location; area tissue necrosis is a direct result of area tissue destruction and death of healthy cells.

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18. A client with nonspecific signs/symptoms has gone to the primary health care provider.

The client's chief complaints revolve around extreme fatigue, unplanned weight loss, and being so weak in the muscles. The diagnostic workup included a carcinoembryonic antigen (CEA) tumor marker. The CEA result was elevated. The nurse should anticipate the physician will order which of the following diagnostic tests related to the elevated CEA? Select all that apply.

A) Testicular ultrasound B) Colonoscopy C) Mammogram D) Thyroid scan E) Brain CT Ans: B, C Feedback: CEA normally is produced by embryonic tissue in the gut, pancreas, and liver and is elaborated by a number of different cancers, including colorectal carcinomas, pancreatic cancers, and gastric and breast tumors.

19. A client is scheduled for a bronchoscopy related to a history of “bronchitis” for the last 3 months that has been unresponsive to antibiotics. The nurse shares with the client that a primary purpose for this bronchoscopy is to help diagnose the problem by: A) Visualizing airways looking for adhesions B) Opening airways looking for any aspirated food C) Flushing out the airway to remove debris and sputum D) Taking tissue biopsy and looking for abnormal cells Ans: D Feedback: Tissue biopsy involves the removal of a tissue specimen for microscopic study. It is of critical importance in designing the treatment plan should cancer cells be found.

Biopsies are obtained in a number of ways, including needle biopsy; endoscopic methods, such as bronchoscopy or cystoscopy, which involve the passage of an endoscope through an orifice and into the involved structure; and laparoscopic methods.

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20. A breast cancer client has just learned that her tumor clinical stage is T3, N2, M0. After the physician leaves, the client asks the nurse to explain this to her again. The nurse will use which of the following statements in his or her answer? Your: A) Tumor is very small and has zero number of mitoses.

B) Tumor has metastasized to at least three distal sites and you have cancer in your lymph nodes.

C) Tumor is large and at least two lymph nodes are positive for cancer cells.

D) Extent of disease is unknown, but it looks like your cancer has stayed intact and not spread to the bloodstream.

Ans: C Feedback: Tumor staging groups clients according to the extent and spread of the disease, using the TNM (tumor, node, and metastasis) system. In the TNM system, T1, T2, T3, and T4 describe tumor size, N0, N1, N2, and N3, lymph node involvement; and M0 or M1, the absence or presence of metastasis.

21. Which of the following subjective/objective findings can be considered an adverse effect to the radiation treatment the client is undergoing to “shrink” a tumor prior to surgery? Select all that apply.

A) Urine output less than 30 mL/hr (low) B) Increase production of nasal secretions C) Stiff, painful joints in the AM D) Hemoglobin 9.0 g/dL (low)] E) Complains of frequent nausea and vomiting Ans: D, E Feedback: To some extent, radiation is injurious to all rapidly proliferating cells, including those of the bone marrow and the mucosal lining of the gastrointestinal tract. This results in many of the common adverse effects of radiation therapy, including infection, bleeding, and anemia due to loss of blood cells and nausea and vomiting due to loss of gastrointestinal cells.

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22. A 51-year-old client has been diagnosed with stage IV breast cancer with lung metastases. The oncologist sits down with the client/family to explain treatment options.

The nurse knows that which of the following treatment options will be discussed for her cancers?

A) Radiation therapy B) Chemotherapy C) Surgery D) Hormone therapy Ans: B Feedback: One of the advantages of chemotherapy is that, unlike surgery and radiation, it is able to treat cancer both at the primary site and at sites of metastasis. Hormone therapy is also able to exert therapeutic effects at a more systemic level, but to a lesser degree than chemotherapy.

23. A client's oncologist has presented the possibility of implementing biotherapy in the treatment of the client's brain tumor. Which of the following mechanisms of action provide the therapeutic effects of biotherapy? Select all that apply.

A) Stimulating the immune response to tumor cells B) Inhibiting tumor protein synthesis C) Reversing angiogenesis D) Altering the hormonal environment of tumor cells E) Causing breaks in the DNA of tumor cells Ans: A, B Feedback: Biotherapy exerts therapeutic effects by way of altering host responses (such as by stimulating the immune response) or by inhibiting tumor cell biology (e.g., inhibiting protein synthesis). Biotherapy does not reverse existing angiogenesis, and the hormonal environment is not a particular focus of biotherapy. Radiation is the primary means by which breaks in tumor DNA are made.

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24. A 2-year-old child has been diagnosed with neuroblastoma. The tumor is extremely large. Parents ask how this cancer could be so extensive, yet the child has not displayed many symptoms until this past week. Nurses explain that early diagnosis of childhood cancers is often difficult because the signs and symptoms are: A) Already present at birth B) Absent until the late stage C) Similar to those of other childhood diseases D) Seen as developmental delays Ans: C Feedback: Early diagnosis is missed in childhood cancers because the signs and symptoms are similar to those of other childhood diseases. Multiple chromosomal mutations can cause some of the early childhood cancers, with signs and symptoms similar to other childhood diseases. Signs and symptoms are present even in the early stages of cancer.

Childhood growth delays (rather than developmental delays) are associated with cancers and other diseases.

25. A 5-year-old girl's diagnosis of bone cancer required an aggressive treatment regimen.

The client immediately receives doxorubicin chemotherapy. The nurse administering this medication should perform a detailed assessment of which body system that has been greatly affected by this drug?

A) CNS B) Renal C) Cardiac D) Respiratory Ans: C Feedback: There are numerous, multisystemic sequelae of chemotherapy and radiation that are required in childhood. Vital organs such as the heart and lungs may be affected by cancer treatment. Children who received anthracyclines (i.e., doxorubicin or daunorubicin) may be at risk for developing cardiomyopathy and congestive heart failure.

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1. Chapter 8 A client develops interstitial edema as a result of decreased: A) Vascular volume B) Hydrostatic pressure C) Capillary permeability D) Colloidal osmotic pressure Ans: D Feedback: Edema can be defined as palpable swelling produced by an increased interstitial fluid volume. The physiologic mechanisms that contribute to edema formation include factors that (1) increase capillary filtration (hydrostatic) pressure, (2) decrease the capillary colloid osmotic pressure, (3) increase capillary permeability, or (4) produce obstruction to lymph flow.

2. A client has been receiving intravenous normal saline at a rate of 125 mL/hour since her surgery 2 days earlier. As a result, she has developed an increase in vascular volume and edema. Which of the following phenomena accounts for this client's edema?

A) Obstruction of lymph flow B) Increased capillary permeability C) Decreased capillary colloidal osmotic pressure D) Increased capillary filtration pressure Ans: D Feedback: An increase in vascular volume results in an increase in capillary filtration pressure.

Consequently, movement of vascular fluid into the interstitial spaces increases and edema ensues. An increase in vascular volume does not directly result in obstruction of lymph flow, increased capillary permeability, or decreased capillary colloidal osmotic pressure.

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3. The most reliable method for measuring body water or fluid volume increase is by assessing: A) Tissue turgor B) Intake and output C) Body weight change D) Serum sodium levels Ans: C Feedback: Daily weights are a reliable index of water volume gain (1 L of water weighs 2.2 pounds). Daily weight measurements taken at the same time each day with the same amount of clothing provide a useful index of water gain due to edema. When an unbalanced distribution of body water exists in the tissues and organs, assessment of surface skin tissue turgor will be inaccurate. Measurement of renal output is unreliable because fluid retention may be a compensatory response, or the renal system may be dysfunctional. Serum sodium levels are affected by multiple variables other than body water volume.

4. A client with a diagnosis of liver cirrhosis secondary to alcohol abuse has a distended abdomen as a result of fluid accumulation in his peritoneal cavity (ascites). Which of the following pathophysiologic processes contributes to this third spacing?

A) Abnormal increase in transcellular fluid volume B) Increased capillary colloidal osmotic pressure C) Polydipsia D) Impaired hormonal control of fluid volume Ans: A Feedback: Third spacing represents the loss or trapping of extracellular fluid (ECF) in the transcellular space and a consequent increase in transcellular fluid volume. The serous cavities are part of the transcellular compartment located in strategic body areas where there is continual movement of body structures—the pericardial sac, the peritoneal cavity, and the pleural cavity. Polydipsia and increased fluid intake alone are insufficient to cause third spacing, and increased capillary colloidal osmotic pressure would result in increased intracellular fluid (ICF). The etiology of third spacing does not normally include alterations in hormonal control of fluid balance.

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5. A 2-week-old infant (full-term at birth) is admitted to the pediatrics unit with “spitting up large amounts of formula” and diarrhea. The infant has developed a weak suck reflex. Which of the following statements about total body water (TBW) is accurate in this situation?

A) About 52% of the infants' weight accounts for the amount of water in their body.

B) Because of the infants' higher fat ratio, one should anticipate an increased TBW to as high as 90%.

C) Most full-term infants have a TBW of approximately 75% due to their high metabolic rate.

D) Most of an infant's TBW remains in the ICF compartment, so they should be able to transfer needed water into the ECF space.

Ans: C Feedback: Infants normally have more TBW than older children or adults. TBW constitutes approximately 75% to 80% of body weight in full-term infants and an even greater percentage in premature infants. In males, the TBW decreases in the elderly population to approximately 52% TBW. Obesity decreases TBW, with levels as low as 30% to 40% of body weight in adults. Infants have more than half of their TBW in their ECF compartment, as compared to adults.

6. A client diagnosed with schizophrenia has been admitted to the emergency department (ED) after ingesting more than 2 gallons of water in one sitting. Which of the following pathophysiologic processes may result from the sudden water gain?

A) Hypernatremia B) Water movement from the extracellular to the intracellular compartment C) Syndrome of inappropriate secretion of ADH (SIADH) D) Isotonic fluid excess in the extracellular fluid compartment Ans: B Feedback: Excess water ingestion coupled with impaired water excretion (or rapid ingestion at a rate that exceeds renal excretion) in persons with psychogenic polydipsia can lead to water intoxication (hyponatremia). A disproportionate gain of water with no accompanying gain in sodium results in the movement of water from the extracellular to the intracellular compartment. Hyponatremia accompanies this process. Because of the lack of sodium increase, accumulated fluid is hypotonic, not isotonic. SIADH is not a consequence of excess water intake.

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7. A nurse caring for a client with a diagnosis of diabetes insipidus (DI) should prioritize the close monitoring of which of the following electrolyte levels?

A) Potassium B) Sodium C) Magnesium D) Calcium Ans: B Feedback: The high water intake and high urine output that characterize diabetes insipidus create a risk of sodium imbalance. DI may present with hypernatremia and dehydration, especially in persons without free access to water, or with damage to the hypothalamic thirst center and altered thirst sensation.

8. The syndrome of inappropriate antidiuretic hormone (SIADH) is characterized by: A) Increased osmolality level of 360 mOsm/kg B) Excessive thirst with fluid intake of 7000 mL/day C) Copious dilute urination with output of 5000 mL/day D) Low serum sodium level of 122 mEq/L Ans: D Feedback: SIADH results from a failure of the negative feedback system that regulates the release and inhibition of antidiuretic hormone (ADH). ADH secretion continues even when serum osmolality is decreased, causing water retention and dilutional hyponatremia.

Diabetes insipidus, deficiency or decreased response to ADH, is characterized by increased serum osmolality, excessive thirst, and polyuria. Urine output decreases in SIADH despite adequate or increased fluid intake.

9. In isotonic fluid volume deficit, changes in total body water are accompanied by: A) Intravascular hypotonicity B) Increased intravascular water C) Increases in intracellular sodium D) Proportionate losses of sodium Ans: D Feedback: Isotonic fluid volume deficit causes a proportionate loss of sodium and water.

Hypotonicity results from water retention or sodium loss. Increased intravascular water causes sodium to move into the cell excessively.

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10. A client with a history of heart and kidney failure is brought to the emergency department. Upon assessment/diagnosis, it is determined the client is in decompensated heart failure. Of the following assessment findings, which are associated with excess intracellular water? Select all that apply.

A) Lethargy B) Confusion C) Hyperactive deep tendon reflexes D) Seizures E) Firm, rubbery tissue when palpating lower extremities Ans: A, B, D Feedback: Hyponatremia is usually defined as a serum sodium concentration of less than 135 mEq/L. Muscle cramps, weakness, and fatigue reflect the effects of hyponatremia on skeletal muscle function and are often early signs of hyponatremia. The cells of the brain and nervous system are the most seriously affected by increases in intracellular water. Symptoms include apathy, lethargy, and headache, which can progress to disorientation, confusion, gross motor weakness, and depression of deep tendon reflexes. Seizures and coma occur when serum sodium levels reach extremely low levels. Hypovolemia, third spacing (maldistribution of body fluid), and dehydration are associated with hypernatremia and/or hypertonicity.

11. Which of the following assessments should be prioritized in the care of a client who is being treated for a serum potassium level of 2.7 mEq/L? A) Detailed fluid balance monitoring checking for pitting edema B) Arterial blood gases looking for respiratory alkalosis C) Cardiac monitoring looking for prolonged PR interval and flattening of the T wave D) Monitoring of hemoglobin levels and oxygen saturation Ans: C Feedback: The most serious effects of hypokalemia are on the heart, a fact that necessitates frequent electrocardiography or cardiac telemetry. Hypokalemia produces a decrease in the resting membrane potential, causing prolongation of the PR interval. It also prolongs the rate of ventricular repolarization, causing depression of the ST segment, flattening of the T wave, and appearance of a prominent U wave. This supersedes the importance of fluid balance monitoring, arterial blood gases, oxygen saturation, or hemoglobin levels.

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12. Of the following clients, which would be at highest risk for developing hyperkalemia?

A) A male admitted for acute renal failure following a drug overdose B) A client diagnosed with an ischemic stroke with multiple sensory and motor deficits C) An elderly client experiencing severe vomiting and diarrhea as a result of influenza D) A postsurgical client whose thyroidectomy resulted in the loss of some of the parathyroid glands Ans: A Feedback: There are three main causes of hyperkalemia: (1) decreased renal elimination; (2) a shift in potassium from the ICF to ECF compartment; and (3) excessively rapid rate of administration. The most common cause of serum potassium excess is decreased renal function. Stroke does not typically have a direct influence on potassium levels, whereas vomiting and diarrhea can precipitate hypokalemia. Loss of the parathyroid influences calcium, not potassium, levels.

13. A heart failure client has gotten confused and took too many of his “water pills” (diuretics). On admission, his serum potassium level was 2.6 mEq/L. Of the following assessments, which correlate to this hypokalemia finding? Select all that apply.

A) Polyuria B) Constipation C) Bradycardia D) Paresthesia with numbness of the lips/mouth E) ECG showing short runs of ventricular fibrillation Ans: A, B, D Feedback: The manifestations of hypokalemia include alterations in neuromuscular, gastrointestinal, renal, and cardiovascular function. There are numerous signs and symptoms associated with gastrointestinal function, including anorexia, nausea, and vomiting. Atony of the gastrointestinal smooth muscle can cause constipation, abdominal distention, and, in severe hypokalemia, paralytic ileus. Urine output and plasma osmolality are increased; urine specific gravity is decreased; and complaints of polyuria, nocturia, and thirst are common. The most serious effects of hypokalemia are on the heart. The first symptom associated with hyperkalemia typically is paresthesia (a feeling of numbness and tingling). Hyperkalemia results in prolongation of the PR interval; widening of the QRS complex with no change in its configuration; and decreased amplitude, widening, and eventual disappearance of the P wave. The heart rate may be slow. Ventricular fibrillation and cardiac arrest are terminal events.

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14. A client has been admitted for deterioration of her renal function due to chronic renal failure. Her admission K+ level is 7.8 mEq/L. The nurse would expect to see which of the following abnormalities on her telemetry (ECG) strip? Select all that apply.

A) Tachycardia (fast rate) with frequent early ventricular beats (PVCs) B) Prolonged PR interval with widening of the QRS complex C) Ventricular fibrillation D) Atrial flutter with a 2:1 conduction ratio Ans: B, C Feedback: Hyperkalemia decreases membrane excitability, producing a delay in atrial and ventricular depolarization, and it increases the rate of ventricular repolarization. If serum K+ levels continue to rise (above 6 mEq/L), there is a prolongation of the PR interval; widening of the QRS complex with no change in its configuration; and decreased amplitude and widening and eventual disappearance of the P wave. The heart rate may be slow. Ventricular fibrillation and cardiac arrest are terminal events.

15. Hypoparathyroidism causes hypocalcemia by: A) Increasing serum magnesium B) Increasing phosphate excretion C) Blocking release of calcium from bone D) Blocking action of intestinal vitamin D Ans: C Feedback: The most common causes of hypocalcemia are abnormal losses of calcium by the kidney, impaired ability to mobilize calcium from bone due to hypoparathyroidism, and increased protein binding or chelation such that greater proportions of calcium are in the nonionized form. Magnesium deficiency inhibits PTH release and impairs PTH action on bone resorption. Phosphate and calcium are inversely related, and PTH does not control phosphate excretion. PTH does not exert control of vitamin D action in the intestine, but elevated vitamin D levels can suppress PTH release.

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16. A female client with a history of chronic renal failure has a total serum calcium level of 7.9 mg/dL. While performing an assessment, the nurse should focus on which of the following clinical manifestations associated with this calcium level?

A) Complaints of shortness of breath on exertion with decreased oxygen saturation levels B) Difficulty arousing the client and noticing she is disoriented to time and place C) Heart rate of 120 beats/minute associated with diaphoresis (sweaty) D) Intermittent muscle spasms and complaints of numbness around her mouth Ans: D Feedback: Spasms and numbness are characteristic of hypocalcemia. Respiratory effects, tachycardia, and diaphoresis are not associated with low calcium levels, whereas decreased level of consciousness can be indicative of hypercalcemia.

17. An elderly client is admitted with elevated magnesium level related to a history of renal insufficiency and excess use of antacids and laxatives containing magnesium. On admission assessment, the nurse notes which clinical manifestations that correlate to hypermagnesemia? Select all that apply.

A) Hyporeflexia B) Blood pressure 180/90 C) Tetanic muscle contractions D) Muscle weakness causing shallow breathing E) Paresthesia of the lips Ans: A, D Feedback: The signs and symptoms occur only when serum magnesium levels exceed 4.0 mg/dL. Hypermagnesemia affects neuromuscular and cardiovascular function. Increased levels of magnesium cause hyporeflexia and muscle weakness. Blood pressure is decreased, and the ECG shows an increase in the PR interval, a shortening of the QT interval, T-wave abnormalities, and prolongation of the QRS and PR intervals. Severe hypermagnesemia is associated with muscle and respiratory paralysis, complete heart block, and cardiac arrest. Signs of magnesium deficiency are not usually apparent until the serum magnesium is less than 1.0 mEq/L. Hypomagnesemia is characterized by an increase in neuromuscular excitability as evidenced by hyperactive deep tendon reflexes, paresthesias (i.e., numbness, pricking, tingling sensation), muscle fasciculations, and tetanic muscle contractions.

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18. Magnesium is important for the overall function of the body because of its direct role in: A) Cell membrane permeability B) Somatic cell growth control C) Sodium and tonicity regulation D) DNA replication and transcription Ans: D Feedback: Magnesium is essential to all reactions that require ATP, for every step related to replication and transcription of DNA, and for translation of messenger RNA. Magnesium does not have a direct role in controlling the growth of cells, extracellular tonicity and sodium balance, or permeability of the cell surface.

19. Which of the following scenarios place the client at a high risk for developing hypoparathyroidism and require close supervision for assessing for development of muscle cramps, carpopedal spasm, convulsions, and paresthesia in the hands and feet?

Select all that apply.

A) A neck cancer client returning from OR after having a radical neck dissection B) A hyperthyroid client experiencing a “thyroid storm” requiring urgent thyroidectomy C) A client with seizure experiencing some anoxic deficits and memory loss D) A client with a history of human papillomavirus (HPV) in the uvula Ans: A, B Feedback: Hypoparathyroidism reflects deficient PTH secretion, resulting in low serum levels of ionized calcium. PTH deficiency may occur because of a congenital absence of all of the parathyroid glands or because of an acquired disorder due to inadvertent removal or irreversible damage to the glands during thyroidectomy, parathyroidectomy, or radical neck dissection for cancer. Seizures or history of HPV is not associated with this disorder.

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20. As other mechanisms prepare to respond to a pH imbalance, immediate buffering is a result of increased: A) Intracellular albumin B) Hydrogen/potassium binding C) Sodium/phosphate anion absorption D) Bicarbonate/carbonic acid regulation Ans: D Feedback: The bicarbonate buffering system, which is the principal ECF buffer, uses H 2CO3 as its weak acid and bicarbonate salt such as sodium bicarbonate (NaHCO3) as its weak base.

It substitutes the weak H2CO3 for a strong acid such as hydrochloric acid or the weak bicarbonate base for a strong base such as sodium hydroxide. The bicarbonate buffering system is a particularly efficient system because its components can be readily added or removed from the body. Hydrogen and potassium exchange freely across the cell membrane to regulate acid–base balance. Sodium is not part of the buffering system.

Intracellular protein is part of the body protein buffer system; albumin is extracellular.

21. Arterial blood gases of a client with a diagnosis of acute renal failure reveal a pH of 7.25, HCO3– level of 21 mEq/L, and decreased PCO2 level accompanied by a respiratory rate of 32. This client is most likely experiencing which disorder of acid–base balance?

A) Metabolic acidosis B) Metabolic alkalosis C) Respiratory acidosis D) Respiratory alkalosis Ans: A Feedback: Metabolic acidosis involves a decreased serum HCO3– concentration along with a decrease in pH. In metabolic acidosis, the body compensates for the decrease in pH by increasing the respiratory rate in an effort to decrease PCO 2 and H2CO3 levels.

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22. A client is brought to the emergency department semicomatose and a blood glucose reading of 673. He is diagnosed with diabetic ketoacidosis (DKA). Blood gas results are as follows: serum pH 7.29 and HCO3– level 19 mEq/dL; PCO2 level 32 mm Hg. The nurse should anticipate that which of the following orders may correct this diabetic ketosis?

A) Administration of potassium chloride B) Initiating an insulin IV infusion along with fluid replacement C) Administering supplemental oxygen and rebreathing from a paper bag D) Instituting a cough and deep breathing schedule for every hour while awake to improve ventilation Ans: B Feedback: The treatment of metabolic acidosis focuses on correcting the condition that is causing the disorder and restoring the fluids and electrolytes that have been lost from the body.

For example, insulin administration and fluid replacement are frequently sufficient to correct a low pH in persons with diabetic ketosis. Administration of potassium chloride is used as a treatment of metabolic alkalosis. Administering supplemental oxygen and rebreathing from a paper bag are usual treatment of respiratory alkalosis. Instituting a cough and deep breathing schedule for every hour while awake to improve ventilation is usual treatment of respiratory acidosis.

23. A 77-year-old woman has been brought to the emergency department by her daughter because of a sudden and unprecedented onset of confusion. The client admits to ingesting large amounts of baking soda this morning to treat some “indigestion.” How will the woman's body attempt to resolve this disruption in acid–base balance?

A) Increase the depth of inspiration B) Increasing renal H+ excretion C) Increased renal HCO3– reabsorption D) Hypoventilation Ans: D Feedback: When neurologic manifestations occur with metabolic alkalosis, they include mental confusion, hyperactive reflexes, tetany, and carpopedal spasm. Respiratory compensation will take place in an effort to counteract the client's metabolic alkalosis.

This will involve hypoventilation. In addition, her kidneys are likely to decrease H + excretion and HCO3– reabsorption.

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24. A client has received too much morphine (narcotic) in the postsurgical recovery room.

Blood gas results reveal the patient has developed respiratory acidosis. Which of the following assessment findings correlate with acute primary respiratory acidosis? Select all that apply.

A) Irritability B) Tingling/numbness in the fingers and toes C) Muscle twitching D) Respiratory depression E) Cardiac palpitations Ans: A, C, D Feedback: The signs and symptoms of respiratory acidosis depend on the rapidity of onset and whether the condition is acute or chronic. Elevated levels of CO2 produce vasodilation of cerebral blood vessels, causing headache, blurred vision, irritability, muscle twitching, and psychological disturbances. If severe and prolonged, it can cause an increase in CSF pressure and papilledema. Impaired consciousness, ranging from lethargy to coma, develops as the PCO2 rises to extreme levels. Paralysis of extremities may occur, and there may be respiratory depression. Respiratory alkalosis is associated with light-headedness, dizziness, tingling, and numbness of the fingers and toes. These manifestations may be accompanied by sweating, palpitations, panic, air hunger, and dyspnea.

25. A very ill client has been admitted to the hospital for testing for possible septic shock.

The client reports light-headedness, dizziness, and tingling/numbness of the fingers and toes. The nurse understands that this is likely due to which physiological phenomenon?

A) Decrease in cerebral blood flow B) Impaired alveolar ventilation C) Gain in bicarbonate D) Inability of the kidney to excrete the body's fixed acids Ans: A Feedback: The sign/symptoms of respiratory alkalosis are associated with hyperexcitability of the nervous system and a decrease in cerebral blood flow. A decrease in the CO2 content of the blood causes constriction of cerebral blood vessels. CO2 crosses the blood–brain barrier rather quickly; the manifestations of acute respiratory alkalosis are usually of sudden onset. The person often experiences light-headedness, dizziness, tingling, and numbness of the fingers and toes. Impaired alveolar ventilation is associated with respiratory acidosis. A gain in bicarbonate is associated with metabolic alkalosis.

Inability of the kidney to excrete the body's fixed acids occurs with metabolic acidosis.

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1. Chapter 9 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.

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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.

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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. Allostasis is characterized by: A) Organ-specific physiologic responses B) Interactive physiologic changes in numerous systems C) Systems that detect psychological function D) Future expectations as a catalyst for change Ans: B Feedback: Allostasis describes the interactive physiologic changes in the neuroendocrine, autonomic, and immune systems that occur in response to either real or perceived challenges to homeostasis. Organ-specific responses are a part of the general adaptation syndrome response to stress. Control systems detect changes in physiologic function and regulate the physical and chemical set points.

7. A client is experiencing stress as a nurse prepares to insert a peripheral intravenous catheter into his forearm. The client's locus ceruleus (LC) is consequently producing which of the following hormones?

A) Norepinephrine (NE) B) Corticotropin-releasing factor (CRF) C) Antidiuretic hormone (ADH) D) Adrenocorticotropic hormone (ACTH) Ans: A Feedback: The LC is densely populated with neurons that produce norepinephrine (NE); it does not produce CRF, ADH, or ACTH.

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8. Which manifestation of stress reflects the nonspecific “fight-or-flight” response?

A) Decreased pupillary light response B) Increased gastrointestinal motility C) Decreased short-term memory D) Increased cardiopulmonary rates Ans: D Feedback: The fight-or-flight response is a manifestation of the sympathetic nervous system response to a situation. The resulting physiologic changes include increased heart rate and respiratory rates, to increase delivery of oxygen to the activated organs. The sympathetic response causes pupil dilation, decreased gastrointestinal motility, and increased alert/awareness and memory.

9. Which of the following manifestations would be considered a result of stress-induced cortisol hormone secretion?

A) Increased blood glucose level to 180 with excess hunger and thirst B) Increased hematopoiesis resulting in hemoglobin levels in the 20s with blood clots in legs C) Increased thyroid-stimulating hormone secretions resulting in signs of hyperthyroidism D) Depressed CNS function exhibited by drowsiness and change in level of consciousness Ans: A Feedback: Cortisol acts as both a mediator of the stress response and an inhibitor of the stress response. Prolonged presence of cortisol leads to suppression of growth hormone and decreased levels of thyroid-stimulating hormone. The neuroendocrine stress response affects the corticotropin-releasing factor (CRF) that increases adrenocorticotropic hormone (ACTH) secretion. ACTH stimulates the adrenal to secrete increased amounts of cortisol.

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10. A college student has just learned that her latest Pap smear revealed atypical cells, a fact that has resulted in stress and an accompanying release of angiotensin II. How would the effects of this hormone be objectively demonstrated?

A) Increased respiratory rate B) Increased blood pressure C) Decreased oxygen saturation D) Decreased blood sugar Ans: B Feedback: The central nervous system (CNS) effects of angiotensin II include the release of vasopressin and a consequent increase in blood pressure. Increased respiratory rate often accompanies stress, but this is not a direct effect of angiotensin II. Oxygen saturation and blood sugar are objective measures that are unlikely to decrease.

11. As a nurse working in the newborn nursery and intensive care unit, when an infant has been diagnosed with failure to thrive, which of the following statements about hormones' effect on the body will the nurse explain to the family?

A) The catecholamine norepinephrine is primarily responsible for the failure to thrive.

B) CRF increases somatostatin levels, which inhibits secretion of growth hormone.

C) ACTH release from the pituitary causes babies to not gain weight.

D) Antidiuretic hormone is involved in the stress response and can increase water retention.

Ans: B Feedback: Although growth hormone is initially elevated with the onset of stress, prolonged presence of cortisol leads to suppression of growth hormone, insulin-like growth factor 1 (IGF-1), and other growth factors, exerting a chronically inhibitory effect on growth.

In addition, CRF directly increases somatostatin, which in turn inhibits growth hormone secretion. Although the connection is speculative, effects of stress on growth hormone may provide one of the vital links to understanding failure to thrive in children.

Angiotensin II enhances CRF formation and release, contributes to the release of ACTH from the pituitary, enhances stress-induced release of vasopressin from the posterior pituitary, and stimulates release of norepinephrine from the locus ceruleus. Antidiuretic hormone (ADH) released from the posterior pituitary is also involved in the stress response, particularly in hypotensive stress or stress due to fluid volume loss.

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12. A nursing student's current clinical placement has been a source of stress due to high client acuity combined with interpersonal conflict with some of the unit staff. At the same time, the student has been fighting a cold for more than 2 weeks and has been unable to regain a normal feeling of health. How might these two phenomena be related?

A) Epinephrine and norepinephrine inhibit the release and action of lymphocytes.

B) Stress and illness lack a statistical correlation, though they are often thought to coexist.

C) The effects of stress on the cerebellum initiate a decrease in immunity.

D) Endocrine–immune interactions may suppress the student's immune response.

Ans: D Feedback: Although the exact mechanisms of the effects of stress on immunity are not completely understood, it is generally thought that endocrine–immune interactions suppress immunity. The most significant arguments for interaction between the neuroendocrine and immune systems derive from evidence that the immune and neuroendocrine systems share common signal pathways (i.e., messenger molecules and receptors), that hormones and neuropeptides can alter the function of immune cells, and that the immune system and its mediators can modulate neuroendocrine function. Stress has the capacity to either enhance or suppress immune function. Epinephrine and norepinephrine do not directly inhibit lymphocytes; the cerebellum is not centrally involved in the stress response.

13. A student is participating in an extended fast as part of a charitable fundraising effort.

Which of the following is an example of the physiologic reserve that will facilitate the student's adaptation to the stress of this sudden change in diet?

A) The student has experience in demonstrating perseverance from previous participation in competitive sports.

B) The student's adipose tissue contains large and accessible stores of energy.

C) The student is young, is a male, and has no preexisting medical conditions.

D) The student is utilizing guided imagery to achieve a sense of “mind over matter.”

Ans: B Feedback: The ability of body systems to increase their function given the need to adapt is known as the physiologic reserve, an example of which is the energy stored in fat tissue.

Previous experience, health, and relaxation are all likely to foster the student's ability to adapt, but these are not dimensions of physiologic reserve.

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14. Which of the following clients will be more able to adapt to a stressor based on an individual's ability to adapt? Select all that apply.

A) A Muslim male experiencing abnormal GI bleeding B) An infant with decreased water intake due to diarrhea C) A child living in a crowded apartment with his financially poor, immediate family D) A male client producing increased corticotropin-releasing factor (CRF) E) A client with known CAD, expressing problems affording all his prescribed medication Ans: B, D, E Feedback: An individual's ability to adapt to a stressor is determined by the interplay of numerous variables, including age, gender, and preexisting health status. Ethnicity and socioeconomic status have not been noted to directly influence the adaptation process.

15. A nurse working at nights is constantly complaining of being tired and sick. It seems like she catches every illness that is on the unit. One possible reason for this may relate to: A) She does not contain the “hardiness” gene in her system.

B) Alterations in sleep–wake cycle have decreased her immune function.

C) She is stressing too much about being tired and sleepy.

D) Maybe she should get tested for sleep apnea.

Ans: B Feedback: Sleep disorders and alterations in the sleep–wake cycle have been shown to alter immune function, the normal circadian pattern of hormone secretion, and physical and psychological functioning. The concept of hardiness describes a personality characteristic that includes a sense of having control over the environment, a sense of having a purpose in life, and an ability to conceptualize stressors as a challenge rather than a threat. Lower levels of hardiness have been linked with greater reaction to stress.

Stress is probably one of the primary factors interfering with sleep. At this time, we do not have enough data to speak to the need for a sleep apnea exam.

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16. Two people experience the same stressor, yet only one is able to cope and adapt adequately. An example of the person with an increased capacity to adapt is the one with: A) A sense of purpose in life B) Circadian rhythm disruption C) Age-related renal dysfunction D) Excessive weight gain Ans: A Feedback: A person with “hardiness” has a sense of purpose in life and is better able to adapt to stress. Other factors that decrease physical stress and increase the ability to adapt include a regular circadian rhythm pattern and appropriate weight for body size.

Impaired renal function is related to the inability of the kidneys to adapt to the conditions present in the very young and the very old.

17. Which of the following emergency department clients is most likely demonstrating clinical manifestations of acute stress? A client with: A) An acute heightened sense of alertness to surroundings and personnel B) Inattention to details of the accident with memory issues C) Negative feedback overactivity resulting in mental instability D) Muscle impairment and fatigue Ans: A Feedback: Acute stress is time limited, and reactions are those of the autonomic nervous system—the fight-or-flight response. Acute stress is short term and does not recur.

Centrally, there is facilitation of neural pathways mediating arousal, alertness, vigilance, cognition, and focused attention, as well as appropriate aggression. Acute stress situations are controlled by a negative feedback system. When chronic stress continues, components of the system become abnormally active or fatigued and fail. The other distractors may relate to a physical problem and not “acute stress.”

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18. A 70-year-old client admitted to a hospital for a prostatectomy is surprised to learn that his physician has prescribed insulin on a sliding scale, despite the fact that the client successfully manages his type 2 diabetes using diet and oral antihyperglycemics when at home. Which of the following facts may underlie the physician's action?

A) The stress of illness stimulates the hypothalamus to release corticotropin-releasing factor (CRF).

B) Stress-induced release of vasopressin increases serum blood glucose.

C) Stress and illness can increase glycogenolysis and insulin resistance.

D) Increased levels of epinephrine and norepinephrine cause alterations in glucose metabolism.

Ans: C Feedback: Stress-induced hyperglycemia results from numerous factors, including enhanced release of glucose from glycogen stores, increased production of glucose from noncarbohydrate sources such as amino acids, and an accompanying state of insulin resistance that impairs glucose uptake into skeletal muscle. CRF, vasopressin, epinephrine, and norepinephrine do not have direct and pronounced effects on blood glucose levels during times of stress and illness.

19. A client asks, “Why do I keep getting these cold sores on my lips? Am I kissing people too much?” The nurse will base her response by saying: A) “These sores usually develop when you are not sleeping well or are emotionally upset.”

B) “Have you been forgetting to wash your hands after going to the restroom?”

C) “Have you been going outside with a wet head?”

D) “Maybe you should stay away from crowds for the next few weeks.”

Ans: A Feedback: Herpes simplex virus type 1 infection (i.e., cold sores) often develops during periods of inadequate rest, fever, ultraviolet radiation exposure, and emotional upset. The resident herpes virus is kept in check by body defenses, probably T lymphocytes, until a stressful event occurs that causes suppression of the immune system. You do not catch cold sores by not washing after the restroom. The other responses about going out with a wet head or staying away from crowds have no bearing to the development of cold sores.

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20. The client recently returned from a year of military battle duty and has posttraumatic stress disorder (PTSD). This disorder includes an “intrusion” state that is experienced as: A) Excessive anxiety and safety concerns B) Repeated relived memories as nightmares C) Loss of concentration and increased vigilance D) Emotional numbing and feelings of depression Ans: B Feedback: Intrusion state is a repeated reliving of the traumatic events, as “flashbacks” while awake and as nightmares while asleep. PTSD is also characterized by avoidance, with emotional numbing and depression. Another characteristic of PTSD, hyperarousal, refers to increased vigilance, concerns about safety, concentration difficulties, and anxiety.

21. A female client experienced a random assault several months earlier, and her recent vigilance around her own safety is described as “obsessive” by her friends and family.

Which of the following aspects of posttraumatic stress disorder (PTSD) characterizes the client's behavior?

A) Avoidance B) Intrusion C) Hyperarousal D) Flashbacks Ans: C Feedback: Hyperarousal refers to the presence of increased irritability, difficulty concentrating, an exaggerated startle reflex, and increased vigilance and concern over safety. Avoidance refers to the emotional numbing that accompanies PTSD. Intrusion is characterized by the occurrence of flashbacks, in which the traumatic experience is relived.

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22. Following a school shooting, many of the children want to talk about the traumatic event. The school nurse knows this is very therapeutic and would be called: A) Nonadaptive functioning B) Fatalism C) Debriefing D) Guided imagery Ans: C Feedback: Debriefing, or talking about the traumatic event at the time it happens, often is an effective therapeutic tool. Crisis teams are often among the first people to attend to the emotional needs of those caught in catastrophic events. Some people may need continued individual or group therapy. Guided imagery is a mind–body technique intended to relieve stress and promote a sense of peace and tranquility during periods of stress or difficulty. The individual is guided to focus on creating a specific mental image designed to bring about positive physical and/or emotional effects. Instructions are given to focus on the present; if possible, it is desirable to tune out all outside thoughts and ideas. Frequently, instructions include going to a “special place” in their minds, such as a secluded beach or a babbling brook.

23. A client is extremely anxious about his impending surgery. Which of the following measures should the nurse implement to create an atmosphere for effective use of relaxation techniques?

A) A quiet, dim environment B) A soothing, warm foot soak C) Gentle muscle stroking D) Repetitive questioning Ans: A Feedback: Relaxation techniques do not involve touching the client. Gentle muscle stroking is part of massage therapy. The atmosphere for practicing effective relaxation technique should include a quiet environment and a mental word or phrase that is repeated by the client.

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24. An occupational therapist is preparing to begin a relaxation program on an oncology unit of a hospital. Which of the following variables will assist in the success of the program?

A) Verbal rapport between the therapist, staff, and clients B) The therapist's own ability to demonstrate relaxation techniques C) A quiet, calm, and therapeutic environment D) Appropriate use of pharmacologic agents for clients prior to attending the program Ans: C Feedback: According to Herbert Benson, a physician who worked in developing the technique, four elements are integral to the various relaxation techniques: a repetitive mental device, a passive attitude, decreased mental tonus, and a quiet environment. These factors supersede rapport, the therapist's own ability to relax, and the use of drugs.

25. A client's primary care provider has recommended biofeedback in an effort to address her chronic stress and reduce the potential for complications. What will be the goal of this intervention?

A) Using exercise to control the client's endocrine function B) Helping the client to accommodate continued nervous stimulation C) Relieving tension by using tactile stimulation D) Teaching the client to consciously control her own body functioning Ans: D Feedback: Biofeedback is a technique in which an individual learns to control physiologic functioning. It does not use exercise alone, and it aims to resolve, not simply accommodate, stress. Various types of stimulation are used, but not all are tactile.

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1. Chapter 10 A large, high-calorie meal has resulted in the intake of far more energy than a person requires. What will the individual's body do with the excess carbohydrates provided by this meal?

A) Convert them into glucose and store them in the liver and muscles B) Excrete most of the excess polysaccharides through the kidneys C) Convert the carbohydrates into amino acids in preparation for long-term storage D) Create structural proteins from some of the carbohydrates and store the remainder as triglycerides Ans: A Feedback: Dietary carbohydrates are largely converted to glucose, which is stored as glycogen in the liver and skeletal muscle cells. They are not excreted by the kidneys, and carbohydrates cannot be directly converted into amino acids or structural proteins.

2. While educating a class about adipocytes in adipose tissue, the faculty will emphasize these cells not only serve as storage sites but also are able to: A) Produce linoleic fatty acid B) Synthesize triglycerides C) Increase glucagon release D) Degrade fat-soluble vitamins Ans: B Feedback: Adipocytes synthesize and store lipids as triglycerides. Polyunsaturated linoleic fatty acid is obtained from dietary fats. Fat-soluble vitamins are components of the enzyme system required for energy to be released from fat. Adipocytes store glycerol and release it as an energy source when needed.

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3. When educating students about the differences between brown fat versus white fat, the instructor will share that brown fat has iron in its mitochondria that will facilitate: A) Production of a protein that releases the energy generated from metabolism as heat B) The primary function of storing fat energy C) Insulation and cushioning of the body's vital organs D) Concentration of the fat tissue in the greater omentum and around the kidneys Ans: A Feedback: Brown fat differs from white fat in terms of its thermogenic capacity (its ability to produce heat). The color of brown fat reflects the presence of iron in its abundant mitochondria. Brown fat mitochondria produce a specific protein called uncoupling protein-1 (UCP-1) that releases the energy generated from metabolism as heat. The functions of white fat include energy storage, endocrine and adipocytokine secretion, insulation, and cushioning of vital organs. Internally, white adipose tissue is preferentially located in the greater omentum, mesentery, and retroperitoneal space and is usually abundant around the kidney.

4. Which of the following clients is most likely to be in positive nitrogen balance? A client: A) Who is receiving treatment for sepsis B) Whose diagnosis of pneumonia is causing a fever C) Who has been admitted to the hospital in early labor D) Who sustained extensive burns in a recent industrial accident Ans: C Feedback: Pregnancy is associated with a positive nitrogen balance, whereas illness, fever, infection, and burns typically result in a negative nitrogen balance.

5. Protein contains nitrogen. A negative nitrogen balance represents: A) More protein consumed than excreted B) A reduced need for nitrogen as protein C) More nitrogen excreted than consumed D) Less use of nitrogen for protein synthesis Ans: C Feedback: Negative nitrogen balance represents more excretion of nitrogen than consumed as protein. It represents a state of tissue breakdown. Positive nitrogen balance is when more protein (nitrogen) is consumed than is needed or excreted. A normal nitrogen balance is when protein intake is equivalent to nitrogen output.

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6. In addition to facilitating bowel movements, a diet that is high in fiber confers which of the following benefits?

A) Lowering cholesterol and blood glucose B) Removing toxins and metabolic by-products C) Lowering blood pressure and resting heart rate D) Increasing intestinal absorption of vitamins and minerals Ans: A Feedback: Fiber binds with cholesterol and prevents it from being absorbed by the body as well as lowers blood glucose. It does not directly detoxify the body or increase intestinal absorption of vitamins and minerals. Fiber alone does not cause a reduction in blood pressure or heart rate.

7. Which of the following body mechanisms is necessary for food intake control?

A) Ketoacid deficiency B) Cholecystokinin storage C) Decreased blood glucose D) Leptin receptor stimulation Ans: D Feedback: Leptin receptor stimulation of the hypothalamus causes decreased appetite and increased metabolic rate/energy consumption. Natural appetite suppression is a response to cholecystokinin release and increased ketoacids. Decreased blood glucose causes a hunger response.

8. From the following list of physical assessment results, which would be interpreted as the client has developed obesity?

A) Female body fat of 20% B) Body mass index (BMI) of 40 C) Relative body weight of 70% D) Abdominal fat/hip ratio of 0.8 Ans: B Feedback: A person with a BMI of 30 or greater is classified as obese. Relative body weight greater than 120% indicates obesity. Body fat percentage over 30% indicates obesity in females. Waist–hip ratio that calculates abdominal fat in proportion to total body fat is greater than 1.0 when upper body obesity is present.

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9. A client is undergoing a bioelectrical impedance test to estimate body fat. The nurse will explain to the client that this test involves: A) Not eating anything after midnight and walking/running on a treadmill B) Measuring skin fold thicknesses in a number of different sites on the body C) Taking quantitative pictures to determine the thickness of the body fat D) Using electrodes to send harmless current through the body to measure resistance to estimate body fat Ans: D Feedback: Bioelectrical impedance involves the use of electrodes attached to the wrists and ankles to send a harmless current through the body. The flow of the current is affected by the amount of water in the body. Because fat-free tissue contains virtually all the water and current-conducting electrolytes, measurements of the resistance (i.e., impedance) can be used to estimate the percentage of body fat present. Computed tomography and MRI can be used to provide quantitative pictures from which the thickness of fat can be determined. Measurements of skinfold thickness can provide a reasonable assessment of body fat, particularly if taken at multiple sites.

10. Which of the following statements best conveys the endocrine function of adipose tissue? Adipose tissue: A) Antagonizes the effects of insulin on cell membranes B) Produces ghrelin, which stimulates both appetite and eating C) Produces and secretes cholecystokinin (CCK), which stimulates the hypothalamic feeding center D) Produces leptin, which mediates body weight Ans: D Feedback: Adipose tissue is now recognized as an endocrine organ that produces several hormones, including leptin, an important mediator of body weight. It does not produce CCK or ghrelin, however, and adipose tissue does not directly antagonize the effects of insulin.

11. Knowing that excess adipose tissue can result in chronic inflammation, the high school nurse should be assessing obese students for which of the following health problems?

A) Osteoporosis B) Type 2 diabetes C) Rheumatoid arthritis D) Systemic lupus erythematosus (SLE) Ans: B Feedback: The inflammatory response that is initiated by adipose tissue is implicated in the pathogenesis of insulin resistance and type 2 diabetes. This inflammatory process is not known to contribute directly to osteoporosis, rheumatoid arthritis, or SLE.

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12. Following yearly routine physical examination by the health care provider, a client has been diagnosed with upper body obesity along with central fat distribution. The client is at greater risk for developing which of the following disease processes?

A) Osteoporosis B) Renal disease C) Cardiometabolic disorders D) Chronic anemia Ans: C Feedback: Upper body obesity, more than other types of obesity, carries a high cardiometabolic risk. Obese people tend to develop joint problems and arthritis, but there is no direct association with osteoporosis. Chronic anemia is associated with malnutrition and starvation. Primary renal disease is unrelated to excessive weight.

13. When discussing adolescent health with a group of high school teachers, the school nurse shares that each year their student population is becoming increasingly obese.

Therefore, the school nurse took the opportunity to educate the teachers about signs and symptoms of which of the following high-risk disease processes?

A) Type 2 diabetes mellitus B) Attention deficit disorder C) Juvenile rheumatoid arthritis D) Antibiotic-resistant bacterial infections Ans: A Feedback: Childhood obesity is directly related to the increased incidence of type 2 diabetes. Until recently, type 2 diabetes rarely developed in children. Rheumatoid arthritis, attention deficit disorder, and resistant bacterial infections are unrelated to excessive fat storage (obesity).

14. In collecting assessment data on the school-aged population, which of the following factors could be the most significant predictor of childhood obesity?

A) Low socioeconomic status B) Low self-esteem C) Having parents who are obese D) Living in a rural neighborhood Ans: C Feedback: The most significant risk for childhood obesity is having parents who are obese. This variable is more important than socioeconomic status, low self-esteem, or a rural or inner-city residence.

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15. Which of the following measures should a school nurse prioritize in the treatment and prevention of childhood obesity?

A) Group cognitive therapy B) Use of selective serotonin reuptake inhibitors (SSRIs) C) Education on exercise and nutrition D) High-protein, low-carbohydrate diet Ans: C Feedback: Teaching children about the pivotal roles of regular exercise and a healthy diet should be the primary focus of treatment for the majority of obese children. Pharmacologic treatments and cognitive therapy are measures that are likely to be appropriate for only a small minority of obese children. A high-protein, low-carbohydrate diet is a short-term weight loss strategy that is not synonymous with creating lifelong healthy eating habits.

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.

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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.

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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. A frail, 87-year-old female client has been admitted to a hospital after a fall and has been diagnosed with failure to thrive. Which of the following laboratory values would suggest that the client may be experiencing malnutrition?

A) Low prealbumin B) High C-reactive protein C) High bilirubin D) Low fasting blood sugar Ans: A Feedback: Prealbumin levels are a reliable indicator of calorie–protein malnutrition. Low blood sugar does not necessarily indicate malnutrition, and neither C-reactive protein nor bilirubin levels are sensitive or specific indicators of nutritional status.

22. Similarities between girls or women with anorexia nervosa and bulimia nervosa include: A) Periodontal disease B) Low estrogen level C) Electrolyte imbalances D) Enlarged parotid gland Ans: C Feedback: Diagnostic criteria for anorexia nervosa and bulimia nervosa are distinctly different.

Anorexia nervosa is a form of starvation that causes complications that include low estrogen levels with osteoporosis and life-threatening electrolyte imbalances. Bulimia nervosa, unbalanced binge eating, also causes life-threatening electrolyte imbalances.

The self-induced vomiting of bulimia causes acid-related periodontal disease and enlarged parotid glands.

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23. Which of the following assessments should be the priority when caring for a client with anorexia nervosa?

A) Serum electrolyte levels B) Chest auscultation C) White blood cell count with differential D) Blood pressure monitoring Ans: A Feedback: Electrolyte disturbances are common and potentially severe in clients with anorexia nervosa. The importance of close monitoring supersedes the need to auscultate the client's chest or monitor white blood cells (WBCs) and blood pressure, although all of these may be relevant and appropriate parameters for assessment.

24. While assessing a teenage girl suspected of having bulimia nervosa, the health care provider may find which of the following clinical manifestations that would confirm the diagnosis? Select all that apply.

A) Large number of teeth with dental caries B) Eroded tooth enamel leading to sensitive teeth C) Kyphosis D) Painless parotid gland enlargement E) Skin with lanugo Ans: A, B, D Feedback: The complications of bulimia nervosa include those resulting from overeating, self-induced vomiting, and cathartic and diuretic abuse. Dental abnormalities, such as sensitive teeth, increased dental caries, and periodontal disease, occur with frequent vomiting because the high acid content of the vomitus causes tooth enamel to dissolve.

An unexplained physical response to vomiting is the development of benign, painless parotid gland enlargement. The most frequent complication of anorexia nervosa is amenorrhea and loss of secondary sex characteristics with decreased levels of estrogen, which can eventually lead to osteoporosis. Bone loss can occur in young women after as short a period of illness as 6 months. Symptomatic compression fractures and kyphosis have been reported. Skin with lanugo (i.e., increased amounts of fine hair) is also commonly seen in clients with anorexia nervosa.

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25. Knowing that both binge-eating and bulimia nervosa clients consume excessive amounts of foods secretively, which assessment data lead the high school nurse to suspect the student is a binge eater?

A) Remain overweight B) Eat when not hungry C) Are alcohol and substance abusers D) Being treated for depression Ans: A Feedback: Binge eaters are overweight or obese because they do not use excessive exercise or self-induced vomiting to control their weight after an eating episode. Bulimic and binge eaters eat when not hungry and experience depression related to their eating disorder.

Bulimics often abuse laxatives or diuretics.

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1. Chapter 11 Cytokines that affect hematopoiesis in bone marrow are called colony-stimulating factors (CSFs) based on their ability to: A) Support lymphocytes B) Differentiate red cells C) Regulate blood cells D) Stimulate lymphocytes Ans: C Feedback: CSFs stimulate and regulate the growth of hematopoietic cell colonies from bone marrow precursors. Interleukins support the development of lymphocytes. CSFs do not have a role in differentiation. Lymphocyte stimulation occurs in the lymphoid tissues.

2. Which of the following genes for the hematopoietic growth factors has been cloned and its recombinant protein is now used to treat anemia of kidney failure and cancer?

A) Epogen (EPO) B) Immunoglobulin genes C) Monoclonal immunoglobulin D) Interleukins (IL-3) Ans: A Feedback: The genes for most hematopoietic growth factors have been cloned, and their recombinant proteins have been generated for use in a wide range of clinical conditions.

The clinically useful factors include EPO. It is used for treatment of bone marrow failure caused by chemotherapy or aplastic anemia and the anemia of kidney failure and cancer. Immunoglobulin genes, monoclonal immunoglobulin, and interleukins (IL-3) are not given for anemia.

3. Leukocytes consist of three categories of cells that have different roles in the inflammatory and immune responses. Which of the following leukocytes is correctly matched with its function?

A) Lymphocyte—phagocytosis B) Eosinophils—allergic reactions C) Basophils—engulf antigens D) Monocytes—release heparin Ans: B Feedback: Eosinophils, a type of granulocyte, increase in number during allergic reactions.

Lymphocytes (agranulocytes) consist of three cell types that are not phagocytes but do have an important role in the immune response. Basophils and mast cells release heparin and histamine in response to allergens. Monocytes and macrophages are phagocytes that engulf antigens.

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4. A client asks, “What do these basophils and mast cells do in the body?” The health care provider responds that they: A) Are involved when you have an allergic reaction B) Stiffen your cell membranes so bacteria cannot enter C) Help your body to eliminate parasitic infections D) Help your body produce immune responses Ans: A Feedback: The basophil, which is a blood cell, is related to the connective tissue mast cell that contains similar granules. Both the basophils and mast cells are thought to be involved in allergic and hypersensitivity reactions. These cells do not stiffen the cell membranes.

In parasitic infections, the eosinophils use surface markers to attach themselves to the parasite and then release hydrolytic enzymes that kill it. Lymphocytes migrate through the peripheral lymphoid organs, where they recognize antigens and participate in immune responses.

5. T-cell lymphocytes leave the bone marrow and travel to the thymus. If successful, they differentiate into which of the following cells? Select all that apply.

A) CD4+ helper T cells B) Epstein-Barr virus (EBV) C) Hematopoietic stem cell D) Kupffer cells E) CD8+ cytotoxic T cells Ans: A, E Feedback: The body's lymphatic system consists of the lymphatic vessels, lymphoid tissue, and lymph nodes, thymus, and spleen. T lymphocytes leave the bone marrow as precursor T lymphocytes travel to the thymus, where they differentiate into CD4+ helper T cells and CD8+ cytotoxic T cells, after which many of them move to lymph nodes, where they undergo further proliferation. Infectious mononucleosis is a self-limiting lymphoproliferative disorder caused by the Epstein-Barr virus (EBV), a member of the herpesvirus family. Kupffer cells of the liver are not a component of the lymphatic system. The human T-cell lymphotropic virus (HTLV-1), which is endemic in the southwestern islands of Japan, has been associated with adult T-cell leukemia/lymphoma.

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6. A client with a long-standing diagnosis of human immunodeficiency virus (HIV) has recently developed neutropenia and been admitted to a hospital. Which of the following measures should be prioritized by the nurses who are providing his care?

A) Administration of prophylactic antibiotics B) Supplementary oxygen and administration of bronchodilators C) Administration of antiretroviral medications D) Vigilant handwashing to protect against severe bacterial infections Ans: D Feedback: Neutropenia carries a greatly increased risk of infection that necessitates vigilant infection control measures and strict adherence to standard precautions such as handwashing. Antiretrovirals do not directly address his neutropenia, and antibiotics are not normally provided prophylactically. The client is susceptible to respiratory infections, but therapeutic interventions are not required until indicated by a diagnosis such as pneumonia.

7. Which of the following clients experiencing an abnormally low neutrophil count (neutropenia) could have developed this as a side effect to his or her medical regimen?

A client with: A) Diagnosed infectious mononucleosis with a high Epstein-Barr virus count being treated with NSAIDs B) Kostmann syndrome receiving G-CSF, a granulocyte colony–stimulating factor C) Hyperthyroidism being treated with propylthiouracil to maintain normal metabolic rate D) Psoriasis, a skin infection, being treated with methotrexate to suppress the immune system Ans: C Feedback: A number of drugs, such as chloramphenicol (an antibiotic), phenothiazines (antipsychotic agents), propylthiouracil (used in the treatment of hyperthyroidism), and phenylbutazone (used in the treatment of arthritis), may cause idiosyncratic depression of bone marrow function. Many cases of neutropenia are drug related, often caused by chemotherapeutic drug suppression of bone marrow function. The Epstein-Barr virus causes mononucleosis, whereas Kostmann syndrome is a less common cause of neutropenia. Skin infections are often a result of neutropenia, not a cause.

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8. The 16-year-old boy has enlarged lymph nodes and a sore throat. His girlfriend was recently diagnosed with infectious mononucleosis. While educating this teenager, the nurse emphasizes that infectious mononucleosis is caused by which pathogen and usually transmitted via: A) Heterophil antibodies; blood B) Epstein-Barr virus; saliva C) T-cell infection; plasma D) Bacterial infection; monocytes Ans: B Feedback: Infectious mononucleosis is caused by Epstein-Barr virus and is commonly transmitted through saliva. Once the B cells are infected, mononucleosis is diagnosed by the presence of heterophil antibodies in the blood. Infectious mononucleosis is a B-cell viral infection. Cytotoxic T cells attack the virus and limit the number of infected B cells without eliminating them.

9. A 16-year-old girl has been brought to her primary care provider by her mother due to the daughter's recent malaise and lethargy. Which of the following assessments should the clinician perform in an effort to confirm or rule out infectious mononucleosis?

A) Auscultating the client's lungs B) Palpating the client's lymph nodes C) Assessing the client's cranial nerve reflexes D) Assessing the client for bone pain Ans: B Feedback: In cases of infectious mononucleosis, the lymph nodes are typically enlarged throughout the body, particularly in the cervical, axillary, and groin areas. Palpation of these nodes is a priority assessment in cases of suspected mononucleosis. Bone pain, adventitious lungs sounds, and abnormal cranial nerve reflexes do not accompany mononucleosis.

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10. Leukemias are classified according to the predominant cell type. The myelogenous cell type of leukemia can: A) Interfere with thrombocyte cell maturation B) Originate in marrow and infiltrate nodes C) Affect B and T stem cells in bone marrow D) Transform mature cells into immature ones Ans: A Feedback: Myelogenous leukemia interferes with maturation of all blood cells, including granulocytes, erythrocytes, and thrombocytes, in the bone marrow. Lymphocytic leukemia originates in the marrow and infiltrates the spleen, lymph nodes, and tissues.

Lymphocytic leukemia has immature precursor B and T cells in the marrow. Chronic lymphocytic leukemia results from the malignant transformation of relatively mature B lymphocytes into immature ones.

11. Which of the following clients are at high risk for developing acute myeloid leukemia?

Select all that apply.

A) Owner of a convenience store who pumps gas for his customers B) A factory worker who makes popcorn C) Wife married to a “chain” smoker who smokes 3 packs/day for the past 50 years D) A person who has tested positive for HIV infection E) A person with a history of infectious mononucleosis Ans: A, C Feedback: Exposure to certain chemicals such as formaldehyde and benzene (a compound in cigarette smoke and gasoline) also increases the risk of AML. There is evidence of EBV infection in essentially all people with Burkitt lymphoma. It appears that people with a history of infectious mononucleosis are at increased risk for the development of Hodgkin lymphoma.

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12. A client presents to the emergency clinic not feeling well. Which of the following complaints leads the health care provider to suspect the client may have acute leukemia?

A) Frequent nausea and vomiting for past week B) Bleeding from the gums, not related to brushing the teeth C) Muscle aches and pains in large muscle groups, especially while lying in bed D) Severe headache with associated photophobia Ans: B Feedback: Although ALL and AML are distinct disorders, they typically present with similar clinical features. Both are characterized by an abrupt onset of symptoms, including fatigue resulting from anemia; low-grade fever, night sweats, and weight loss due to the rapid proliferation and hypermetabolism of the leukemic cells; bleeding due to a decreased platelet count; and bone pain and tenderness due to bone marrow expansion.

Nausea and vomiting, muscle aches, and headaches could be associated with other diagnoses like influenza.

13. A client asks the health care worker why he is taking allopurinol. The client states, “I don't have gout. My grandpa took this for his gout.” The best response would be: A) “We just don't want you to hurt in your toes if you don't have to.”

B) “I will check with the doctor. Maybe it is a mistake.”

C) “When the chemo kills the leukemia cells, this causes your uric acid levels to rise.

Allopurinol will help lower uric acid levels.”

D) “Everyone who is on chemotherapy will develop gout. We give it prophylactically to prevent you for getting the severe pain associated with gout.”

Ans: C Feedback: Hyperuricemia occurs as the result of increased proliferation or increased breakdown of purine nucleotides (i.e., one of the components of nucleic acids) secondary to leukemic cell death that results from chemotherapy. It may increase before and during treatment.

Prophylactic therapy with allopurinol, a drug that inhibits uric acid synthesis, is routinely administered to prevent renal complications secondary to uric acid crystallization in the urine filtrate.

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14. Which of the following factors differentiates chronic leukemias from acute leukemias?

A) Leukemic cells are disseminated throughout the body by the circulatory system.

B) The leukemic cells are more fully differentiated than in acute leukemias.

C) The prevalence among individuals with Down syndrome is high.

D) They are cancers of the hematopoietic progenitor cells.

Ans: B Feedback: In contrast to acute leukemias, chronic leukemias are malignancies involving proliferation of more fully differentiated myeloid and lymphoid cells. Down syndrome is associated with acute leukemias, and both acute leukemias and chronic leukemias involve systemic distribution of leukemic cells.

15. An elderly client presents to the clinic just not “feeling well.” Which of the following bone marrow results would confirm the diagnosis of chronic lymphocytic leukemia?

A) Production of undifferentiated blood cells in the marrow B) Proliferation of well-differentiated blood cells in the marrow C) Uncontrolled growth of immature blood cells in the marrow D) Replication of pluripotent precursor blood cells in the marrow Ans: B Feedback: Chronic leukemia involves abnormal proliferation and growth of well-differentiated blood cell types. Acute leukemia is associated with proliferation of undifferentiated, immature, and precursor blood cells.

16. A child has Down syndrome and has been experiencing unexplained nose bleeds for the past several months. His blood tests identify blast cells in the peripheral smear. In addition to nose bleeds, his acute leukemia will typically manifest which of the following signs/symptoms? Select all that apply.

A) Infections due to neutropenia B) Fatigue due to RBC deficiency C) Hypogammaglobulinemia due to progressive infiltration of the bone marrow and lymphoid tissues D) Bleeding due to thrombocytopenia E) Palpation of solid tumors on the kidneys Ans: A, B, D Feedback: Hypogammaglobulinemia is common with chronic lymphocytic leukemia, in addition to all of the manifestations of a blood cell malignancy. Infections, fatigue, and bleeding are seen in all clients with acute leukemias and will also be present in clients with chronic leukemias. The accelerated phase of CML is characterized by enlargement of the spleen and progressive symptoms. Splenomegaly often causes a feeling of abdominal fullness and discomfort. Solid tumors on the kidneys are not associated with CLL.

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17. Following peripheral blood testing and a bone marrow biopsy, a client has been diagnosed with chronic myelogenous leukemia. Which of the following is most likely to have preceded the client's diagnosis?

A) The presence of a Philadelphia chromosome B) Down syndrome C) Radiation exposure D) Exposure to the Epstein-Barr virus Ans: A Feedback: Chronic myelogenous leukemia develops when a single, pluripotent hematopoietic stem cell acquires a Philadelphia chromosome. Down syndrome and radiation exposure are associated with acute leukemias, and exposure to the Epstein-Barr virus is not implicated in the etiology of leukemias.

18. A client with chronic myelogenous leukemia (CML) has been diagnosed with terminal blast crisis. Which of the following clinical manifestations should the nurse focus the assessment on for this client? Select all that apply.

A) Shortness of breath and progressive dyspnea B) Low temperature of 96°F C) Headache and lethargy D) Increasing confusion E) Bleeding from the gums Ans: A, C, D Feedback: The terminal blast crisis phase of CML represents evolution to acute leukemia and is characterized by an increasing number of myeloid precursors, especially blast cells, in the blood. With very high blast counts (>100,000 cells/mL), symptoms of leukostasis may occur. The high number of circulating leukemic blasts increases blood viscosity and predisposes to the development of leukoblastic emboli with obstruction of small blood vessels in the pulmonary and cerebral circulations. Occlusion of the pulmonary vessels leads to vessel rupture and infiltration of lung tissue, resulting in sudden shortness of breath and progressive dyspnea. Cerebral leukostasis leads to diffuse headache and lethargy, which can progress to confusion and coma.

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19. A client has been diagnosed with non-Hodgkin lymphoma (NHL), a form of malignancy that most likely originated in which of the following sites?

A) Thymus B) Spleen C) Bone marrow D) Lymph nodes Ans: D Feedback: NHLs can develop in any of the lymphoid tissues, but the most common site of origin is the lymph nodes.

20. A young adult is preparing to begin treatment for non-Hodgkin lymphoma (NHL), a disease that has disseminated widely. What is the most likely treatment regimen for this client?

A) Antiviral medications B) Surgery and whole-blood transfusion C) Radiation and chemotherapy D) Bone marrow or stem cell transplantation Ans: C Feedback: NHL is normally treated with either radiation (early stage) or radiation and chemotherapy (later stages). Antivirals, blood transfusion, surgery, bone marrow transplantation, and stem cell transplantations are not common treatment modalities for NHLs.

21. The client is undergoing diagnostic workup for possible Hodgkin type of lymphoma.

Which of the following laboratory results would confirm the diagnosis of Hodgkin lymphoma?

A) Reed-Sternberg cells B) Bence Jones proteins C) M-type protein antibodies D) Philadelphia chromosome Ans: A Feedback: Hodgkin lymphoma is diagnosed by the presence of Reed-Sternberg cells. Philadelphia chromosomes are found in chronic myelogenous leukemia cells. M-type protein antibodies are diagnostic for multiple myeloma. Bence Jones proteins are found in the urine of people with multiple myeloma.

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22. A client is suspected of having Hodgkin lymphoma. Which of the following assessment findings would confirm Hodgkin lymphoma rather than non-Hodgkin lymphoma?

A) Noncontiguous nodal spread B) Superficial lymphadenopathy and pathologic fractures C) Pruritus and night fevers D) Poor humoral antibody response Ans: C Feedback: Pruritus and intermittent fevers associated with night sweats are classic symptoms of Hodgkin lymphoma. Noncontiguous nodal spread, superficial lymphadenopathy, and poor humoral antibody response are all manifestations of non-Hodgkin lymphoma.

Multiple myeloma clients experience increased bone resorption, which predisposes the individual to pathologic fractures.

23. A client is undergoing a diagnostic workup to rule out multiple myeloma. Which of the following diagnostic findings would confirm the diagnosis of multiple myeloma?

A) Plasma cells greater than 10% on bone marrow biopsy B) Decreased production of bone osteoblasts C) T-cell lymphocyte level of 34% (normal) D) Immunoglobulin A level of 200 mg/dL (normal) Ans: A Feedback: Multiple myeloma is a plasma cell malignancy that results in proliferation of a single monoclonal immunoglobulin. Multiple myeloma cells are found in the marrow and as osteolytic lesions in all bones. B-cell lymphocytes normally stimulate plasma cells to produce immunoglobulin when needed; T cells are not involved in the process.

24. Which of the following client complaints should prompt a clinician to order a diagnostic workup for multiple myeloma?

A) “Lately my bones just seem to ache so badly, and nothing seems to help.”

B) “Every morning my joints are so stiff that it takes me 10 or 15 minutes just to get going.”

C) “I feel so weak, and the last few days I've actually fallen asleep on my coffee break at work.”

D) “I vomited yesterday evening, and it looked like coffee grounds mixed with some fresh blood.”

Ans: A Feedback: Bone pain is the most characteristic symptom of multiple myeloma. Joint stiffness is unlikely. Lethargy and bleeding may also result from the disease, but these symptoms are less specific to multiple myeloma.

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25. Which of the following abnormal blood work results is most closely associated with a diagnosis of multiple myeloma?

A) Decreased hemoglobin, hematocrit, and red blood cells B) Extremely high levels of abnormal lymphocytes C) Low glomerular filtration rate and high calcium levels D) Low potassium levels and increased blood urea nitrogen Ans: C Feedback: Hypercalcemia and signs of impaired renal function, such as decreased glomerular filtration rate (GFR), are typical of multiple myeloma. The disease does not result in a proliferation of abnormal lymphocytes, hypokalemia, or low red blood cells.

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1. Chapter 12 A nursing student asks her instructor, “I don't understand this coagulation system. When we donate blood, what keeps it from clotting in the bag?” The instructor responds: A) “Calcium gluconate is added to the bag to keep it from clotting.”

B) “If the blood is used within 24 hours from retrieval, there will be no clot formation yet.”

C) “The blood bank adds heparin to every bag prior to actually collecting the blood from the donor.”

D) “Citrate is added to the blood bag, which prevents it from clotting.”

Ans: D Feedback: The addition of citrate to blood stored for transfusion purposes prevents clotting by chelating ionic calcium. Calcium (factor IV) is required for coagulation to occur, and calcium is supplied by the body for the first two steps. Blood coagulation is regulated by several natural anticoagulants, such as antithrombin III and proteins C and S, which work by inactivating some of the clotting factors. Obviously, if blood not processed but used 24 hours later, it will have clotted.

2. While taking an exam on disorders of hemostasis, the students were asked to identify endothelial mediators that inhibit platelet aggregation and also vasodilate vessels.

Which of the following would be considered a correct answer? Select all that apply.

A) Adenosine diphosphate B) Prostaglandin I2 C) Thromboxane A2 (TXA2) D) Nitric oxide E) Plasminogen Ans: B, D Feedback: If platelets are activated, they are inhibited from adhering to the surrounding uninjured endothelium by endothelial prostacyclin (prostaglandin I2 [PGI2]) and nitric oxide. Both of these mediators are potent vasodilators and inhibitors of platelet aggregation.

Endothelial cells also elaborate an enzyme called adenosine diphosphatase that degrades ADP and further inhibits platelet aggregation. The plasma also contains a plasma protein called plasminogen that gets activated and converted to plasmin, an enzyme capable of digesting the fibrin strands of the clot. Release of the vasoconstrictor TXA2 is responsible for much of the vessel spasm. Dense granules mainly contain adenosine diphosphate (ADP), ATP, ionized calcium, serotonin, and histamine, which facilitate platelet adhesion and vasoconstriction at the site of vessel injury.

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3. Following a lecture on hemostasis, a nursing student accidently cuts her hand while preparing supper for her family. She watches the laceration very closely. Sure enough, the first thing she notes is: A) Small hair-like strands form a blood (fibrin) clot.

B) Limited bleeding initially as a response to the small vessel walls being sealed by a platelet plug.

C) Clot retraction by pushing serum out of the clot and joining the edges of the broken vessel.

D) Initially, it takes a few seconds for blood to appear as a result of vessel spasm.

Ans: D Feedback: There are five stages in hemostasis, with the first step being transient vessel vasospasm.

Vessel spasm is initiated by endothelial injury and caused by local and humoral mechanisms. It is a transient event, usually lasting less than 1 minute. For smaller vessels, release of the vasoconstrictor TXA2 is responsible for much of the vessel spasm. Formation of the platelet plug, development of an insoluble fibrin clot, and clot retraction happen after vessel spasm.

4. To form a platelet plug, platelets must adhere to the vessel inner layer. For this to occur, which protein molecule is required?

A) Von Willebrand factor B) Plasminogen C) Lipoprotein D) Thromboxane A2 Ans: A Feedback: Platelet adhesion requires a protein molecule called von Willebrand factor (vWF). This factor is produced by both megakaryocytes and endothelial cells and circulates in the blood as a carrier protein for coagulation factor VIII. The plasma also contains a plasma protein called plasminogen, which gets activated and converted to plasmin, an enzyme capable of digesting the fibrin strands of the clot. The extrinsic pathway of coagulation, which is a much faster process, begins with trauma to the blood vessel or surrounding tissues and with the release of an adhesive lipoprotein called tissue factor (also known as thromboplastin or factor III) from the subendothelial cells. Thromboxane A 2 (TXA2) is released during platelet aggregation, the step after adhesion.

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5. Removal of a client's peripheral intravenous catheter resulted in brief bleeding and the loss of a small amount of blood. Which of the following processes occurred during the formation of the platelet plug that helped to stop blood flow?

A) Activation of factor X B) Conversion of prothrombin to thrombin C) Release of von Willebrand factor from the epithelium D) Conversion of fibrinogen to fibrin threads Ans: C Feedback: The release of von Willebrand factor from the epithelium contributes to platelet adhesion and the eventual formation of a platelet plug. Activation of factor X and the conversions of prothrombin to thrombin and fibrinogen to fibrin threads take place during the stage of blood coagulation.

6. A 69-year-old client who is obese and has a diagnosis of angina pectoris has been prescribed clopidogrel (Plavix) by his primary care provider. The client asks, “Why do I need this medication? It won't help my chest pain.” The best response would be this medication: A) Prevents the blood cells from forming a clot in your heart vessels B) Activates plasminogen, which converts to plasmin to digest clots in your heart vessels C) Inhibits the intrinsic clotting pathway to keep RBCs from clumping together in the heart vessels D) Inactivates calcium ions, thereby preventing blood clotting Ans: A Feedback: Clopidogrel (Plavix) is a common platelet aggregation inhibitor. It does not achieve a therapeutic effect by activating plasminogen, inhibiting the intrinsic pathway, or inactivating calcium ions.

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7. Blood coagulation is initiated by either the intrinsic or extrinsic pathway. The final step in both pathways would be: A) Activation of factor XII B) Deactivation of fibrinogen, preventing the conversion to fibrin C) Activation of factor X, leading to conversion of prothrombin II to thrombin IIa D) Activation of factors VII, X, V, and II Ans: C Feedback: The terminal steps in both pathways are the same: the activation of factor X and the conversion of prothrombin (II) to thrombin (IIa). Thrombin then acts as the enzyme to convert fibrinogen (I) to fibrin (Ia), the material that stabilizes a clot. Factor XII initiates the intrinsic pathway in circulation, whereas the extrinsic pathway is initiated by tissue factor when tissues are injured. Protein C acts as an anticoagulant by inactivating factors V and VIII. Thrombin is formed during the coagulation process and does initiate it.

8. A client who had a pulmonary embolism is receiving IV heparin and has just begun taking his first dose of warfarin (Coumadin). The client asks the nurse, “How long will this pill take in order to prevent me from developing more clots. I would like to go home soon.” The nurse responds: A) “It usually takes 2 to 3 days for warfarin to become therapeutic, meaning your blood will be thin enough to prevent further clot formation.”

B) “I don't really know. Right now you are on two blood thinners, so we won't be able to tell if it's working until the doctor discontinues your heparin drip.”

C) “That's a good question. If warfarin has a long half-life, it could take many days. I will have to ask the pharmacist this question.”

D) “First, we have to have your health care provider switch you from IV heparin to a low molecular weight heparin, which you need to inject in your belly.”

Ans: A Feedback: The anticoagulant drugs warfarin and heparin are used to prevent thromboembolic disorders, such as deep vein thrombosis and pulmonary embolism. Warfarin acts by decreasing prothrombin. It alters vitamin K in a manner that reduces its ability to participate in the synthesis of the vitamin K–dependent coagulation factors in the liver.

Warfarin's maximum effect takes 36 to 72 hours because of the varying half-lives of different clotting factors that remain in the circulation. Heparin ultimately suppresses the formation of fibrin and therefore inhibits coagulation. The low molecular weight heparins are given by subcutaneous injection and require less frequent administration and monitoring compared with the standard (unfractionated) heparin. Clients usually are not sent home with an IV medication. Once warfarin is in therapeutic range, heparin or low molecular weight heparins are no longer required.

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9. Which of the following clients are at risk for developing a platelet clot? Select all that apply.

A) A COPD client experiencing an acute exacerbation requiring intravenous steroids B) A trauma client who had a splenectomy following injury and laceration of the liver C) A school-aged child prescribed iron supplements for iron deficiency anemia D) A breast cancer client receiving chemotherapy E) An acute myocardial infarction client with elevated troponin levels Ans: B, C, D, E Feedback: Increased platelet function has several causes, one of which is vascular wall damage that promotes platelet adhesion. An increase in platelet count can occur as a reactive disorder associated with iron deficiency anemia, especially in children; splenectomy; cancer; and chronic inflammatory conditions such as rheumatoid arthritis and Crohn disease.

10. A public health nurse is conducting a health promotion campaign under the auspices of the local community center. Which of the following measures that the nurse is promoting are likely to influence the participants' risk of hypercoagulability disorders?

Select all that apply.

A) Smoking cessation B) Blood glucose screening C) Daily dose of vitamins with minerals D) Cholesterol screening and management E) Eliminating consumption of all alcoholic beverages Ans: A, B, D Feedback: All of the noted measures influence an individual's risk of hypercoagulation; smoking, diabetes, obesity, blood lipid levels, and hemodynamic stress are all risk factors for hypercoagulation.

11. During a client's admission assessment prior to reduction mammoplasty surgery, the nurse notes a reference to a Leiden mutation in the client's history. The nurse assesses this client for an increased risk of developing which of the following postsurgical complications?

A) Hemorrhage B) Myocardial infarction C) Hemophilia A or B D) Deep vein thrombosis Ans: D Feedback: The Leiden mutation predisposes to venous thrombosis. It is not associated with hemophilia or an increased risk of hemorrhage. The client's risk of deep vein thrombosis likely supersedes her risk of myocardial infarction.

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12. Which of the following clients are at risk for developing blood clots and should be assessed frequently? Select all that apply.

A) A college-aged female taking oral contraceptives for irregular menstrual periods B) A middle-aged male who smokes three packs of cigarettes/day C) A young adult who has a history of asthma and utilizes steroid inhalers daily D) A marathon runner who exercises more than 4 hours/day E) A diabetic client who is also greater than 100 pounds over the ideal body weight Ans: A, B, E Feedback: Hypercoagulability is associated with oral contraceptive use. The incidence of stroke, thromboemboli, and myocardial infarction is greater in women who use oral contraceptives, particularly those older than 35 years of age and those who smoke tobacco. Smoking and obesity promote hypercoagulability for unknown reasons.

Asthma does not place one at great risk for developing a blood clot. Exercise is usually considered beneficial for the prevention of clot formation.

13. A client with a history of antiphospholipid syndrome presents to the emergency department. Which of the following complaints lead the nurse to suspect the client is experiencing a complication related to the syndrome? Select all that apply.

A) Swelling in the right calf with redness and tenderness B) Having respiratory symptoms like shortness of breath and chest pain C) Have developed a cough that produced some bloody sputum D) Developed a headache that has lasted for 3 days now E) Having trouble making “water” and has pain in the lower abdomen and groin Ans: A, B, C Feedback: Persons with the disorder present with a variety of clinical manifestations, typically those characterized by recurrent venous and arterial thrombi. Venous thrombosis (DVT), especially in the deep leg veins, occurs in up to 50% of persons with the syndrome, half of whom develop pulmonary emboli. Swelling in the right calf with redness and tenderness, having respiratory symptoms like shortness of breath and chest pain, and having a cough that produced some bloody sputum are signs of DVT and pulmonary emboli. Headache is not conclusive for a clot in the cerebral vessels. Having trouble urinating and pain in the lower abdomen and groin are classic signs of a kidney stone.

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14. The most recent blood work of a client with a diagnosis of acute myelogenous leukemia (AML) reveals thrombocytopenia. Where is the client most likely to experience abnormal bleeding as a result of low platelets?

A) Inside the brain B) Skin and mucous membranes C) Sclerae of the eyes D) Nephrons and ureters Ans: B Feedback: Common sites for spontaneous bleeding from platelet disorders are the skin and mucous membranes of the nose, mouth, gastrointestinal tract, and uterine cavity. Intracranial hemorrhage is rare, and neither the sclerae nor the kidneys are typical sites of spontaneous bleeding.

15. In immune thrombocytopenia purpura (ITP), the client has what type of disorder that primarily destroys which blood component?

A) Allergic; fibrinogen B) Alloimmune; factor VIII C) Autoimmune; platelets D) Immunoglobulin; B cells Ans: C Feedback: ITP is an autoimmune disorder that results in excess platelet destruction, causing severe thrombocytopenia. The disorder is not precipitated by an allergic reaction and does not damage factor VIII, immunoglobulin, or B cells.

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16. A client has been admitted for immune thrombocytopenic purpura. The client has not responded to corticosteroid treatment. The priority nursing intervention for this client would include which of the following treatment measures?

A) Place the client in isolation, so the skin rashes will not spread to other clients.

B) Insert an intravenous catheter, so immune globulin can be administered in a timely manner.

C) Insert a Foley catheter to monitor hourly urine output.

D) Prepare a surgical permit for an emergency splenectomy.

Ans: B Feedback: The decision to treat ITP is based on the platelet count and the degree of bleeding.

Corticosteroids are used as initial therapy; other effective initial treatment includes intravenous immune globulin. However, this treatment is expensive, and the beneficial effect may last only 1 to 2 weeks. Because the spleen is the major site of antibody formation and platelet destruction, splenectomy is the traditional second-line treatment for persons who relapse or do not respond to medications. Isolation is not required; it is not contagious. The client may require a Foley if he does not respond to the immune globulin and must undergo surgery.

17. A client was started on a protocol for the prevention of deep vein thrombosis shortly after admission and has been receiving 5000 units of heparin twice daily for the last week. An immune response to this treatment may increase the client's chance of developing which health problem?

A) Antiphospholipid syndrome B) Disseminated intravascular coagulation (DIC) C) Von Willebrand disease D) Thrombocytopenia Ans: D Feedback: Heparin is often implicated in cases of drug-induced thrombocytopenia. DIC, antiphospholipid syndrome, and von Willebrand disease cannot be induced by the use of heparin.

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18. Knowing that thrombotic thrombocytopenic purpura (TTP) results in thrombi in the microcirculation system, the health care worker should assess the client for which of the following manifestations? Select all that apply.

A) Red/purple skin discoloration that does not blanch when pressure is applied (purpura) B) Jaundice noted on skin and sclera of the eyes C) Petechiae over the entire body D) Erythema around all orifices E) Confusion or seizures caused by decreased circulation to the brain from vascular occlusion Ans: A, C, E Feedback: The clinical manifestations of TTP include purpura, petechiae, vaginal bleeding, and neurologic symptoms ranging from headache to seizures and altered consciousness.

19. In light of the presence of numerous risk factors for coronary artery disease, a client's primary care provider has recommended that he take low-dose (81 mg) aspirin once daily. Doing so will reduce the client's risk of myocardial infarction by altering which of the following stages of hemostasis?

A) Vessel spasm B) Platelet plug formation C) Blood coagulation D) Clot lysis Ans: B Feedback: Aspirin produces irreversible acetylation of platelet cyclooxygenase activity and consequently the synthesis of thromboxane A2 (TXA2), which is required for platelet aggregation. Aspirin does not directly influence vessel spasm, coagulation of blood, or clot dissolution.

20. Hemophilia A is a hereditary blood disorder caused by inadequate activity or absence of: A) Factor VIII B) Prothrombin C) von Willebrand complex D) Intrinsic factor Ans: A Feedback: Factor VIII gene deficiency or absence is the cause of hemophilia A. Intrinsic factor and prothrombin are part of the coagulation process and unrelated to hemophilia A. Von Willebrand factor (vWF) disease is caused by a lack of vWF complex, which binds and stabilizes factor VIII.

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21. A 23-year-old female client has been diagnosed with von Willebrand disease following a long history of “heavy periods” and occasional nosebleeds. Which of the client's following statements demonstrates a sound understanding of her new diagnosis?

A) “I'm really disappointed that I won't be able to do sports anymore.”

B) “I read on a website that I might have to get blood transfusions from time to time.”

C) “I'll make sure to take Tylenol instead of aspirin when I get aches and pains.”

D) “I hope my insurance covers the injections that I'll need to help my blood clot.”

Ans: C Feedback: Most clients with von Willebrand disease, especially less serious variants, require only monitoring and aspirin avoidance. It is likely unnecessary for the client to avoid sports.

Drugs, clotting factors, and transfusions are likely not required, given the moderate bleeding that the client has experienced to this point.

22. The parents are ready to take their newly diagnosed hemophilia child home. Which of the following teaching aspects should the nurse discuss with them prior to discharge?

Select all that apply.

A) Keep the child away from contact sports like football and wrestling.

B) Give ibuprofen (an NSAID) if the child runs a fever.

C) Aspirin should only be given for severe pain in the joints.

D) Administration of factor VIII at home when bleeding occurs.

E) The signs of a MI related to bleeding in the heart vessels.

Ans: A, D Feedback: The prevention of trauma is important in persons with hemophilia. Aspirin and other NSAIDs that affect platelet function should be avoided. Factor VIII replacement therapy (either recombinant or heat-treated concentrates from human plasma) administered at home has reduced the typical musculoskeletal damage. It is initiated when bleeding occurs or as prophylaxis with repeated bleeding episodes. Characteristically, bleeding occurs in soft tissues, the gastrointestinal tract, and the hip, knee, elbow, and ankle joints. Bleeding of the heart vessels is not usually associated with hemophilia A.

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23. Which of the following clients likely faces the highest risk of an acquired hypocoagulation disorder and vitamin K deficiency? A client who: A) Has a diagnosis of liver failure secondary to alcohol abuse B) Has chronic renal failure as a result of type 1 diabetes mellitus C) Is immunocompromised as a result of radiation therapy for the treatment of lung cancer D) Has dehydration and hypokalemia resulting from Clostridium difficile–associated diarrhea Ans: A Feedback: Liver disease is strongly associated with vitamin K deficiency due to decreased synthesis and impaired fat absorption. Renal failure, decreased immune function, and dehydration are not common causes of vitamin K deficiency.

24. In persons with a bleeding disorder caused by vascular defects, platelet counts and INR results will most often reveal: A) Normal values B) Hypocalcemia C) Polycythemia D) Thrombocytopenia Ans: A Feedback: If a vascular defect is the cause of easy bruising, petechiae, and purpura, then the platelet count and coagulation factors will be normal. Lack of calcium and high red blood cell (RBC) count are unrelated to vascular defect–related bleeding.

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25. In the ICU, a postsurgical client has developed sepsis and is being treated with multiple medications. During the mid-morning assessment, which finding leads the nurse to suspect the client may be developing a complication called disseminated intravascular coagulation (DIC)? Select all that apply.

A) Headaches associated with light sensitivity B) Oozing from all previous puncture and intravenous sites C) Decreased O2 saturation and diminished breath sounds in lower lobes D) Hemorrhage from the surgical site requiring deep pressure dressings E) Urine from the Foley catheter is bloody Ans: D Feedback: DIC is hemorrhage in the presence of excessive coagulation. Although coagulation and formation of microemboli characterize DIC, its acute manifestations usually are more directly related to the bleeding problems that occur. The bleeding may be present as petechiae, purpura, oozing from puncture sites, or severe hemorrhage. Headache with light sensitivity is usually not associated with DIC unless the client has s/s of a cerebral bleed with CNS deficits. Decreased O2 saturation and diminished breath sounds are usually associated with atelectasis.

26. A healthy, primiparous (first-time) mother delivered a healthy infant several hours ago, but the mother has experienced postpartum hemorrhage. Which of the following disorders is most likely to underlie the client's excessive bleeding after delivery?

A) Disseminated intravascular coagulation B) Hemophilia A C) Von Willebrand disease D) Thrombotic thrombocytopenic purpura (TTP) Ans: A Feedback: Obstetric complications account for 50% of cases of disseminated intravascular coagulation; tissue factors released from necrotic placental or fetal tissue or amniotic fluid may enter the circulation, inciting DIC. Hemophilia A would be a central aspect of the client's medical history if it were present, and von Willebrand disease does not typically cause massive bleeding. The etiology of TTP is not normally obstetric.

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1. Chapter 13 Which of the following clients is most susceptible to experiencing the effects of inadequate erythropoiesis? A client: A) Who has developed renal failure as a result of long-standing hypertension B) Who recently experienced an ischemic stroke and who remains bedridden C) Whose heavy alcohol use has culminated in a diagnosis of pancreatitis D) Whose estimated blood loss during recent surgery was 700 mL Ans: A Feedback: Kidney failure causes an absence of erythropoietin production. As a result, hypoxia does not result in erythropoiesis. Stroke, pancreatitis, and recent blood loss do not directly impair the body's ability to create new red blood cells.

2. Sue is fatigued, and some blood tests are done. Her results include Hct 40%; Hgb 8g/dL; WBC 8000; and platelets 175,000. The nurse should interpret Sue's blood work as indicative of: A) High platelets/thrombocytosis B) Low WBC count/granulocytopenia C) Low hemoglobin/anemia D) High hematocrit/polycythemia Ans: C Feedback: All of the laboratory values are within normal range except for the hemoglobin, which is low. Low hemoglobin is associated with iron deficiency anemia.

3. The client is an average-sized adult and has abnormal microcytic hypochromic red blood cells due to a long-term, chronic disease. Which of the following complete blood count (CBC) results is characteristic of her type of anemia?

A) Hematocrit 44% B) Reticulocytes 1.5% C) Band cells 3000/mL D) Hemoglobin 8 g/dL Ans: D Feedback: Anemia of chronic disease is characterized by a low hemoglobin level, low hematocrit, and low reticulocyte count. The quantity of band cells, immature neutrophils released from the marrow, is unrelated to the anemia.

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4. A client presents to the emergency department with severe menstrual bleeding where she is soaking three to 4 pads/hour. Following assessment, which of the following findings indicates that her body is trying to increase its cardiac output? Select all that apply.

A) Heart rate 120 beats/minute B) Deep respirations with expiratory wheezes C) Light pink mucous membranes D) Complaints of chest “palpitations” E) Pale bluish nail beds Ans: A, D Feedback: Anemia is frequently the result of tissue oxygen deficit, which is secondary to decreased circulating red blood cells (RBCs) or hemoglobin for oxygen delivery. The redistribution of the blood from cutaneous tissues or the lack of hemoglobin causes pallor of the skin, mucous membranes, conjunctivae, and nail beds. Tachycardia and palpitations may occur as the body tries to compensate with an increase in cardiac output.

5. A 72-year-old woman with complaints of increasing fatigue has completed a series of fecal occult blood tests that indicate the presence of blood in her stool. Which of the following health problems is likely to accompany this client's gastrointestinal bleed?

A) Hemolytic anemia B) Aplastic anemia C) Iron deficiency anemia D) Megaloblastic anemia Ans: C Feedback: Chronic blood loss does not affect blood volume but instead leads to iron deficiency anemia when iron stores are depleted. Such blood loss is not associated with hemolysis, aplastic anemia, or megaloblastic anemia.

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6. Hemolytic anemia is characterized by excessive red blood cell destruction and compensatory: A) Hypoactive bone marrow B) Increased erythropoiesis C) Iron retention in the body D) Shrinkage of the spleen Ans: B Feedback: A compensatory response to hemolysis is to increase erythropoiesis, to increase RBC replacement. The bone marrow is hyperactive and releases an increased number of reticulocytes. Iron from the destroyed RBCs is retained, but this is not a compensatory function. The spleen will be abnormally hyperactive, causing hyperplasia and enlargement.

7. A 6-month-old infant was born with a murmur. The pediatrician is recommending valve replacement/repair surgery based on which of the following lab values indicating intravascular hemolysis?

A) Increase in the number of red blood cells (polycythemia) B) Excess of hemoglobin in the blood plasma (hemoglobinemia) C) Elevated bilirubin levels D) Decreased number of reticulocytes Ans: B Feedback: Intravascular hemolysis is less common and occurs as a result of mechanical injury caused by defective cardiac valves, complement fixation in transfusion reactions, or exogenous toxic factors. Regardless of cause, intravascular hemolysis leads to hemoglobinemia, hemoglobinuria, and hemosiderinuria.

8. Conditions that predispose to sickling of hemoglobin in persons with sickle cell anemia include: A) Impaired red blood cell maturation B) Increased iron content of blood C) Decreased oxygen saturation D) Increased intravascular volume Ans: C Feedback: Low oxygen in the tissues will cause red blood cells to take on the sickle shape in persons with sickle cell anemia. Sickle cell disease is a disorder of hemoglobin S and does not affect red blood cell maturation. The iron content is not affected by the sickling, but the capacity to carry the iron can be an effect of the affected RBCs. Dehydration can cause sickling by increasing the concentration of hemoglobin.

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9. Hemoglobin solubility results and hemoglobin electrophoresis have resulted in a diagnosis of sickle cell anemia in an African American infant. The parents of the child should be aware that their child is at a significant risk for which of the following health problems? Select all that apply.

A) Acute pain B) Stroke C) Respiratory disease D) Autoimmune diseases E) Fractures Ans: A, B, C Feedback: Clients with sickle cell anemia are at significant risk for vasoocclusive pain crisis and acute chest syndrome. As well, increased blood viscosity creates a risk for stroke. Sickle cell disease is not associated with an increased risk for fractures or the development of autoimmune diseases.

10. The pathologic effects of the thalassemias are primarily due to which of the following pathophysiologic processes?

A) Impaired hemoglobin synthesis B) Impaired folic acid absorption C) Erythropoietin deficiency D) Loss of iron Ans: A Feedback: The thalassemias are a heterogeneous group of inherited disorders caused by mutations that decrease the rate of - or -globin chains. The pathologic effects of the thalassemias are not direct results of impaired folic acid absorption or a lack of erythropoietin or iron.

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11. An infant from parents of Mediterranean decent has been diagnosed with a severe form of -thalassemia anemia. The nurse caring for this infant knows that the infant will likely receive which of the following medical treatments?

A) Transfusion therapy B) Iron sulfate supplements C) Stem cell transplant D) Warfarin, a blood thinner to decrease clot formation Ans: A Feedback: Persons who are homozygous for the trait (thalassemia major) have severe, transfusion-dependent anemia that is evident at 6 to 9 months of age when the hemoglobin switches from HbF to HbA. If transfusion therapy is not started early in life, severe growth retardation occurs in children with the disorder. Iron and blood thinners will not be therapeutic for this client. Stem cell transplantation is a potential cure for low-risk clients, particularly in younger persons with no complications of the disease or its treatment, and has excellent results.

12. A 12-month-old infant is displaying pale skin, rapid heart rate, and increased respiratory rate. The parents bring the child to the clinic. Which statement by the parents points the health care worker to suspect iron deficiency anemia?

A) “He has one to two bowel movements/day.”

B) “We give him regular cow's milk with all his meals and snacks.”

C) “He doesn't like to eat any vegetables.”

D) “His grandma feeds him cookies every time she comes to visit.”

Ans: B Feedback: The manifestations of iron deficiency anemia are related to impaired oxygen transport and lack of hemoglobin. Depending on the severity of the anemia, pallor, easy fatigability, dyspnea, and tachycardia may occur. Iron requirements are proportionally higher in infancy (3 to 24 months) than at any other age, although they are also increased in childhood and adolescence. In infancy, a diet consisting mainly of cow's milk, which is low in absorbable iron, is a main cause of iron deficiency anemia.

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13. Megaloblastic anemias caused by folic acid or vitamin B12 deficiencies can seriously affect RBC production. Which of the following lab results would correlate with this diagnosis?

A) Iron level of 70 g/dL (normal) B) Mean corpuscular hemoglobin (MCV) 120 fL (high) C) Platelet count 200,000 (normal) D) Reticulocyte count 3.6% (high) Ans: B Feedback: Megaloblastic anemias are caused by impaired DNA synthesis that results in enlarged red cells (MCV >100 fL) due to impaired maturation and division. Folic acid and/or vitamin B12 do not have a critical role in normal iron and platelet levels or a high reticulocyte count.

14. Which of the following individuals likely faces the highest risk of megaloblastic anemia?

A) A 69-year-old woman who takes ASA four times daily to treat her arthritis B) A 44-year-old man who lost approximately 500 mL of blood in a workplace accident C) A 21-year-old college student who lives a vegan lifestyle D) An infant who is exclusively fed commercial baby formula Ans: C Feedback: Megaloblastic anemia is caused by a deficiency of vitamin B12, which is found in most animal products. Commercial infant formulas do not lack vitamin B 12, and acute or chronic blood loss does not result in megaloblastic anemia.

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15. Which of the following clients are at high risk for developing anemia? Select all that apply.

A) A HIV-positive client who is experiencing frequent infection and elevated CD4+ counts B) A breast cancer client undergoing chemotherapy and radiation therapy C) A client who had a colectomy 3 weeks ago to remove adhesions and fecal impaction D) A COPD client with acute exacerbation requiring O2 therapy via C-PAP E) A middle-aged renal failure client who has hemodialysis three times/week Ans: A, B, E Feedback: Anemia often occurs as a complication of infections, inflammation, and cancer. The most common causes of chronic disease anemias are acute and chronic infections, including AIDS and osteomyelitis; cancers; autoimmune disorders such as rheumatoid arthritis, systemic lupus erythematosus, and inflammatory bowel disease; and chronic kidney disease. Postsurgical clients do experience some blood loss and may become anemic but not always. COPD clients do not routinely have low hemoglobin levels.

16. Which of the following clients are at risk of developing folic acid deficiency anemia?

Select all that apply.

A) A vegetarian who consumes no meats but gets protein from nuts/legumes B) A HIV-positive client who consumes “green juice” at least twice/day made with organic fruits and vegetables C) An elderly male with poor dietary habits who drinks approximately five alcoholic beverages/day D) A pregnant client with prolonged morning sickness lasting most of the day with nausea and frequent vomiting noted E) A toddler who wants to eat chicken nuggets and French fries but refuses to eat anything green Ans: C, D Feedback: Folic acid is readily absorbed from the intestine. It is found in vegetables (particularly the green leafy types), fruits, cereals, and meats. Much of the vitamin, however, is lost in cooking. The most common causes of folic acid deficiency are malnutrition or dietary lack, especially in the elderly or in association with alcoholism. Because pregnancy increases the need for folic acid 5- to 10-fold, a deficiency commonly occurs. Poor dietary habits, anorexia, and nausea are other reasons for folic acid deficiency during pregnancy. Studies have shown an association between folate deficiency and neural tube defects.

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17. For which of the following health problems is stem cell transplantation likely to be of therapeutic benefit?

A) Aplastic anemia B) -Thalassemias C) Chronic disease anemias D) Secondary polycythemia Ans: A Feedback: The etiology of aplastic anemia involves depression of the bone marrow, a problem that can sometimes be treated by stem cell transplantation. -Thalassemia, polycythemia, and anemias caused by chronic diseases are not amenable to stem cell transplantation.

18. A 48-year-old male client, who normally enjoys good health, has been admitted to the hospital for the treatment of polycythemia vera. The nurse who is providing care for the client should prioritize assessments aimed at the early identification of which of the following health problems?

A) Orthostatic hypotension B) Hyperventilation C) Vasculitis D) Thromboembolism Ans: D Feedback: The increased blood viscosity that accompanies primary polycythemia creates a significant risk of thromboembolism. Hypertension, not hypotension, is also a common sign. Vasculitis and hyperventilation are unlikely to result directly from polycythemia vera.

19. Polycythemia develops in clients with lung disease as a result of: A) Hyperventilation B) Chronic hypoxia C) Decreased blood viscosity D) Excessive respiratory fluid loss Ans: B Feedback: Secondary polycythemia results from a physiologic increase in the level of erythropoietin, commonly as a compensatory response to hypoxia. Conditions causing hypoxia include living at high altitudes, chronic heart and lung disease, and smoking.

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20. A 68-year-old client with an 80 pack/year history of smoking was diagnosed with emphysema 18 months ago. The client's most recent scheduled blood work showed excessive increase in production of red blood cell (erythrocytes), a problem that suggests the need for which of the following interventions?

A) Vitamin B12 supplements B) Increased supplementary oxygen therapy C) Hemodialysis or peritoneal dialysis D) Scheduled erythropoietin injections Ans: B Feedback: Treatment of secondary polycythemia focuses relief of the underlying hypoxia.

Secondary polycythemia increases in the production of erythropoietin, hence an increased production of erythrocytes. A vitamin B12 deficiency does not underlie secondary hypoxia, and dialysis is not a relevant treatment option. Erythropoietin injections would exacerbate the client's polycythemia.

21. Which of the following trends in the hematologic status of a 6-week-old infant (born at 32 weeks' gestation) most clearly warrants medical intervention?

A) Decreasing red blood cell counts B) Increasing HgA levels C) Decreasing mean corpuscular volume (MCV) D) Extremely low hematocrit Ans: D Feedback: Signs and symptoms include apnea, poor weight gain, pallor, decreased activity, and tachycardia. In infants born before 33 weeks' gestation or those with hematocrits below 33%, the clinical features are more evident. Decreasing red blood cell counts, hematocrit, and MCV are normal postnatal findings. Levels of HgA rise gradually following delivery.

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22. An infant (5 days old) has lab results revealing an elevated level of unconjugated bilirubin, due to hemolysis of RBCs. Because of this, which assessment findings would correlate with this abnormal lab result? Select all that apply.

A) Difficulty to arouse (lethargy) B) Cyanosis in hands and feet C) Click in the right hip area when adducted D) Jaundice E) Rigidity and tremors Ans: A, D Feedback: Unconjugated bilirubin and iron cause yellowing of the skin, or jaundice.

Hyperbilirubinemia places the neonate at risk for the development of a neurologic syndrome called kernicterus. This condition is caused by the accumulation of unconjugated bilirubin in brain cells. The manifestations of kernicterus may appear 2 to 5 days after birth in term infants or by day 7 in premature infants. Lethargy, poor feeding, and short-term behavioral changes may be evident in mildly affected infants.

Severe manifestations include rigidity, tremors, ataxia, and hearing loss. Extreme cases cause seizures and death. Cyanosis relates to low oxygen levels in the blood (hypoxia) and a click in a hip usually is associated with a fracture.

23. A mother has brought her 2-week-old infant to the emergency department due to the baby's persistent and increasing jaundice. Blood testing reveals that the infant's unconjugated bilirubin level is 28 mg/dL, and assessment does not reveal neurologic deficits. The infant's weight is normal, and the mother claims to have had no significant difficulty feeding the infant. The most likely treatment for this infant will be: A) Phototherapy B) Packed red blood cell transfusion C) Phlebotomy D) Intravenous antibiotics Ans: A Feedback: Phototherapy is the standard treatment for mild to moderate hyperbilirubinemia, with exchange transfusion an option for greater risks of kernicterus. Blood transfusions, phlebotomy, and antibiotics are not indicated in hyperbilirubinemia.

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24. When an Rh-negative mother has been sensitized and is pregnant with an Rh-positive fetus, what happens to the fetus?

A) Bilirubin deficiency B) Nothing, this is normal C) Plasma volume depletion D) Profound red cell hemolysis Ans: D Feedback: This situation is totally detrimental to the health of the fetus. Rh incompatibility and production of antibodies by the mother will result in life-threatening fetal red cell hemolysis. The bilirubin will be sufficiently elevated to cause brain damage. The infant will have massive edema from a lack of albumin production.

25. An 85-year-old male has been brought to the emergency department by his family.

Routine lab work reveals low hemoglobin of 8.7 g/dL. While taking a detailed history, which of the following statements by the client/family correlate with this anemia? Select all that apply.

A) “I get up to the bathroom two to three times/night.”

B) “When I go food shopping, I have to sit down and rest after one or two aisles.”

C) “He seems to get confused once in a while.”

D) “Some nights I just don't feel like eating a big meal.”

E) “Every now and then, my big toes gets swollen and hurts real bad.”

Ans: B, C Feedback: Undiagnosed and untreated anemia can have severe consequences and is associated with increased risk of mortality, cardiovascular disease, lower functional ability, self-care deficits, cognitive disorders, and reduced bone density that increases the risk for fractures with falls. Nocturia, anorexia, nor gout signs/symptoms are related to anemia.

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1. Chapter 14 A hospital client was swabbed on admission for antibiotic-resistant organisms and has just been informed that methicillin-resistant Staphylococcus aureus (MRSA) is present in his groin. The client has a normal core temperature and white blood cell count. This client is experiencing: A) Infection B) Proliferation C) Colonization D) Inflammation Ans: C Feedback: Colonization describes the act of establishing a presence, a step required in the multifaceted process of infection; infection describes the presence and multiplication within a host of another living organism. However, this client displays no signs of infection, inflammation, or proliferation of the microorganism.

2. Which most accurately describes the characteristics of saprophytes? They: A) Derive energy from decaying organic matter B) Are beneficial components of human microflora C) Have RNA or DNA, but never both D) Are capable of spore production Ans: A Feedback: Saprophytes are free-living organisms obtaining their growth from dead or decaying organic material in the environment. They are not necessarily spore producing, and they are not typical components of human microflora. Because most are bacterial or fungal, they contain both RNA and DNA.

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3. Which of the following are accurate characteristics of prions? Select all that apply.

A) Disease usually progresses slowly.

B) The primary manifestation includes ataxia and dementia.

C) Prions are protease sensitive.

D) Prions tend to aggregate into amyloid-like plaques in the brain.

E) Prions lack reproductive functions so are not very harmful to humans.

Ans: A, B, D Feedback: The various prion-associated diseases produce very similar pathologic processes and symptoms in the hosts and are collectively called transmissible neurodegenerative diseases. All are characterized by a slowly progressive, noninflammatory neuronal degeneration, leading to loss of coordination (ataxia), dementia, and death over a period ranging from months to years. Prion proteins in disease (called PrPSC) are resistant to the action of proteases (enzymes that degrade excess or deformed proteins). It is believed that PrPSC binds to the normal PrPC on the cell surface, causing it to be processed into PrPSC, which is released from the cell and then aggregates into amyloid-like plaques in the brain.

4. Although both eukaryotes and prokaryotes are capable of causing infectious diseases in humans, eukaryotes are unique because they have a/an: A) Organized nucleus B) Circular plasmid DNA C) Cytoplasmic membrane D) Variation of shape and size Ans: A Feedback: Eukaryotic cells have an organized nucleus. Many prokaryotes contain extra chromosomal pieces of circular DNA (plasmids). Prokaryotic cells have a flexible lipid cytoplasmic membrane. Both types of cells vary in shape and size.

5. Some viruses have the ability to transform host cells into cancer cells. For which of the following viruses should the client be assessed regularly for the potential development of cancer? Select all that apply.

A) Hepatitis A B) Hepatitis B C) Human papillomavirus D) Varicella Ans: B, C Feedback: Certain viruses have the ability to transform normal host cells into malignant cells during the replication cycle. This group of viruses is referred to as oncogenic and includes certain retroviruses and DNA viruses, such as the Epstein-Barr virus, hepatitis B virus, and human papillomavirus.

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6. Although growth rate is variable among types of bacteria, the growth of bacteria is dependent on: A) Biofilm communication B) Availability of nutrients C) An intact protein capsid D) Individual cell motility 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.

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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.

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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. Which of the following individuals is experiencing a health problem that is the result of a parasite?

A) A college student who contracted Chlamydia trachomatis during an unprotected sexual encounter B) A man who acquired malaria while on a tropical vacation C) A hospital client who has developed postoperative pneumonia D) A woman who developed hepatitis A from eating at an unhygienic restaurant Ans: B Feedback: Malaria is caused by a parasite. Chlamydial infections are bacterial, whereas hepatitis is viral. Pneumonia may be either viral or bacterial.

12. When skin is broken, germs can enter. Transmission of infectious agents is directly related to the: A) Source of contact B) Site of infection C) Number of pathogens absorbed D) Virulence factors Ans: C Feedback: Regardless of the source, site, or mechanism of entry and virulence, transmission of infectious agents is directly related to the number (infectious dose) of agents absorbed by the host.

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13. A 33-year-old client who is a long-term intravenous user of heroin has been recently diagnosed with hepatitis C. Which of the following portals of entry most likely led to the client's infection?

A) Direct contact B) Vertical transmission C) Ingestion D) Penetration Ans: D Feedback: Direct inoculation from intravenous drug use, and the accompanying disruption in the integrity of the body's surface barrier, is an example of entry by penetration. Vertical transmission occurs from mother to child, and neither direct contact nor ingestion is a likely source of this client's infection.

14. A public health nurse notes an increase in regional throat cancer cases. Upon epidemiological studies, many of the throat cancer clients also had oral exposure to human papillomavirus (HPV). This exposure to HPV would be considered by: A) Deep penetration of open lesions B) Direct contact with infected secretions C) Ingestion of HPV through the GI tract D) Accidental aspiration and inhalation of pathogens Ans: B Feedback: Most STIs are spread by direct contact. In addition to causing infectious diseases, certain viruses also have the ability to transform normal host cells into malignant cells during the replication cycle. This group of viruses is referred to as oncogenic and includes certain retroviruses and DNA viruses, such as the Epstein-Barr virus, hepatitis B virus, and human papillomavirus. Vertical transmission is possible for many sexually transmitted pathogens, but direct contact is more common. Ingestion and penetration are less likely mechanisms.

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15. Which of the following would be considered an example of transmitting an infection from person-to-person through shared inanimate objects (fomites)?

A) Malaria from mosquito bites B) HIV from a contaminated IV drug user needle C) Tuberculosis from inhalation of air after a cough D) Typhoid fever from traveling to a third-world country Ans: B Feedback: Infections can be transmitted from person-to-person through shared inanimate objects (fomites) contaminated with infected body fluids. An example of this mechanism of transmission would include the spread of the HIV and hepatitis B virus through the use of shared syringes by intravenous drug users. Infection can also be spread through a complex combination of source, portal of entry, and vector. Infection with hantavirus pulmonary syndrome is a prime example. This viral illness is transmitted from mice to humans by inhalation of dust contaminated with saliva, feces, and urine of infected rodents.

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.

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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.

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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.

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21. A premature neonate in the ICU suspected of having an infection has blood drawn for class specific antibodies. Which of the following confirms that the neonate has developed a congenital infection?

A) IgG titer is decreased.

B) IgM antibodies are elevated.

C) IgG antibodies remain elevated throughout entire ICU admission.

D) Initial IgM-specific antibodies are negative.

Ans: B Feedback: Serology samples are used to identify infectious organisms by measuring the levels of antibodies. The measurement of antibody titers has another advantage in that specific antibody types such as IgM and IgG are produced by the host during different phases of an infectious process. IgM-specific antibodies generally rise and fall during the acute phase of the disease, whereas the synthesis of the IgG class of antibodies increases during the acute phase and remains elevated until or beyond resolution. Measurements of class-specific antibodies are also useful in the diagnosis of congenital infections. IgM antibodies do not cross the placenta, but certain IgG antibodies are transferred passively from mother to child during the final trimester of gestation. Consequently, an elevated level of pathogen-specific IgM antibodies in the serum of a neonate must have originated from the child and therefore indicates congenital infection. A similarly increased IgG titer in the neonate does not differentiate congenital from maternal infection.

22. A client's primary care provider has ordered direct antigen detection in the care of a client with a serious symptomatology of unknown origin. Which of the following processes will be conducted?

A) Detecting DNA sequences that are unique to the suspected pathogen B) Growth of biofilms on various media in the laboratory setting C) Quantification of IgG and IgM antibodies in the client's blood D) Introduction of monoclonal antibodies to a blood sample from the client Ans: D Feedback: Direct antigen testing involves the introduction of labeled monoclonal antibodies to a sample of the client's tissue. This method of testing does not rely on detection of specific DNA sequences, growth of biofilms, or quantification of specific antibodies.

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23. A client has begun taking acyclovir, an antiviral medication, to control herpes simplex outbreaks. What is this drug's mechanism of action?

A) Inhibition of viral adhesion to cells B) Elimination of exotoxin production C) Antagonism of somatic cell–binding sites D) Interference with viral replication processes Ans: D Feedback: Acyclovir, like most antiviral drugs, interferes with normal viral replication. Antiviral drugs do not normally affect adhesion, and viruses are not associated with the production of exotoxins.

24. A client with cancer has been receiving amphotericin B intravenously. The client asks, “How will this help with my fungal disease?” The health care provider responds: A) “This medication inhibits the synthesis of ergosterol.”

B) “This drug binds to ergosterol and forms holes in the cell membrane, killing the fungus.”

C) “This medication will keep the body from growing any new fungi.”

D) “This drug impairs the synthesis of enzymes needed for viral replication.”

Ans: B Feedback: The polyene family of antifungal compounds (e.g., amphotericin B, nystatin) preferentially binds to ergosterol and forms holes in the cell membrane, causing leakage of the fungal cell contents and, eventually, lysis of the cell. The imidazole class of drugs (e.g., fluconazole, itraconazole) inhibits the synthesis of ergosterol, thereby damaging the integrity of the fungal cytoplasmic membrane. Zidovudine as well as nonnucleoside inhibitors impair the synthesis of the HIV-specific enzyme reverse transcriptase. This key enzyme is essential for viral replication.

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25. Which of the following is an example of how international travel has contributed to increased prevalence and incidence of nonindigenous diseases?

A) An airline pilot getting ill after eating pork in a restaurant in Hong Kong B) Outbreak of hemolytic–uremic syndrome related to contaminated salad being shipped to various regions C) Increase in the number of reported Lyme disease cases related to hot summer with local large deer population D) Hepatitis A outbreak when a restaurant worker forgot to wash the hands after using the rest room Ans: B Feedback: Travel results in more sources of infection, but it does not necessarily influence portals of entry, virulence, and the course of diseases. In 2011, one of the largest foodborne outbreaks of E. coli emerged as a global threat. Beginning in May 2011, German public health authorities reported an outbreak of hemolytic–uremic syndrome. Within 3 weeks, German authorities announced the source of the outbreak was cucumbers from Spain, a report later proven incorrect. As the investigation into the source of the outbreak continued, clients in surrounding countries also began to report illness. As the outbreak continued, epidemiologists focused their investigation on bean sprouts from a farm in Lower Saxony, Germany.

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1. Chapter 15 Innate immunity, also called natural or native immunity, consists of mechanisms that respond specifically to: A) Self-cells B) Microbes C) Antibodies D) Inflammation Ans: B Feedback: Innate immunity is the first line of defense against microbial invasion and is in place before infection. Inflammation and antibody production are responses to microbes after they have invaded the body. The innate immune system is able to identify non–self from self-cells.

2. A client who was exposed to hepatitis A at a local restaurant has recovered from the disease. At her annual physical, the client asks the health care provider if she should go to her health department and get the hepatitis A “shot.” The best response, based on the concepts of adaptive immunity, by the health care provider would be: A) “Yes, because you could get a worse case the next time you are exposed.”

B) “Of course. The virus changes every year.”

C) “I wouldn't since the vaccine can damage your liver.”

D) “No, since having an active case, you have already developed antigens against hepatitis A.” Ans: D Feedback: The adaptive immune system consists of two groups of lymphocytes and their products, including antibodies. Whereas the cells of the innate immune system recognize structures shared by classes of microorganisms, the cells of the adaptive immune system are capable of recognizing numerous microbial and noninfectious substances and developing a unique specific immune response for each substance. Substances that elicit adaptive immune responses are called antigens. A memory of the substance is also developed so that a repeat exposure to the same microbe or agent produces a quicker and more vigorous response. The hepatitis A virus does not change from year to year.

The vaccine does not damage the liver; however, the active hepatitis A disease can.

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3. A student asks, “What does cell-mediated immunity mean to the client?” The instructor responds. “This means: A) The body is trying to defend itself against intracellular microbe invasion by engulfing and destroying the microbe.”

B) The person's immune system is trying to eliminating all responses to certain antigens.”

C) The person's immune system is trying to rapidly mature more killer cells to protect against any microbial invasion.”

D) Our body is trying to systematically control the immune response.”

Ans: A Feedback: Cell-mediated immunity, which defends against intracellular microbes such as viruses, is provided by cells called T lymphocytes. Some T lymphocytes activate phagocytes to destroy microbes that have been engulfed, whereas others kill any type of host cell that is harboring microbes.

4. A teenager presents to the clinic with an infected wound from a bike accident. He asks, “How does my body fight off the germs in my scraped arm?” Which is the nurse's best response? “The cells that plays the central role related to the innate immune response to an infectious microorganism are: A) T lymphocytes.”

B) Antibodies.”

C) B lymphocytes.”

D) Neutrophils.”

Ans: D Feedback: Neutrophils are phagocytic cells that play a central role in innate immunity. Antibodies and B lymphocytes and T lymphocytes contribute exclusively to the adaptive immune response.

5. A mother of a child diagnosed with strep throat asks, “Why are the lymph nodes in my child's neck swollen?” The nurse will base her response knowing that dendritic cells help: A) Phagocytose foreign agents/microbes and migrate them to regional lymph nodes B) Produce more killer cells to assist building more immunity against strep throat C) Dispose of metabolic waste products D) Delay the inflammatory response Ans: A Feedback: Dendritic cells have the same function as macrophages—to initiate the adaptive immune response and present the processed antigen to T lymphocytes. Dendritic cells are found in skin tissue and transport antigens to lymph nodes. Dendritic cells do not dispose of normal metabolic waste products or control the inflammatory response.

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6. The cells that mediate humoral immunity do so because they are capable of producing: A) Platelets B) Antibodies C) Stem cells D) Helper T cells Ans: B Feedback: B lymphocytes (B cells) are the only cells capable of producing antibodies; therefore, they are the cells that mediate humoral immunity. B lymphocytes (B cells) differentiate into plasma cells that produce the needed immunoglobulins (antibodies) for responding to that particular antigen. Stem cells are undifferentiated cells. T helper cells differentiate into cytotoxic and other T-cell forms.

7. A client has recently received a pneumococcal vaccine and the client's B cells are consequently producing antibodies. Which of the following cells may enhance this production of antibodies?

A) Helper T cells B) Regulatory T cells C) Cytotoxic T cells D) Natural killer cells Ans: A Feedback: Among T lymphocytes are a subset of T cells called helper T cells, which help B lymphocytes produce antibodies. Natural killer cells as well as regulatory and cytotoxic T cells do not perform this function.

8. While caring for a pediatric client admitted with a viral infection, the nurse knows that which type of cell will be the child's primary defense against the virus?

A) Complement B) Bradykinin C) Leukotrienes D) Natural killer (NK) cells Ans: D Feedback: The third type of lymphocyte, the natural killer (NK) cell is part of the innate immune system and may be the first line of defense against viral infections. The NK cell also has the ability to recognize and kill tumor cells, abnormal body cells, and cells infected with intracellular pathogens, such as viruses and intracellular bacteria. Complement is activated in the inflammatory response. Leukotrienes and bradykinin are also a part of the inflammatory response.

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9. A child's thymus gland is fully formed and proportionately larger than an adult's. Which of the following processes that contributes to immunity takes place in the thymus gland?

A) Differentiation of B cells B) Production of natural killer (NK) cells C) Proliferation of T cells D) Filtration of antigens from the blood Ans: C Feedback: Phenotypically immature T cells enter the thymus from the bone marrow and undergo maturation and thymic selection. B cells are not differentiated in the thymus, and NK cells result from the common lymphoid progenitor. The spleen filters antigens from the blood.

10. While explaining immunity to a client, the nurse responds, “The body's internal organs are protected from pathogens because: A) Our mucosal tissue contains all the necessary cell components to fight a pathogen with an immune response.”

B) The tonsils store a large amount of natural killer cells at that location.”

C) We have special glands that can secrete cytokines on a moment's notice.”

D) The actions of the cytokines in the mouth can act on different cell types at the same time it is fighting pathogens.”

Ans: A Feedback: Secondary lymphoid tissues contain all the necessary cell components (i.e., T cells, B cells, macrophages, and dendritic cells) for an immune response. Because of the continuous stimulation of the lymphocytes in these tissues by microorganisms constantly entering the body, large numbers of plasma cells are evident. Immunity at the mucosal layers helps to exclude many pathogens and thus protects the vulnerable internal organs. Although cells of both the innate and adaptive immune systems communicate critical information by cell-to-cell contact, many interactions and effector responses depend on the secretion of short-acting soluble molecules called cytokines.

The actions of cytokines are often pleiotropic and redundant. Pleiotrophism refers to the ability of a cytokine to act on different cell types.

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11. A client's exposure to an antibiotic-resistant microorganism while in the hospital has initiated an immune response. Which of the following is responsible for the mediated and regulated actions that occur in this situation?

A) Peripheral lymphoid tissues B) Chemokines that contribute to an ongoing immune response C) Cytokines released at cell-to-cell interfaces, binding to specific receptors D) Phagocytosis in the response to viral invasion Ans: C Feedback: Most cytokines are released at cell-to-cell interfaces, where they bind to specific receptors on the membrane surface of their target cells. All cytokines are secreted in a brief, self-limited manner. They are not usually stored as preformed molecules. The short half-life of cytokines ensures that excessive immune responses and systemic activation do not occur. Cytokines are proteins, not cells, and are thus incapable of phagocytosis.

12. When discussing colony-stimulating factors (CSFs), the nurse explains that recombinant CSF is currently used to: A) Assist kidney dialysis clients to maintain a therapeutic potassium level B) Stimulate the bone marrow to produce more immature cells C) Grow stem cells in the laboratory D) Increase the success rate of bone marrow transplantation Ans: D Feedback: Recombinant CSF molecules are currently being used to increase the success rates of bone marrow transplantations. CSF does not affect potassium levels, encourage bone marrow to produce immature cells, or grow stem cells.

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13. A sixth grade science teacher asks the students to explain the role of cilia in the lower respiratory tract. Which student response is the best?

A) “These little hairs move germs trapped in mucous toward the throat so the body can cough them out.”

B) “Cilia help to warm the airways so that moisture in the air can neutralize any germs that get in our lungs.”

C) “Cilia can trap the microbes in one location so the body can grow scar tissue around them and wall them off so they can't cause disease.”

D) “Cilia help facilitate a chemical defense against germs by secreting an enzyme that will cement the germ to the lining of the airways.”

Ans: A Feedback: Also in the lower respiratory tract, hair-like structures called cilia protrude through the epithelial cells. The synchronous action of the cilia moves many microbes trapped in the mucous toward the throat. The physiologic responses of coughing and sneezing further aid in their removal from the body. Chemical defenses against trapped microbes include the following: lysozyme, which is a hydrolytic enzyme capable of cleaving the walls of bacterial cells; complement, which binds and aggregates bacteria to increase their susceptibility to phagocytosis or disrupt their lipid membrane; and members of the collectin family of surfactant proteins in the respiratory tract. The best-defined function of the surfactants is their ability to opsonize pathogens, including bacteria and viruses, and to facilitate phagocytosis by innate immune cells such as macrophages.

14. The entrance of a microbe into an individual's vascular space has initiated opsonization.

How will the health care provider explain this process critical in stopping the infiltration of the microbe through opsonization? Opsonization: A) Stimulates B cells by helper T cells B) Coats a microbe to activate phagocytosis recognition C) Releases proteins that stimulate cell production by the bone marrow D) Involves lysis of intracellular microbes by cytotoxic T cells Ans: B Feedback: The coating of particles, such as microbes, is called opsonization, and the coating materials are called opsonins. The opsonin bound to the microbe then activates the phagocyte after attachment to a complementary receptor on the phagocyte. Opsonization does not involve stimulation by T cells, stimulation of the bone marrow, or the lysis of microbes by cytotoxic T cells.

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15. While discussing the effector function of activated members of the complement system, the faculty member will include which of the following concepts? Select all that apply.

A) Chemotaxis B) Opsonization C) Pathogen lysis D) Phagocytosis E) Mobilization of immunoglobulins Ans: A, B, C Feedback: Activated complement initiates chemotaxis, opsonization, and formation of membrane attack complexes and pathogen lysis. Complement is a system and is not a phagocytic cell. The complement system also does not mobilize immunoglobulins.

16. The effector cells of the immune system have the primary function of: A) Activating phagocytic cells B) Eliminating the antigens C) Processing antigen into epitopes D) Controlling the immune response Ans: B Feedback: Effector cells function in the final stages of the immune response to eliminate the antigens. Control and activation are functions of the regulatory cells of the immune system. Processing antigen into epitopes is a function of accessory cells such as dendrite cells.

17. Major histocompatibility complex (MHC) molecules, with human leukocyte antigens (HLAs), are markers on all nucleated cells and have an important role in: A) Identifying blood types B) Cell membrane transport C) Suppressing viral replication D) Avoiding transplant rejections Ans: D Feedback: MHC and HLA markers are unique for each individual, except possibly for identical twins. Tissue and organ transplantation success is dependent on how closely matched the MHC molecules and HLAs are on the donor and recipient. MHC molecules and HLAs are not involved in transport or viral replication. Red blood cells do not have a nucleus and thus do not have HLA or MHC molecules on the surface.

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18. A 1-day-old infant was exposed to an infectious microorganism prior to discharge home from the hospital, but was able to affect a sufficient immune response in the hours and days following exposure. The nurse knows that which of the following immunoglobulins assisted with this process?

A) IgA B) IgG C) IgM D) IgD Ans: B Feedback: IgG is the only class of immunoglobulins to cross the placenta, and maternally transmitted IgG is effective against most microorganisms and viruses.

19. A newborn has been lethargic, is not nursing well, and is basically looking ill.

Following lab tests, it has been found that the newborn has IgM present in his blood.

How should the nurse interpret this finding?

A) All newborns have IgM in their blood so this is a normal finding.

B) IgM in the blood means the infant may be allergic to breast milk.

C) The presence of IgM suggests the infant has a current infection.

D) IgM is usually only found in saliva so the specimen must be contaminated.

Ans: C Feedback: IgM is the first immunoglobulin to appear in response to antigen and is the first antibody type made by a newborn. This is diagnostically useful because the presence of IgM suggests a current infection in the infant by a specific pathogen. IgE is involved in inflammation, allergic responses, and combating parasitic infections. It binds to mast cells and basophils. The binding of antigen to mast cell– or basophil-bound IgE triggers these cells to release histamine and other mediators important in inflammation and allergies. IgA is found in saliva and tears, and is a primary defense against infections in mucosal tissues.

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20. Prior to leaving on a backpacking trip to Southeast Asia, a college student has received a tetanus booster shot. This immunization confers protection by way of what immune process?

A) Secondary humoral response B) Cell-mediated immune response C) Primary humoral response D) Innate immunity Ans: A Feedback: Booster immunizations make use of the memory, or secondary, response that is a component of humoral immunity. A primary response occurs on first exposure to an antigen. This immunization does not make use of the cell-mediated immune response of innate immunity.

21. A client's cell-mediated immune response has resulted in the release of regulator T cells.

These cells will perform which of the following roles?

A) Suppressing the immune response to limit proliferation of potentially harmful lymphocytes B) Presenting antigens to B cells to facilitate the production of antibodies C) Differentiating into subpopulations of helper T cells D) Destroying target cells by releasing cytolytic enzymes and other toxins Ans: A Feedback: Regulatory T cells suppress immune responses by inhibiting the proliferation of other potentially harmful self-reactive lymphocytes. They do not present antigens to B cells, and activated CD4+ T cells differentiate into subpopulations of other helper T cells.

Cytotoxic T cells participate in the active destruction of target cells.

22. Which of the following clients is at the greatest risk for developing an intracellular pathogen infection?

A) A teenager who attends a crowded high school B) An AIDS client with a decreased CD4+ TH1 count C) A breast cancer client who has a WBC count of 8000 D) A hyperthyroid client who has received treatment with radioactive iodine Ans: B Feedback: Thus, the CD4+ TH1 cell controls and coordinates host defenses against certain intracellular pathogens, a function that helps to explain why a decreased CD4 + TH1 count in persons with acquired immunodeficiency syndrome (AIDS) places them at high risk for intracellular pathogen infections. If the teenager has a healthy immune system, high school should not place him or her at high risk for infection. A WBC of 8000 is normal. Radioactive iodine attacks the thyroid gland and does not usually interfere with immunity.

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23. The employee health nurse is working with a nursing student who has just sustained a needlestick injury and has received a dose of hepatitis B immune globulin. The nurse is counseling the student about vaccination against hepatitis B. Which statement by the student indicates understanding?

A) “I will make an appointment to start the hepatitis B vaccination series within the next 3 months.”

B) “I will only need to receive two doses of the hepatitis B vaccine because you just gave me one dose of the immune globulin.”

C) “I need to start the hepatitis B vaccination series as soon as possible.”

D) “I don't need to receive the hepatitis B vaccine because I will now produce antibodies against hepatitis B.” Ans: C Feedback: Some protection against infectious disease can be provided by the injection of hyperimmune serum, which contains high concentrations of antibodies for a specific disease, or immune serum or gamma globulin, which contains a pool of antibodies from many individuals, providing protection against many infectious agents. Passive immunity produces only short-term protection that lasts weeks to months.

24. Following delivery, the parents have chosen to have their infant's cord blood frozen. A blood test is performed on the cord blood and found to contain IgM antibodies. The nurse interprets this to mean: A) The infant has been exposed to an intrauterine infection.

B) The infant has received active antibodies from the mother.

C) The child's placenta was defective since it did not filter the IgM out of the blood.

D) The child likely already has developed an immunocompromised disease.

Ans: A Feedback: Protection of a newborn against antigens occurs through transfer of maternal antibodies.

Maternal IgG antibodies cross the placenta during fetal development and remain functional in the newborn for the first months of life. IgG is the only class of immunoglobulins to cross the placenta. Cord blood does not normally contain IgM or IgA. If present, these antibodies are of fetal origin and represent exposure to intrauterine infection.

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25. Which of the following findings are considered part of normal aging? Select all that apply.

A) Increased absolute number of lymphocytes B) Decrease in CD4+ count C) Decreased IL-2 level D) Elevated CD8+ T cells E) Increase in B-cell production Ans: B, C Feedback: There is a decrease in the size of the thymus gland, which is thought to affect T-cell function. A suggested biologic clock in T cells that determines the number of times it divides may regulate cell number with age. Some researchers have reported a decrease in the absolute number of lymphocytes, and others have found little, if any, change. The most common finding is a slight decrease in the proportion of T cells to other lymphocytes and a decrease in CD4+ and CD8+ T cells. Evidence indicates that aged T cells have a decreased rate of synthesis of the cytokines that drive the proliferation of lymphocytes and a diminished expression of the receptors that interact with those cytokines. For example, it has been shown that IL-2, IL-4, and IL-12 levels decrease with aging. Although B-cell function is compromised with age, the range of antigens that can be recognized is not diminished.

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1. Chapter 16 A 5-year-old child is experiencing itchy, watery eyes and an increased respiratory rate with some inspiratory wheezes. He has been outside playing in the yard and trees. The mother asks, “Why does he get like this?” The health care worker's best response is: A) “This is what we call a type I hypersensitivity reaction and usually occurs a few minutes after exposure to his allergen. It is primarily caused by mast cells in his body.”

B) “Because his allergy is related to something in his environment, the best thing you can do is try to keep him indoors as much as possible.”

C) “This sounds like he is on his way to having an anaphylactic reaction and you need to get a prescription for an EpiPen to decrease his response to monocytes.”

D) “This is pretty common in children. He is just getting used to all the allergens in the air. I suggest you just give him a shower after every time he plays outside.”

Ans: A Feedback: The immediate response to allergen exposure is mast cell degranulation and release of mediators such as histamine and acetylcholine. Monocytes respond as part of the acute immune response. There is no truth to this being an anaphylactic reaction. Showers may help, but the underlying cause is the mast cell degranulation and the release of preformed mediators.

2. A child has experienced a “bee-sting” while at the park. The health care provider is walking by and notices the child has swelling around the eyes, lips, and face in general.

What priority assessment should the nurse make at this time?

A) Palpate for carotid pulses in the neck.

B) Assess skin on the truck and back for development of hives.

C) Assess and establish an open airway.

D) Try to listen to breath sounds by placing your ear on the child's chest.

Ans: C Feedback: The initial management of anaphylaxis focuses on the establishment of a stable airway and intravenous access and the administration of epinephrine. Epinephrine produces relaxation of bronchial smooth muscle and inhibits the immediate life-threatening cardiovascular effects of anaphylaxis. All the other assessments (pulse rate, skin, and breath sounds) can be done after the airway is assessed and managed.

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3. The clinic nurse suspects the client is having a genetically determined hypersensitivity to common environmental allergens since the client is experiencing which of the following clinical manifestations? Select all that apply.

A) Hives B) Runny nose C) Diarrhea D) Topical pustules E) Wheezes Ans: A, B, E Feedback: Localized, inherited allergic reactions mediated by IgE are known as atopic reactions, such as urticaria (hives). Atopic reactions are immediate (not delayed such as type IV poison ivy rash). Infections are not part of type I hypersensitivity. Autoimmune reactions are in response to antigens, not allergens.

4. A client with a long history of “hay fever” has recently begun a series of immunotherapy (allergy shots). This treatment potentially will achieve a therapeutic effect by: A) Blocking cytokine release from sensitized mast cells B) Preventing mast cells from becoming sensitized C) Causing T cells to be sequestered in the thymus for longer periods D) Stimulating production of IgG to combine with antigens Ans: D Feedback: In immunotherapy, injected antigens stimulate production of high levels of IgG, which acts as a blocking antibody by combining with the antigen before it can combine with the cell-bound IgE antibodies. This therapy does not block cytokine release, prevent mast cell sensitization, or change the maturation process of T cells.

5. Which of the following lab values correlate to the fact that the client has developed a lytic drug reaction and is having an antibody response that lyses the drug-coated cell?

Select all that apply.

A) CD4 T-cell count of 500 cells B) Low hemoglobin of 9.1 C) WBC level of 5000 D) Low platelet level of 10,000 E) Elevated liver enzyme levels Ans: B, D Feedback: Lytic drug reactions can produce transient anemia (low RBCs and hemoglobin), leukopenia, or thrombocytopenia (low platelet levels), which often are corrected by the removal of the offending drug. A WBC of 5000 is normal. Changes in CD4 T cell counts relate to HIV infection. Liver enzymes do not rise because of a drug reaction.

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6. Which of the following clients should the nurse assess for a type III hypersensitivity immune responses resulting in injury to the vascular system? A client admitted with: Select all that apply.

A) Extensive edema associated with acute glomerulonephritis B) Newly diagnosed systemic lupus erythematosus (SLE) C) Facial droop and impaired speech D) Wheezing on inspiration E) Liver failure exhibiting bleeding tendencies Ans: A, B Feedback: Type III responses create immune complexes that are deposited in the affected tissues, activating an inflammatory response. Autoantibodies are involved with type II responses; cytotoxic cells are involved with type II and type IV responses.

Immunoglobulins are released in response to B-cell activation of plasma cells, which does not occur as part of type III reactions.

7. Contact with poison ivy has resulted in intense pruritus, erythema, and weeping on a client's forearm. Which of the following processes resulted in the client's signs and symptoms?

A) IgE-mediated mast cell degranulation B) Formation of antigen–antibody complexes C) Cytokine release by sensitized T cells D) Formation of antibodies against cell surface antigens Ans: C Feedback: The characteristic reaction to poison ivy is an example of contact dermatitis, a type IV hypersensitivity reaction. As such, the reaction is caused by sensitized T cells and the release of cytokines. IgE-mediated mast cell degranulation causes type I reactions, whereas antigen–antibody complexes are associated with type III reactions. Antibody formation against cell surface antigens are associated with type II reactions.

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8. A client who has undergone a liver transplant 7 weeks ago has developed the following assessment data: ALT/AST elevation; jaundice of skin and sclera; weight gain with increase in abdominal circumference; and low-grade fever. The nurse suspects: A) Hyperacute graft rejection B) Acute graft rejection C) Chronic rejection D) Atherosclerosis of arteries of the liver Ans: B Feedback: Allograph rejection is caused by tissue incompatibility that causes the recipient immune cells to attack and destroy the donor cells. The opposite, graft versus host disease, is characterized by recipient immune cells being destroyed by the donor cells because the recipient cells are recognized by the donor cells as foreign.

9. A client with a diagnosis of cirrhosis has experienced an acute rejection of a donor liver.

Which of the following cells is responsible for the rejection of the client's transplanted organ?

A) Natural killer cells B) Mast cells C) T cells D) Neutrophils Ans: C Feedback: Although different patterns of rejection exist, a general commonality is that T cells play a central role in the process of rejection. Mast cells and leukocytes do not participate directly in the physiology of rejection.

10. A client with a diagnosis of aplastic anemia has undergone allogenic bone marrow transplantation. Which of the following signs and symptoms would most clearly suggest the existence of graft versus host disease (GVHD)?

A) Shortness of breath, audible crackles, and decreasing PaO2 B) Presence of a pruritic rash that has begun to slough off C) Development of metabolic acidosis D) Diaphoresis, fever, and anxiety Ans: B Feedback: In cases of GVHD, there is development of a pruritic, maculopapular rash that begins on the palms and soles and frequently extends over the entire body, with subsequent desquamation. Respiratory complications are atypical, and neither metabolic acidosis nor diaphoresis and fever are common.

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11. The mechanism by which humans recognize self-cells from non–self (antigens)-cells is called: A) Autoimmunity B) Self-tolerance C) Nonself anergy D) Immunocompatibility Ans: B Feedback: Self-tolerance is the mechanism that humans have for recognizing self-cells from non–self-cells. When tolerance fails, an autoimmune disorder can be the result.

Immunocompatibility is how closely the cell surface markers of one human match with those of another human. Anergy is when T cells fail to respond to the presence of an antigen in the body.

12. A 70-year-old female client has had her mobility and independence significantly reduced by rheumatoid arthritis. Which of the following processes likely contributed to the development of her health problem?

A) Delayed-type hypersensitivity (DTH) reaction B) Proliferation of cytotoxic T cells C) Failure of normal self-tolerance D) Deletion of autoreactive B cells Ans: C Feedback: Ultimately, all autoimmune diseases are attributable to a disruption in self-tolerance that results in damage to body tissues by the immune system. Autoimmune diseases are not known to result from DTH reactions or the proliferation of cytotoxic T cells. Deletion of autoreactive B cells is a normal process that prevents autoimmune reactions in healthy individuals.

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13. A client has just been diagnosed with Graves disease. The primary care provider tells the client that this is due to the presence of autoantibodies to the TSH receptor. The client asks the nurse to explain this in simpler terms. Which response would be the best for this client?

A) “Hyperthyroidism is basically an autoimmune disorder.”

B) “Basically your lymph node system has gone haywire.”

C) “Your body has loss its ability to delete autoreactive T cells in the thyroid.”

D) “The filtration system in your body is no longer working.”

Ans: A Feedback: Several mechanisms are available to filter autoreactive B cells out of the B-cell population: clonal deletion of immature B cells in the bone marrow; deletion of autoreactive B cells in the spleen or lymph nodes; functional inactivation or anergy; and receptor editing, a process that changes the specificity of a B-cell receptor when autoantigen is encountered. There is increasing evidence that B-cell tolerance is predominantly due to help from T cells. Loss of self-tolerance with development of autoantibodies is characteristic of a number of autoimmune disorders. For example, hyperthyroidism in Graves disease is due to autoantibodies to the TSH receptor.

14. A client has developed pericarditis following an episode of acute glomerulonephritis, developments that may be attributable to the presence of similar epitopes on group A beta-hemolytic streptococci and the antigens in the client's heart tissue. Which of the following has most likely accounted for this client's autoimmune response?

A) Breakdown of T-cell anergy B) Release of sequestered antigens C) Superantigens D) Molecular mimicry Ans: D Feedback: Molecular mimicry is the phenomenon that exists when a microbe shares an immunologic epitope with the host, precipitating an autoimmune response. This miscategorization by cells of the immune system does not result from the release of sequestered antigens, failure of T-cell anergy, or the presence of superantigens.

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15. Which of the following would constitute a normal assessment finding in a neonate?

A) Minimal or absent levels of IgA and IgM B) Absence of plasma cells in the lymph nodes and spleen C) Undetectable levels of all immunoglobulins D) Absence of mature B cells with normal T-cell levels and function Ans: A Feedback: IgA and IgM levels are normally low in the neonate because these immunoglobulins do not cross the placental barrier. An absence of plasma cells in the lymph nodes and spleen accompanies common variable immunodeficiency. An absence of mature B cells with normal T-cell levels and function, as well as undetectable levels of all immunoglobulins, is a pathologic finding in X-linked agammaglobulinemia.

16. While working in the newborn nursery, a nurse is assessing a new admission. The nurse notes the infant has an increased distance between his eyes, a very small jaw, and a split uvula. Thinking this infant might have DiGeorge syndrome, the nurse should be assessing this infant for which of the following electrolyte imbalances?

A) Frequent ventricular beats on ECG due to hyperkalemia B) Loss of consciousness due to hyponatremia C) Tetany due to hypocalcemia D) Decreased reflexes due to hypermagnesemia Ans: C Feedback: Infants born with this defect have partial or complete failure in development of the thymus and parathyroid glands and have congenital defects of the head, neck, and/or heart. The facial disorders can include hypertelorism (increased distance between the eyes); micrognathia (abnormally small jaw); low-set, posteriorly angulated ears; split uvula; and high-arched palate. Urinary tract abnormalities also are common. The most frequent presenting sign is hypocalcemia and tetany that develop within the first 24 hours of life. It is caused by the absence of the parathyroid gland and is resistant to standard therapy.

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17. Which of the following statements from a group of young adults demonstrates the need for further teaching related to HIV and prevention of the spread?

A) “A woman can still get pregnant if she is HIV positive.”

B) “Having oral sex is one way I can prevent passing on HIV to my partner.”

C) “Good perineal care following sex will not have an effect on the transmission of HIV.” D) “My HIV medications do not prevent me from passing the virus on to my partners.”

Ans: B Feedback: Sexual contact is the most frequent mode of HIV transmission. There is a risk of transmitting HIV when semen or vaginal fluids come in contact with a part of the body that lets them enter the bloodstream. This can include the vaginal mucosa, anal mucosa, and wounds or sores on the skin. Condoms are highly effective in preventing the transmission of HIV. Unprotected sex between men is still the main mode of transmission. During the window period, a person's HIV antibody test result will be negative, but he or she can still transmit the virus.

18. A client was diagnosed as HIV positive several years ago. Which of the following blood test results reflects the fact that the client now has developed AIDS? A) 350,000 platelets/L B) CD4+ T-cell count less than 200 cells/L C) Viral load 500,000 copies/mL D) White blood cell count of 5300 cmm Ans: B Feedback: CD4+ cell counts are the primary measure that is used for the staging of HIV infection.

Viral load, platelets, and leukocytes are also important assessments, but these are not used to stage HIV.

19. HIV-positive persons who display manifestations of laboratory category 3 or clinical category C are considered to have: A) Zero viral load B) Seroconversion C) Complete remission D) AIDS-defining illnesses Ans: D Feedback: Laboratory category 3 and clinical category C are the most serious and indicate the presence of AIDS-defining illnesses. Seroconversion is clinical category A; zero viral load and remission could also be category A.

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20. A client has been admitted to the hospital for the treatment of HIV infection, which has recently progressed to overt AIDS. Which of the following nursing actions should the nurse prioritize when providing care for this client?

A) Frequent neurologic vital signs and thorough skin care B) Hemodynamic monitoring and physical therapy C) Careful monitoring of fluid balance and neurologic status D) Astute infection control and respiratory assessments Ans: D Feedback: Although all of the cited assessments and interventions may be of some value, infection control and the early identification of potential respiratory infections are paramount in the care of clients with AIDS.

21. The nurse caring for a population of HIV clients needs to be assessing for which of the following diseases that amounts to the leading cause of death for people with HIV? A) Leukemia B) Tuberculosis C) Pneumonia D) Toxoplasmosis Ans: B Feedback: Although HIV-positive people can develop all types of cancer, have viral or bacterial pneumonia, and be infected with the parasite that causes toxoplasmosis, tuberculosis is the disease that leads to death most often. Tuberculosis (TB) is the leading cause of death for people with HIV infection worldwide and is often the first manifestation of HIV infection. In 2011, 23% of those with TB tested positive for HIV.

22. The nurse can anticipate which of the following interventions to be prescribed for a client with AIDS who is experiencing involuntary weight loss of more than 10% of baseline body weight and frequent diarrhea daily? Select all that apply.

A) Enteral or parental nutrition B) Order for megestrol acetate C) Calcium carbonate for mineral replacement D) Benadryl, an antihistamine E) Prenatal vitamins Ans: A, B Feedback: Wasting syndrome is at least 10% weight loss in the presence of diarrhea, more than two stools a day, or chronic weakness and fever. Treatment for wasting syndrome includes nutritional interventions such as oral supplements or enteral or parenteral nutrition, as well as pharmacologic agents, including appetite stimulants, cannabinoids, and megestrol acetate.

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23. A college student has been called into the student health office because she tested positive for HIV on the enzyme-linked immunosorbent assay (ELISA). The student asks, “What is this Western blot assay going to tell you?” The best response by the health care provider is: A) “We always want two positive test results before we give you medicine.”

B) “The Western blot is a more sensitive assay that looks for the presence of antibodies to specific viral antigens.”

C) “This assay will actually look at all the individual cells in your blood and count how many HIV cells you have, so we can treat you with the proper medication.”

D) “If you are afraid of another blood test, we can do a rapid oral test to see if we get the same results.”

Ans: B Feedback: The Western blot is a more sensitive assay than the EIA that looks for the presence of antibodies to specific viral antigens. In the case of a false-positive EIA result, the Western blot test can identify the person as uninfected. Technologic advances have led to new forms of testing, such as the oral test, home testing kits, and the new rapid blood test. Oral fluids contain antibodies to HIV. In the late 1990s, the FDA approved the OraSure test. The OraSure uses a cotton swab, which is inserted into the mouth for 2 minutes, placed in a transport container with preservative, and then sent to a laboratory for EIA and Western blot testing.

24. Shortly after being diagnosed with HIV, a client has begun highly active antiretroviral therapy (HAART). The client asks, “My doctor tells me that my viral load is going down. What does that mean?” The nurse's best response is: A) “This means that you are in the long-term nonprogressors stage of HIV.” B) “Your HAART medications are working to slow the progression of the disease.”

C) “Your medications are going to decrease your ability to transmit the virus to your sexual partners.”

D) “You are developing drug resistance and may need to have your medications adjusted.”

Ans: B Feedback: Antiviral therapies such as HAART are prescribed to slow the progression of AIDS and improve the overall quality of life and survival time of persons with HIV infection.

Extension, not limitation, of the latent period is a goal. Minimizing transmission and preventing seroconversion are not normally achievable goals through drug therapy alone. The final 5% to 15% are long-term nonprogressors, who remain asymptomatic for 10 years or more after seroconversion, with stable CD4+ T-cell counts and low plasma HIV RNA levels.

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25. A home health nurse suspects that a child living with his IV drug–abusing mother may have HIV. Which of the following clinical manifestations would confirm this diagnosis?

Select all that apply.

A) Extremely small for his age to the point of failure to thrive B) CNS abnormalities like seizures, difficulty with walking C) Pneumonia culture reveals a fungal infection of the lungs D) Isolating himself in a back room with the lights dim E) Uncontrolled crying every time the mother approaches Ans: A, B, C Feedback: Children may have a different clinical presentation of HIV infection than adults. Failure to thrive, CNS abnormalities, and developmental delays are the most prominent primary manifestations of HIV infection in children. Children born with HIV infection usually weigh less and are shorter than noninfected infants. A major cause of early mortality for HIV-infected children is P. jiroveci pneumonia, which occurs early in children, with the peak age of onset at 3 to 6 months.

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1. Chapter 17 Upon admission assessment, the nurse hears a murmur located at the fifth intercostal space, midclavicular line. The client asks, “What does that mean?” The nurse will base her answer on which of the following physiologic principles?

A) “You have been exposed to an infection that went into your blood stream.”

B) “You have a heart valve that is diseased.”

C) “You heart has been pumping your blood so hard, that the pressure has damaged your valves.”

D) “Your heart has enlarged, so naturally your valves had to enlarge as well.”

Ans: B Feedback: Turbulence is often accompanied by vibrations of the blood and surrounding cardiovascular structures. Some of these vibrations are in the audible range and can be heard using a stethoscope. For example, a heart murmur results from turbulent flow through a diseased heart valve. The other distractors are not feasible.

2. A client is diagnosed with an abdominal aortic aneurysm that the physician just wants to “watch” for now. When teaching the client about signs/symptoms to watch for, the nurse will base the teaching on which of the following physiological principles?

A) Small diameter of this vessel will cause it to rupture more readily.

B) The larger the aneurysm, the less tension placed on the vessel.

C) As the aneurysm grows, more tension is placed on the vessel wall, which increases the risk for rupture.

D) The primary cause for rupture relates to increase in abdominal pressure such as straining to have a bowel movement.

Ans: C Feedback: Because the pressure is equal throughout, the tension in the part of the balloon with the smaller radius is less than the tension in the section with the larger radius. The same holds true for an arterial aneurysm in which the tension and risk of rupture increase as the aneurysm grows in size. Wall tension is inversely related to wall thickness, such that the thicker the vessel wall, the lower the tension, and vice versa. Although arteries have a thicker muscular wall than veins, their distensibility allows them to store some of the blood that is ejected from the heart during systole, providing for continuous flow through the capillaries as the heart relaxes during diastole.

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3. A client has entered hypovolemic shock after massive blood loss in a car accident.

Many of the client's peripheral blood vessels have consequently collapsed. How does the Laplace law account for this pathophysiologic phenomenon?

A) Blood pressure is no longer able to overcome vessel wall tension.

B) Decreasing vessel radii has caused a decrease in blood pressure.

C) Wall thickness of small vessels has decreased due to hypotension.

D) Decreases in wall tension and blood pressure have caused a sudden increase in vessel radii.

Ans: A Feedback: In circulatory shock, there is a decrease in blood volume and vessel radii, along with a drop in blood pressure. As a result, many of the small vessels collapse as blood pressure drops to the point where it can no longer overcome the wall tension. Decreases in vessel wall radii do not cause the decrease in blood pressure, and wall thickness generally remains static.

4. Which of the following statements about vascular compliance is accurate?

A) Arteries are much more distensible than veins.

B) Veins can act as a reservoir for storing large quantities of blood.

C) Arteries have thick muscular walls that constrict tightly, thereby ejecting blood without storing it for later use.

D) A continuous flow through the capillaries occurs primarily during systole.

Ans: B Feedback: The most distensible of all vessels are the veins, which can increase their volume with only slight changes in pressure, allowing them to function as a reservoir for storing large quantities of blood that can be returned to the circulation when it is needed. Although arteries have a thicker muscular wall than veins, their distensibility allows them to store some of the blood that is ejected from the heart during systole, providing for continuous flow through the capillaries as the heart relaxes during diastole.

5. In the days following a tooth cleaning and root canal, a client has developed an infection of the thin, three-layered membrane that lines the heart and covers the valves. What is this client's most likely diagnosis?

A) Pericarditis B) Endocarditis C) Myocarditis D) Vasculitis Ans: B Feedback: The endocardium is a thin, three-layered membrane that lines the heart and covers the valves; infection of this part of the heart is consequently referred to as endocarditis.

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6. Following several weeks of increasing fatigue and a subsequent diagnostic workup, a client has been diagnosed with mitral valve regurgitation. Failure of this heart valve would have which of the following consequences?

A) Backup of blood from the right atrium into the superior vena cava B) Backflow from the right ventricle to the right atrium during systole C) Inhibition of the SA node's normal action potential D) Backflow from the left ventricle to the left atrium Ans: D Feedback: The mitral valve separates the left ventricle from the left atrium; failure of this valve would cause backflow from the former to the latter during systole. Valve function does not directly affect cardiac contractility.

7. Heart muscle differs from skeletal muscle tissue by being able to generate: A) Contractions B) Calcium influx C) Action potentials D) Sarcomere binding Ans: C Feedback: Heart muscle, or the myocardium, is unique among other muscles in that it is capable of generating and rapidly conducting its own electrical impulses or action potentials. These action potentials result in excitation of muscle fibers throughout the myocardium.

Similarities to skeletal muscle include contractility, calcium influx, and actin–myosin (sarcomeres) binding.

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8. When discussing the AV node's role in the electrical conduction of the heart with a client newly diagnosed with an AV block, which of the following statements are accurate? Select all that apply.

A) The AV node offers a two-way conduction area between the atria and the ventricles.

B) The velocity of conduction through the AV junctional fibers is very fast, which greatly increases impulse transmission.

C) A block at the AV bundle of His interferes with the normal delay of the impulse, thereby interfering with complete ejection of blood from the atria prior to ventricular contraction.

D) When there is an AV block, impulses from the atria and ventricles beat independently of each other so, the heart rhythm is usually chaotic and not regular.

Ans: C, D Feedback: The AV node connects the atrial and ventricular systems and normally provides for a one-way conduction between the atria and ventricles. The velocity of conduction through the AV junctional fibers is very slow, which greatly delays impulse transmission. A further delay occurs as the impulse travels through the transitional fibers and into the AV bundle, known as the bundle of His. This delay provides a mechanical advantage whereby the atria can complete their ejection of blood before ventricular contraction begins. Under normal circumstances, the AV node provides the only connection between the atrial and ventricular conduction systems. The atria and ventricles would beat independently of each other if the transmission of impulses through the AV node were blocked.

9. If the parasympathetic neurotransmitter releases acetylcholine, the nurse should anticipate observing what changes in the ECG pattern?

A) Heart rate 150 beats/minute, labeled as supraventricular tachycardia B) Disorganized ventricular fibrillation C) Complete cardiac standstill D) Slowing of heart rate to below 60 beats/minute Ans: D Feedback: Acetylcholine, the parasympathetic neurotransmitter released during vagal stimulation of the heart, slows down the heart rate by decreasing the slope of phase 4. The catecholamines, the sympathetic nervous system neurotransmitters epinephrine and norepinephrine, increase the heart rate by increasing the slope or rate of phase 4 depolarization. Fibrillation is the result of disorganized current flow within the ventricle (ventricular fibrillation). Fibrillation interrupts the normal contraction of the atria or ventricles. In ventricular fibrillation, the ventricles quiver but do not contract. Thus, there is no cardiac output, and there are no palpable or audible pulses (i.e., cardiac standstill).

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10. When explaining a new diagnosis of complete heart block to a client/family, the nurse should include which of the following statements?

A) “This means that your atria are not contracting normally, they are quivering.”

B) “One consequence of this type of block is a very slow heart rate that limits circulation to the brain.”

C) “This type of arrhythmia requires defibrillation, which will occur in the cardiac catheter lab later today.”

D) “It's pretty common for everyone to experience this arrhythmia, especially during times of stress in their lives.”

Ans: B Feedback: In complete heart block, the atria and ventricles beat independently of each other. The most serious effect of some forms of AV block is a slowing of heart rate to the extent that circulation to the brain is compromised. Atria fibrillation is where there is interruption of the normal contraction of the atria, and the atria are quivering rather than contracting. Ventricular fibrillation requires immediate defibrillation for the client to survive. Complete heart block is not common. However, PVCs do occur under times of stress.

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.

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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.

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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. A client with a diagnosis of secondary hypertension has begun to experience signs and symptoms that are consistent with decreased cardiac output. Which of the following determinants of cardiac output is hypertension most likely to affect directly?

A) Preload B) Afterload C) Contractility D) Heart rate Ans: B Feedback: The afterload is the pressure or tension work of the heart. It is the pressure that the heart must generate to move blood into the aorta. The systemic arterial blood pressure is the main source of afterload work on the left heart. As blood pressure increases, the left ventricle must overcome greater resistance in order to pump blood into the circulatory system. Preload represents the volume work of the heart. It is the amount of blood that the heart must pump with each beat and represents the volume of blood stretching the ventricular muscle fibers at the end of diastole. Heart rate and cardiac contractility are strictly cardiac factors, meaning they originate in the heart, although they are controlled by various neural and humoral mechanisms.

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17. Hypoxia is said to have a negative inotropic effect on the heart, which means: A) The heart rate will slow down, so the atria and ventricles can fill better.

B) The cardiac output will decrease to cause less work for the heart.

C) The heart will adjust so that less time will be spent in diastole and filling of the ventricles will shorten.

D) There will be interference in the generation of ATP, which is needed for muscle contraction.

Ans: D Feedback: An inotropic influence is one that modifies the contractile state of the myocardium independent of the Frank-Starling mechanism. Hypoxia exerts a negative inotropic effect by interfering with the generation of ATP, which is needed for muscle contraction. Hypoxia does not directly slow the heart rate, decrease cardiac output, or interfere with filling times. However, these can develop if the ability of the muscle to contract becomes severe and is not treated promptly.

18. A large increase in heart rate can cause: A) Increased blood viscosity B) Loss of action potential C) Decreased stroke volume D) Reduced cardiac contractility Ans: C Feedback: The time spent in diastole and filling of the ventricles becomes shorter as the heart rate increases. This leads to a decrease in stroke volume and, at high heart rates, may produce a decrease in cardiac output. Increased heart rate does not typically cause increased blood viscosity, a loss of action potential, or reduced cardiac contractility.

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19. Which of the following statements about calcium channel–blocking (CCB) drugs is accurate?

A) Since CCB drugs work the -adrenergic receptors to open the channels, vasoconstriction occurs.

B) CCB drugs work on -adrenergic receptors to close the channels, so vasodilation occurs.

C) CCB drugs prevent reabsorption of calcium in the kidneys and therefore can lower serum calcium levels.

D) CCB drugs cause smooth muscle contraction, thereby allowing more blood to be stored in veins.

Ans: B Feedback: Calcium channel–blocking drugs cause vasodilation by blocking calcium entry through the calcium channels. They do not cause vasoconstriction, lower serum calcium levels, or cause smooth muscle contraction.

20. Following a hypertensive crisis, a client's family asks, “Why are the client's eyes so bloodshot?” The nurse responds that high arterial pressure: A) From straining to have a bowel movement can rupture small vessels in the eyes B) Damages more fragile blood vessels like those in the eyes to the point of rupture C) Can interfere with clotting factor production, so clients bleed more easily D) Cause heart muscle to pump stronger, sending too much blood to small vessels in the eyes Ans: B Feedback: Excessively high arterial pressure and tissue perfusion can be dangerous because they may damage the more fragile blood vessels (like those inside the eyes). The myogenic control mechanisms rely on stretch of the vascular smooth muscle in the vessel wall.

Therefore, it has been proposed that when the arterial pressure stretches the vessel, this in turn causes reactive vascular constriction that reduces the blood flow nearly back to normal.

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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.

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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.

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1. Chapter 18 A client asks, “Why do I have clogged arteries but my neighbor has higher 'bad cholesterol' levels and yet he is just fine?” The health care provider bases the reply on which of the following physiological principles about lipoprotein?

A) “Your neighbor probably has higher amounts of good cholesterol (HDL) as well.”

B) “You more than likely have small, dense type of 'bad cholesterol' (LDL).”

C) “Your neighbor has larger 'bad cholesterol' particles that can move into blood vessels but park in joints/tendons.”

D) “You must have a genetic predisposition to having clogged arteries.”

Ans: B Feedback: There are different types of LDL, and some people with markedly elevated LDL do not develop atherosclerotic vascular disease, whereas other people with only modest elevations in LDL develop severe disease. Small, dense LDL is more toxic or atherogenic to the endothelium than large, buoyant LDL. It is more likely to enter the vessel wall, become oxidized, and trigger the atherosclerotic process.

2. Which of the following would be considered a major cause of secondary hyperlipoproteinemia since it increases the production of VLDL and conversion to LDL? A) High-calorie diet B) Diabetes mellitus C) Bile-binding resin D) Cholesterol ingestion Ans: A Feedback: Obesity with high-calorie intake increases the production of VLDL, with triglyceride elevation and high conversion of VLDL to LDL. Excessive cholesterol intake reduces formation of LDL receptors. Diabetes is associated with high triglycerides and minimal elevation of LDL. Bile salt–binding resin is one treatment used to lower cholesterol levels.

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3. Which elevated serum marker for systemic inflammation is now considered a major risk factor for atherosclerosis and vascular disease?

A) Leukocytosis B) Homocysteine C) Serum lipoprotein D) C-reactive protein Ans: D Feedback: CRP is an acute-phase reactant synthesized in the liver that is a marker for systemic inflammation. A number of population-based studies have demonstrated that baseline CRP levels can predict future cardiovascular events among apparently healthy individuals. High-sensitivity CRP (hs-CRP) may be a better predictor of cardiovascular risk than lipid measurement alone. Homocysteine and serum lipoprotein are also serum markers, but they do not identify inflammation. Leukocytosis is an indicator of infection rather than inflammation alone.

4. The most important complication of atherosclerosis that may cause occlusion of small heart vessels is: A) Ulceration B) Thrombosis C) Fatty streaks D) Fibrous plaque Ans: B Feedback: Thrombus formations on complicated atherosclerotic lesions are the result of sluggish blood flow and turbulence in the ulcerated plaque region. Fatty streaks are preatherosclerotic plaque changes in vessels. Fibrous plaque is part of the atherosclerosis formation, not a complication of it.

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5. In addition to direct invasion of the vascular wall by an infectious agent, this pathogenic mechanism is a common cause of vasculitis?

A) Necrotizing granulomatous B) Tissue necrosis C) Mononuclear cells D) Immune-mediated inflammation Ans: D Feedback: The two most common pathogenic mechanisms of vasculitis are direct invasion of the vascular wall by an infectious agent and immune-mediated inflammation. The most common mechanisms that initiate noninfectious vasculitis are pathological immune responses that result in endothelial activation, with subsequent vessel obstruction, and ischemia of the dependent tissue. In almost all forms of vasculitis, the triggering event initiating and driving the inflammatory process is unknown. Medium-size vessel vasculitides produce necrotic tissue damage. Large-vessel vasculitides involve mononuclear cells. Wegener granulomatosis is characterized by a triad of acute necrotizing granulomatous lesions of the upper respiratory tract (ear, nose, sinuses, and throat), necrotizing vasculitis of the affected small- to medium-sized vessels of the lungs and respiratory airways, and renal disease in the form of focal necrotizing glomerulonephritis.

6. Atherosclerotic peripheral vascular disease is symptomatic with at least 50% occlusion.

The primary peripheral symptom, due to ischemia, is: A) Edema B) Calf pain C) Varicosities D) Strong pulse Ans: B Feedback: The primary symptom of chronic obstructive arterial disease is pain with walking or claudication. Typically, persons with the disorder complain of calf pain because the gastrocnemius muscle has the highest oxygen consumption of any muscle group in the leg during walking. The extremity will be thin, dry (no edema), and have weak low-pressure pulses due to severely reduced blood flow to the distal vessels.

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7. A client with a history of disabling claudication now is in the emergency department with a lower limb that is turning dark purple to black associated with faint Doppler pedal pulses. The client will more than likely undergo: A) Surgery to remove the saphenous vein B) Percutaneous transluminal angioplasty and stent placement C) Injection of a potent anticoagulant into lower leg veins D) Whirlpool therapy with tight wrapping of lower legs immediately following Ans: B Feedback: Treatment includes measures directed at protection of the affected tissues and preservation of functional capacity. Percutaneous or surgical intervention is typically reserved for the client with disabling claudication or limb-threatening ischemia. Surgery (i.e., femoropopliteal bypass grafting using a section of the saphenous vein) may be indicated in severe cases. Percutaneous transluminal angioplasty and stent placement, in which a balloon catheter is inserted into the area of stenosis and the balloon inflated to increase vessel diameter, is another form of treatment.

8. A health care provider was asked by a client, “Why do my hands turn blue when I drive my car in the winter without gloves?” Which of the following is the best response?

A) “Nothing to worry about. We all develop this as we age.”

B) “We better order a CT scan. It might be due to a blood clot in your radial artery.”

C) “This sounds like an inflammation in the lining of your veins. You need to take some NSAIDs.” D) “Your arteries in your hands/fingers are going into spasm, which decreases blood flow and circulating oxygen.”

Ans: D Feedback: Raynaud disease is caused by vasospasms of small distal arteries; thromboangiitis obliterans is caused by an inflammatory process that affects veins and nerves.

9. Because of its location, the presence of an abdominal aortic aneurysm may first be manifested as: A) Constipation B) Indigestion C) A pulsating mass D) Midabdominal pain Ans: C Feedback: An abdominal aortic aneurysm may be noticed as a pulsating mass when the client is lying flat, once the aneurysm is rather large already. Although there may be pressure on the abdominal organs by the mass, it is not associated with constipation or indigestion.

Severe midabdominal pain is a late sign of impending rupture.

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10. While lecturing on blood pressure, the nurse will emphasize that the body maintains its blood pressure by adjusting the cardiac output to compensate for changes in which of the following physiologic processes?

A) Peripheral vascular resistance B) Electrical impulses in the heart C) Release of stress hormones D) Rigidity of the ventricular walls Ans: A Feedback: The systolic and diastolic components of blood pressure are determined by cardiac output and total peripheral vascular resistance and can be expressed as the product of the two (blood pressure = cardiac output × total peripheral resistance). The body maintains its blood pressure by adjusting the cardiac output to compensate for changes in peripheral vascular resistance, and it changes the peripheral vascular resistance to compensate for changes in cardiac output. Electrical impulses from the SA node regulate heart rate. Release of stress hormones and rigidity of the ventricular walls do not primarily influence BP; however, they may impact this secondarily.

11. A client asks why his blood pressure pills seem to make him go to the bathroom to urinate frequently when they are not water pills (diuretics). Which of the following physiologic processes explains the long-term regulation of blood pressure most accurately?

A) Actions of the renin–angiotensin–aldosterone system B) Release of antidiuretic hormone (vasopressin) by the posterior pituitary C) Renal monitoring and adjustment of extracellular fluid volume D) Integration and modulation of the autonomic nervous system (ANS) Ans: C Feedback: Long-term maintenance and control of blood pressure is accomplished primarily through the renal control of fluid balance. These mechanisms function largely by regulating the blood pressure around an equilibrium point, which represents the normal pressure for a given individual. Accordingly, when the body contains too much extracellular fluid, the arterial pressure rises and the rate at which water and sodium are excreted by the kidney is increased. When blood pressure returns to its equilibrium point, water and sodium excretion returns to normal. Hormonal influences, such as those of ADH and the RAA system, and neural controls are utilized in the shorter-term control of blood pressure.

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12. A client consistently has an elevated systolic BP greater than 150 mm Hg but a diastolic pressure in the 80s. The health care provider should be assessing for which of the following complications?

A) Peripheral edema in lower legs from renal disease B) Crackles in bilateral lung bases caused by left-sided heart failure C) Ascites due to liver damage D) Confusion due to atherosclerosis of the carotid arteries Ans: B Feedback: Systolic hypertension has been defined as a systolic pressure of 140 mm Hg or greater and a diastolic pressure of less than 90 mm Hg. Elevated pressures during systole favor the development of left ventricular hypertrophy, increased myocardial oxygen demands, and eventual left heart failure. Peripheral edema and ascites are usually associated with right-sided failure. Confusion due to blockages in carotid arteries can occur independent of hypertension.

13. Which of the following is a nonmodifiable risk factor for the development of primary hypertension?

A) African American race B) High salt intake C) Male gender D) Obesity Ans: A Feedback: Hypertension not only is more prevalent in blacks than whites, but also is more severe, tends to occur earlier, and often is not treated early enough or aggressively enough.

Blacks also tend to experience greater cardiovascular and renal damage at any level of pressure. High salt intake and obesity are modifiable risk factors for hypertension. Male gender is not identified as a risk factor for hypertension.

14. A 52-year-old man who is moderately obese has recently been diagnosed with hypertension by his primary care provider. Which of the client's following statements indicates a need for further health promotion teaching?

A) “I've starting going to the gym before work three times a week.”

B) “I'm trying to cut back on the amount of salt that I cook with and add to my food.”

C) “I'm resolving to eat organic foods from now on and to drink a lot more water.”

D) “I'm planning to lose 15 pounds before the end of this year.”

Ans: C Feedback: Weight loss, exercise, and salt reduction are all useful strategies in the management of hypertension. An organic diet and increased fluid intake are not known to reduce blood pressure.

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15. A client with a diagnosis of chronic renal failure secondary to diabetes has seen a gradual increase in her blood pressure over the past several months, culminating in a diagnosis of secondary hypertension. Which of the following has most likely resulted in the client's increased blood pressure?

A) Increased levels of adrenocortical hormones B) Activation of the renin–angiotensin–aldosterone mechanism C) Increased sympathetic stimulation by the autonomic nervous system (ANS) D) Coarctation of the client's aorta Ans: B Feedback: Renovascular hypertension refers to hypertension caused by reduced renal blood flow and activation of the renin–angiotensin–aldosterone mechanism. It is the most common cause of secondary hypertension, accounting for 1% to 2% of all cases of hypertension.

The reduced renal blood flow that occurs with renovascular disease causes the affected kidney to release excessive amounts of renin, increasing circulating levels of angiotensin II. Angiotensin II, in turn, acts as a vasoconstrictor to increase peripheral vascular resistance and as a stimulus for increased aldosterone levels and sodium retention by the kidney. One or both of the kidneys may be affected. A renal etiology is not associated with secondary hypertension due to hormonal factors, sympathetic stimulation, or coarctation of the aorta.

16. A client with persistent, primary hypertension remains apathetic about his high blood pressure, stating “I don't feel sick, and it doesn't seem to be causing me any problems that I can tell.” How could the nurse best respond to this client's statement?

A) “Actually, high blood pressure makes you very susceptible to getting diabetes in the future.”

B) “That's true, but it's an indicator that you're not taking very good care of yourself.”

C) “You may not sense any problems, but it really increases your risk of heart disease and stroke.”

D) “You're right, but it's still worthwhile to monitor it in case you do develop problems.”

Ans: C Feedback: Hypertension is a highly significant risk factor for heart disease and stroke. It would be inappropriate to promote monitoring without promoting lifestyle modifications or other interventions to lower the client's blood pressure, or teaching the client about the deleterious effects of hypertension. It is likely unproductive to simply characterize the client's hypertension as demonstrating that he does not “take care” of himself.

Hypertension is not a risk factor for the development of diabetes mellitus.

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17. A client's primary care provider has added 20 mg of Lasix (furosemide) to his medication regimen to treat his primary hypertension. How does this agent achieve its therapeutic effect?

A) By decreasing vascular volume by increasing sodium and water excretion B) By blocking the release of antidiuretic hormone from the posterior pituitary C) By inhibiting the conversion of angiotensin I to angiotensin II D) By inhibiting the movement of calcium into arterial smooth muscle cells Ans: A Feedback: Diuretics lower blood pressure initially by decreasing vascular volume (by suppressing renal reabsorption of sodium and increasing sodium and water excretion) and cardiac output. Angiotensin-converting enzyme (ACE) inhibitors block the conversion of angiotensin I, and calcium channels blockers inhibit the movement of calcium into arterial smooth muscle. Common antihypertensives do not act directly on the pituitary.

18. A 29-year-old woman who considers herself active and health conscious is surprised to have been diagnosed with preeclampsia–eclampsia in her second trimester. What should her care provider teach her about this change in her health status?

A) “We don't really understand why some women get high blood pressure when they're pregnant.”

B) “This is likely a result of your nervous system getting overstimulated by pregnancy.”

C) “Hypertension is a common result of all the hormonal changes that happen during pregnancy.”

D) “Even though you're a healthy person, it could be that you have an underlying heart condition.”

Ans: A Feedback: The cause of pregnancy-induced hypertension is largely unknown.

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19. Which of the following children may be considered high risk for developing hypertension? Select all that apply.

A) Diagnosed with coarctation of the aorta as an infant B) Recent scan showing a pheochromocytoma C) Has a history of epilepsy with weekly seizures D) Takes cyclosporine daily since a kidney transplant E) Has a history of frequent sinus infections treated with antibiotics Ans: A, B, D Feedback: Approximately 75% to 80% of secondary hypertension in children is caused by kidney abnormalities. Coarctation of the aorta is another cause of hypertension in children and adolescents. Endocrine causes of hypertension, such as pheochromocytoma and adrenal cortical disorders, are rare. The nephrotoxicity of the drug cyclosporine, an immunosuppressant used in transplant therapy, may cause hypertension in children after kidney transplantation. Epilepsy and sinus infections do not cause hypertension.

20. An elderly client newly diagnosed with systolic hypertension asks her health care provider why this happens. The most accurate response would be: A) “Everyone over the age of 50 tends to have their blood pressure creep up over the years.”

B) “With age, your arteries lose their elasticity and are replaced with collagen, which makes your arteries stiffer.”

C) “Your heart has to work harder to pump blood through your vessels as you get older.”

D) “If you slow down and rest more, your blood pressures will more than likely return to its normal level.”

Ans: B Feedback: Systolic blood pressure rises almost linearly between 30 and 84 years of age, whereas diastolic pressure rises until 50 years of age and then levels off or decreases. This rise in systolic pressure is thought to be related to increased stiffness of the large arteries. With aging, the elastin fibers in the walls of the arteries are gradually replaced by collagen fibers that render the vessels stiffer and less compliant.

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21. Which of the following clients should most likely be assessed for orthostatic hypotension?

A) A 78-year-old woman who has begun complaining of frequent headaches unrelieved by over-the-counter analgesics B) A 65-year-old client whose vision has become much less acute in recent months and who has noticed swelling in her ankles C) An 80-year-old elderly client who has experienced two falls since admission while attempting to ambulate to the bathroom D) A 42-year-old client who has a history of poorly controlled type 1 diabetes Ans: C Feedback: Dizziness and syncope are characteristic signs and symptoms of orthostatic hypotension, and both predispose an individual to falls; this is especially the case among older adults.

Headaches, edema, diabetes, and vision changes are not associated with orthostatic hypotension.

22. Which of the following clients would be at high risk for developing primary varicose veins? Select all that apply.

A) A 47-year-old waitress who works 12-hour shifts three or four times/week B) A morbidly obese (>100 pounds overweight) male who works behind the counter of a convenience store 10 hours/day, 5 days/week C) A 56-year-old male who has been immobile due to back surgery and has developed a deep vein thrombosis D) A Marathon runner who has completed three marathons in the past 3 months E) A new peritoneal dialysis client who has been utilizing a home machine and performing dialysis every evening beginning at 8 PM Ans: A, B Feedback: Prolonged standing and increased intra-abdominal pressure are important contributing factors in the development of primary varicose veins. Because there are no valves in the inferior vena cava or common iliac veins, blood in the abdominal veins must be supported by the valves located in the external iliac or femoral veins. Immobility may cause DVTs (a secondary cause of varicose veins). Peritoneal dialysis has no effect on the development of varicose veins.

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23. A client is receiving home care for the treatment of a wound on the inside of her lower leg that is 3 cm in diameter with a yellow wound bed and clear exudate. Assessment of the client's legs reveals edema and a darkened pigmentation over the ankles and shins of both legs. What is this client's most likely diagnosis?

A) Chronic venous insufficiency B) Deep vein thrombosis C) Varicose veins D) Peripheral arterial disease Ans: A Feedback: In contrast to the ischemia caused by arterial insufficiency, venous insufficiency leads to tissue congestion, edema, and eventual impairment of tissue nutrition (development of a venous ulcer). The edema is exacerbated by long periods of standing. Necrosis of subcutaneous fat deposits occurs, followed by skin atrophy. Brown pigmentation of the skin caused by hemosiderin deposits resulting from the breakdown of red blood cells is common. DVTs, varicose veins, and PAD do not have this symptomatology.

24. The client is immobilized following a hip injury and has begun demonstrating lower leg discoloration with edema, pain, tenderness, and increased warmth in the midcalf area.

He has many of the manifestations of: A) Stasis ulcerations B) Arterial insufficiency C) Primary varicose veins D) Deep vein thrombosis Ans: D Feedback: Venous insufficiency with deep vein thrombus formation is characterized by discoloration, edema, pain, tenderness, and warmth most commonly in the mid- or lower calf area of the legs. Immobility raises the risk for thrombus formation. The skin is intact, so venous stasis ulcerations are not present. Distended torturous veins (varicosity manifestations) are not present.

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25. A postsurgical client reports calf pain combined with the emergence of swelling and redness in the area, which have culminated in a diagnosis of deep vein thrombosis. What treatment options will be of greatest benefit to this client?

A) Analgesics and use of a pneumatic compression device B) Massage followed by vascular surgery C) Frequent ambulation and the use of compression stockings D) Anticoagulation therapy and elevation of the leg Ans: D Feedback: Anticoagulants, immobilization, and elevation of the affected extremity are used in the treatment of DVT. Interventions that are used to prevent DVT (ambulation; compression stockings; compression devices) may be harmful when a DVT is present. Surgery is not normally required, and massage has the potential to dislodge a DVT.

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1. Chapter 19 The plaques in a client's coronary arteries are plentiful, and most have small- to moderate-sized lipid cores with thick fibrous caps. This form of atherosclerosis is most closely associated with which of the following diagnoses?

A) Stable angina B) Non–ST-segment elevation MI C) ST-segment elevation MI D) Unstable angina Ans: A Feedback: The fixed or stable plaque is commonly associated with stable angina, and the unstable plaque is implicated in unstable angina and myocardial infarction (MI).

2. Atherosclerotic plaque is most likely to be unstable and vulnerable to rupture when the plaque has a thin fibrous cap over a: A) Red thrombus B) Large lipid core C) Calcified lesion D) Vessel wall injury Ans: B Feedback: Plaque disruption causes thrombus formation, with white platelet-containing thrombi being associated with unstable angina. The major determinants of plaque vulnerability to disruption include the size of its lipid-rich core, lack of stabilizing smooth muscle cells, presence of inflammation with plaque degradation, and stability and thickness of its fibrous cap. Plaques with a thin fibrous cap overlaying a large lipid core are at high risk for rupture. Plaque tends to be stable or fixed unevenly in any area of the coronary arteries. Calcified plaque tends to be stable and encased in a thrombus, until it begins to degrade.

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3. Clients with ischemic coronary vessel disease and acute coronary syndrome (ACS) are classified as low or high risk for acute myocardial infarction based on characteristics that include significant: A) Heart murmurs B) ECG changes C) Pulmonary disease D) Pericardial effusion Ans: B Feedback: Persons with ischemic coronary vessel disease and ACS are routinely classified as low or high risk for acute myocardial infarction based on clinical history, ECG variables, and serum cardiac biomarkers. Chronic pulmonary disease increases pulmonary vascular resistance, leading to right or left heart failure. Pericardial effusion increases intracardiac pressure and venous pressure. Heart murmurs result from turbulent blood flow through a diseased valve.

4. Which of the following individuals is suffering the effects of acute coronary syndrome (ACS)?

A) A client whose most recent ECG indicates that silent myocardial ischemia has occurred B) A client who occasionally experiences persistent and severe chest pain when at rest C) A client who sometimes experiences chest pain when climbing stairs D) A client who has recently been diagnosed with variant (vasospastic) angina Ans: B Feedback: The onset of STEMI involves abrupt and significant chest pain. The pain typically is severe, often described as being constricting, suffocating, and crushing. Substernal pain that radiates to the left arm, neck, or jaw is common, although it may be experienced in other areas of the chest and back. Unlike that of angina, the pain associated with MI is more prolonged and not relieved by rest or nitroglycerin. Silent MI, stable angina, and variant, or vasospastic, angina are subtypes of chronic ischemic coronary artery disease.

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5. A father experienced the onset of chest pain and dies suddenly. The family asks, “What caused him to die so suddenly?” The health care provider's reply that is most appropriate would be, “There's a high probability that your loved one developed an acute heart attack and experienced: A) Acute myocarditis.”

B) High troponin levels.”

C) Acute ventricular arrhythmia.”

D) Hypertrophic cardiomyopathy.”

Ans: C Feedback: Sudden death from an acute myocardial infarction in an adult is usually caused by fatal (ventricular) arrhythmias. Hypertrophic cardiomyopathy is the most common cause of sudden cardiac death in the young, since the disorder can be inherited as an autosomal dominant trait. Troponin is normally present in cardiac muscle; serum levels of troponin enzymes are diagnostic and will elevate within 3 hours of the acute event. Myocarditis is inflammation of the heart muscle and conduction system without evidence of myocardial infarction.

6. The nurse would anticipate that which of the following clients would be considered a good candidate for coronary artery bypass grafting (CABG)?

A) A 56-year-old with a history of MI experiencing new-onset chest pain and ST elevation B) A 24-year-old auto accident client diagnosed with pericardial effusion and cardiac tamponade C) A 87-year-old client admitted with uncontrolled dilated cardiomyopathy D) A 78-year-old client admitted with increasing fatigue related to aortic stenosis Ans: A Feedback: Coronary artery bypass grafting (CABG) may be the treatment of choice for people with significant coronary artery disease (CAD) who do not respond to medical treatment and who are not suitable candidates for percutaneous coronary intervention. CABG does not address valve disorders, pericardial effusion, or cardiomyopathies.

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7. On the 3rd day following an acute myocardial infarction, the client is being discharged home. The nurse is explaining how the heart tissue heals following an MI. “Since today is your 3rd day after your heart attack, the tissue is: A) Soft, mushy, and yellow.”

B) Acutely inflamed.”

C) Forming granulation tissue.”

D) Developed a fibrous scar.”

Ans: B Feedback: Approximately 2 to 3 days post–myocardial infarction, an acute inflammatory response develops in the area surrounding the necrotic tissue. The damaged area is gradually replaced with vascularized granulation tissue, which in turn becomes less vascular and more fibrous in composition. At 4 to 7 days, the center of the infarcted area is soft and yellow. By the 7th week, the necrotic area is completely replaced by fibrous scar tissue.

8. Chronic stable angina, associated with inadequate blood flow to meet the metabolic demands of the myocardium, is caused by: A) Fixed coronary obstruction B) Increased collateral circulation C) Intermittent vessel vasospasms D) Excessive endothelial relaxing factors Ans: A Feedback: Chronic stable angina is caused by fixed coronary obstruction that produces an imbalance between coronary blood flow and the metabolic demands of the myocardium.

Endothelial relaxing factors relax the smooth muscle in the vessel wall and allow increased blood flow; treatment for chronic stable angina is with a vasodilating agent, such as nitroglycerine, that relaxes the vessels and enhances coronary blood flow.

Intermittent vessel vasospasms, in conjunction with coronary artery stenosis, cause the vasospastic type of angina. Increased formation of collateral vessels is a compensatory response that allows adequate blood circulation to tissues distal to an obstruction.

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9. Endocarditis and rheumatic heart disease are both cardiac complications of systemic infections. Characteristics include a new or changed heart murmur caused by: A) Chronic atrial fibrillation B) Myocardial inflammation C) Left ventricle hypertrophy D) Vegetative valve destruction Ans: D Feedback: Murmurs are sounds produced by blood flow through incompetent valves. Both infective endocarditis and carditis of rheumatic heart disease are characterized by growth of vegetation on valve leaflets, causing destruction, regurgitation, and murmur.

Atrial fibrillation is a conduction disorder that impairs atrial emptying rather than valve function. Myocardial inflammation is present but does not cause murmurs. Valve dysfunctions can chronically decrease emptying and lead to left ventricular hypertrophy.

10. An IV drug abuser has been diagnosed with infective endocarditis. He is in the emergency department reporting increasing shortness of breath, rapid breathing, chest pain that worsens with breathing, and coughing up blood. The health care provider recognizes this may be caused by: A) Vegetative emboli traveling in the blood stream to the lungs B) Blood clots in the left ventricle traveling through the aorta C) Microemboli being developed in the carotids by Staphylococcus epidermidis D) Infarction of the tissue surrounding the endocardium of the heart Ans: A Feedback: The client is exhibiting signs of pulmonary emboli. The infectious loci continuously release bacteria into the bloodstream and are a source of persistent bacteremia, sometimes contributing to pericarditis. As the lesions grow, they cause valve destruction and dysfunction such as regurgitation, ring abscesses with heart block, and perforation.

The loose organization of these lesions permits the organisms and fragments of the lesions to form emboli and travel in the bloodstream, causing cerebral, systemic, or pulmonary emboli. If clots are in the left ventricle, they will travel to the brain or kidneys. If emboli are located in the carotids, they will travel to the brain tissue.

Infarction of heart tissue will exhibit signs of a myocardial infarction, not pulmonary emboli.

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11. Which of the following lab results strongly suggest an immunologic response in the client with possible rheumatic heart disease?

A) Elevated white blood cell count B) Elevated erythrocyte sedimentation rate (ESR) C) Group A (-hemolytic) streptococcal antibodies D) High C-reactive protein levels Ans: C Feedback: The pathology of RF does not involve direct bacterial infection of the heart. Rather, the time frame for development of symptoms relative to the onset of pharyngitis and the presence of antibodies to the GAS organism strongly suggests an immunologic response. It is thought that antibodies directed against the M-protein of certain strains of streptococci cross-react with glycoprotein antigens in the heart, joints, and other tissues to produce an autoimmune response through a phenomenon called molecular mimicry.

Elevated erythrocyte sedimentation rate (ESR) is a blood test that can reveal inflammatory activity in your body. The level of CRP rises when there is inflammation throughout the body. Elevated WBC indicates an infection.

12. A child's history of a recurrent sore throat followed by severe knee and ankle pain has resulted in a diagnostic workup and a diagnosis of rheumatic fever. What are the treatment priorities for this child?

A) Cardiac catheterization and corticosteroid therapy B) Implanted pacemaker and -adrenergic blockers C) Antibiotics and anti-inflammatory drugs D) Pain control and oxygen therapy Ans: C Feedback: A diagnosis of rheumatic fever (RF) necessitates the use of antibiotics (usually penicillin) and anti-inflammatory drugs. These measures supersede the importance of pain control and oxygen therapy. Cardiac catheterization, corticosteroid therapy, pacemakers, and -adrenergic blockers are not common treatment modalities for RF.

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13. Which of the following diagnostic/assessment findings would been seen in a client with worsening mitral valve stenosis? Select all that apply.

A) Low-pitched diastolic murmur that is increasing in duration B) Sharp elevation in left atrial pressure C) Decreased cardiac output D) Severe elevation in left ventricular end-diastolic pressure E) Left ventricle increases its stroke volume Ans: A, B, C Feedback: The increased left atrial pressure eventually is transmitted to the pulmonary venous system, causing pulmonary congestion. A characteristic auscultatory finding in mitral stenosis is an opening snap following the second heart sound, which is caused by the stiff mitral valve. As the stenosis worsens, there is a localized low-pitched diastolic murmur that increases in duration with the severity of the stenosis. Manifestations are related to the elevation in left atrial pressure and pulmonary congestion such as dyspnea with exertion, decreased cardiac output owing to impaired left ventricular filling, and left atrial enlargement with the development of atrial arrhythmias and mural thrombi.

Severe elevation in left ventricular end-diastolic pressure and left ventricle increases its stroke volume occur with aortic regurgitation.

14. An elderly female client who reports increasing fatigue has been diagnosed with aortic stenosis, a disease that her primary care provider believes may have been long-standing.

Which of the following compensatory mechanisms has most likely maintained the woman's ejection fraction until recently?

A) Left ventricular hypertrophy B) Increased blood pressure C) Increased heart rate and stroke volume D) Aortic dilation Ans: A Feedback: Because aortic stenosis develops gradually, the left ventricle has time to adapt by increasing in wall thickness to maintain a normal ejection fraction. Increased blood pressure and heart rate and dilation of the aorta are not responses that mitigate the effects or aortic stenosis.

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15. An elderly client is admitted with the diagnosis of severe aortic regurgitation. Which of the following client reports support this diagnosis? Select all that apply.

A) Exertional dyspnea B) Orthopnea C) Frequent angina D) Paroxysmal nocturnal dyspnea E) Palpitations Ans: A, B, D, E Feedback: As aortic regurgitation progresses, signs and symptoms of left ventricular failure begin to appear. These include exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. Angina is a rare symptom. Tachycardia, occurring with emotional stress or exertion, may produce palpitations, head pounding, and premature ventricular contractions.

16. Which of the following would be considered a clinical manifestation of acute pericarditis? Select all that apply.

A) Sharp, abrupt onset of chest pain that radiates to the neck B) Pericardial friction rub C) Narrowed pulse pressure D) Muffled heart sounds E) Abnormal ECG results Ans: A, B, E Feedback: The manifestations of acute pericarditis include a triad of chest pain, an auscultatory pericardial friction rub, and electrocardiographic (ECG) changes. The pain usually is sharp and abrupt in onset, occurring in the precordial area, and may radiate to the neck, back, abdomen, or side. Pain in the scapular area may result from irritation of the phrenic nerve. The pain typically is pleuritic (aggravated by inspiration and coughing) and positional (decreases with sitting and leaning forward) because of changes in venous return and cardiac filling. A pericardial friction rub results from the rubbing and friction between the inflamed pericardial surfaces. Persons with cardiac tamponade usually have heart sounds that become muffled because of the insulating effects of the pericardial fluid and reduced cardiac function. A key diagnostic finding in cardiac tamponade is pulsus paradoxus or an exaggeration of the normal variation in the systolic blood pressure.

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17. A client was in car accident client while not wearing a seatbelt and has sustained multiple rib fractures. During assessment, the nurse is having a hard time hearing heart sounds, and the client reports chest pain/pressure repeatedly. This client may be experiencing: A) Cardiomyopathy B) Pericarditis C) Pulmonary hypertension D) Pericardial effusion Ans: D Feedback: Pericardial effusion is the accumulation of fluid in the pericardial cavity, usually as a result of an inflammatory reaction. It may develop with neoplasms, cardiac surgery, or trauma. Pericardial effusion exerts its effects through compression of the heart chambers. The normal pericardial space contains about 15 to 50 mL of fluid. Increases in the volume of this fluid, the rapidity with which it accumulates, and the elasticity of the pericardium determine the effect that the effusion has on cardiac function. This leads to cardiac standstill or failure. Pericardial sac thickening due to inflammation can restrict the heart, rather than to allow stretching. Rupture of the sac is pathologic, resulting in heart expansion. A friction rub sound (rubbing between the inflamed pericardial surfaces) is characteristic of acute pericarditis. Acquired cardiomyopathies include those that have their origin in the inflammatory process (e.g., myocarditis), pregnancy (peripartum cardiomyopathy), and stress (takotsubo cardiomyopathy). In congenital heart defects, in most cases, pulmonary vascular resistance is only slightly elevated during early infancy, and the major contribution to pulmonary hypertension is the increased blood flow.

18. Which of the following assessment findings would be suggestive of cardiac tamponade?

A) Increasing PaCO2 and decreasing PaO2 B) Audible crackles on chest auscultation and presence of frothy sputum C) A 20 mm Hg drop in systolic blood pressure during respiration D) Normal ECG combined with complaints of chest pain and shortness of breath Ans: C Feedback: A key diagnostic finding in cardiac tamponade is pulsus paradoxus, or an exaggeration of the normal variation in the systolic blood pressure, commonly defined as a 10 mm Hg or more fall in the systolic blood pressure, which occurs with inspiration. Worsening blood gases, chest secretions, and chest pain are not symptoms specific to cardiac tamponade. The client's ECG would not be normal.

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19. Football fans at a college have been shocked to learn of the sudden death of a star player, an event that was attributed in the media to “an enlarged heart.” Which of the following disorders was the player's most likely cause of death?

A) Takotsubo cardiomyopathy B) Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) C) Hypertrophic cardiomyopathy (HCM) D) Dilated cardiomyopathy (DCM) Ans: C Feedback: The most frequent symptoms of HCM are dyspnea and chest pain in the absence of coronary artery disease. Syncope (fainting) is also common and is typically postexertional, when diastolic filling diminishes and outflow obstruction increases.

Ventricular arrhythmias are also common, and sudden death may occur, often in athletes after extensive exertion. Risk factors for sudden cardiac death among clients with HCM include a family history of syncope or sudden cardiac death, certain mutations, and extreme hypertrophy of the left ventricle. HCM is characterized by a massively hypertrophied left ventricle with a reduced chamber size.

20. A client is admitted with dilated cardiomyopathy with left ventricular dysfunction. The nurse should assess for which of the following clinical manifestations? Select all that apply.

A) Dyspnea B) Orthopnea C) Extreme fatigue with activity D) Excess abdominal fluid E) Fainting Ans: A, B, C Feedback: The most common clinical manifestations of DCM are those related to heart failure, such as dyspnea, orthopnea, and reduced exercise capacity. Hypertrophic cardiomyopathy (HCM) is characterized by myocardial thickening and abnormal diastolic filling. They experience fainting/syncope. Restrictive cardiomyopathy, in which there is excessive rigidity of the ventricular wall, increases the work of ventricular emptying and causes cardiac hypertrophy. These clients experience excess abdominal fluid (ascites).

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21. Implantation of a pacemaker is most likely to benefit a client with which of the following cardiomyopathies?

A) Myocarditis B) Takotsubo cardiomyopathy C) Dilated cardiomyopathy (DCM) D) Primary restrictive cardiomyopathy Ans: C Feedback: Arrhythmias and dysrhythmias are characteristic of DCM, often requiring the use of an implanted pacemaker or an implantable cardioverter–defibrillator. Implanted pacemakers are not noted to be among the common treatments for myocarditis, Takotsubo cardiomyopathy, or primary restrictive cardiomyopathy.

22. Congenital heart defects can cause a right heart–to–left heart shunting of blood that results in increased: A) Pulmonary blood volume B) Right ventricle workload C) Unoxygenated blood flow D) Right atrial blood volume Ans: C Feedback: Right-to-left shunts transfer unoxygenated blood from the right side of the heart to the left side, diluting the oxygen content of blood that is being ejected into the systemic circulation and causing cyanosis. Left-to-right shunts cause recycling of blood through the pulmonary vessels and the right side of the heart, causing increased volume and workload of the right side of the heart and pulmonary circulation.

23. When educating the parents of a cyanotic infant diagnosed with of tetralogy of Fallot, the nurse will include which of the following statements related to the physiological abnormalities? The infant has: Select all that apply.

A) A hole in the ventricular septal B) A small, narrow pulmonary outflow channel C) A large, thick, right ventricular wall D) A very small, narrow aorta E) The pulmonary artery arises from the left ventricle Ans: A, B, C Feedback: Tetralogy of Fallot consists of four associated defects: a ventricular septal defect; dextroposition of the aorta; obstruction or narrowing of the pulmonary outflow channel; and hypertrophy of the right ventricle. Narrowing, or coarctation, of the aorta is not associated with tetralogy of Fallot. Rising of pulmonary arteries from the left ventricle instead of the right is a sign of transposition of the great vessels.

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24. Persistent cyanosis has led an infant's care team to suspect a congenital heart defect.

Which of the following assessment findings would suggest coarctation of the infant's aorta?

A) The child has a split S2 heart sound on auscultation.

B) ECG reveals atrial fibrillation.

C) The child experiences apneic spells after feeding.

D) Blood pressure in the child's legs is lower than in the arms.

Ans: D Feedback: The classic sign of coarctation of the aorta is a disparity in pulsations and blood pressures in the arms and legs. In coarctation, the pressure in the legs is lower and may be difficult to obtain. A split S2, dysrhythmias, and apneic spells are not characteristics of coarctation of the aorta.

25. A person newly diagnosed with Kawasaki disease in the acute phase will likely have which of the following clinical manifestations? Select all that apply.

A) Fever B) Peeling of the skin of the fingers and toes C) Edematous hands and feet D) Bilateral conjunctivitis E) Irritability and lability of mood Ans: A, C, D Feedback: The acute phase begins with an abrupt onset of fever, followed by bilateral conjunctivitis, usually without exudates; erythema of the oral and pharyngeal mucosa with “strawberry tongue” and dry, fissured lips; redness and swelling of the hands and feet; rash of various forms; and enlarged cervical lymph nodes. The other symptoms occur in the subacute phase.

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1. Chapter 20 When lecturing to a group of students about the pathophysiological principles behind heart failure, the instructor explains that cardiac output represents: A) Strength of the right ventricular pump to move blood B) The amount of blood the heart pumps each minute C) The amount of blood pumped out of the heart with each beat D) The volume of blood stretching the heart muscle at the end of diastole Ans: B Feedback: Cardiac output, which is the major determinant of cardiac performance, reflects how often the heart beats each minute (heart rate) and how much blood it ejects with each beat (stroke volume). Preload reflects the volume of blood that stretches the ventricle at the end of diastole, just before the onset of systole.

2. A client has been experiencing increasing fatigue in recent months, a trend that has prompted an echocardiogram. Results of this diagnostic test suggest that the client's end-diastolic volume is insufficient. Which of the following parameters of cardiac performance will directly decrease as a result of this?

A) Inotropy B) Cardiac contractility C) Preload D) Afterload Ans: C Feedback: Preload is the volume of blood stretching the heart muscle at the end of diastole and is normally determined mainly by the venous return to the heart. Afterload represents the force that the contracting heart muscle must generate to eject blood from the filled heart.

Cardiac contractility, or inotropy, is the contractile performance of the heart.

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3. One of the principal mechanisms by which the heart compensates for increased workload is: A) Myocardial hypertrophy B) Sodium and water retention C) Endothelin vasoconstrictors D) Ventricular wall tension increase Ans: A Feedback: The development of myocardial hypertrophy constitutes one of the principal mechanisms by which the heart compensates for an increase in workload. There are at least two types of endothelin receptors, and it is thought that the peptide may play a role in mediating noncompensatory pulmonary hypertension in persons with heart failure.

One effect of a lowered cardiac output in heart failure is a noncompensatory reduction in renal blood flow and glomerular filtration rate, which leads to salt and water retention. Because increased wall tension increases myocardial oxygen requirements, it can produce noncompensatory ischemia and further impairment of cardiac function.

4. A client with heart failure asks, “Why am I taking a 'water pill' when it's my heart that is having a problem?” While educating the client about the Frank-Starling mechanism, which of the following explanations is most appropriate to share?

A) “You must be drinking way too many liquids. Your kidneys cannot filter all that you are drinking during the day.”

B) “Since your heart is not pumping efficiently, the kidneys are getting less blood flow; therefore, the kidneys are holding on to sodium and water.”

C) “Your heart muscle is overstretched, so it's not able to pump all the blood out. The prescribed 'water pills' help by decreasing your weight.”

D) “Since your heart function is impaired, the lungs are not able to oxygenate the blood and your kidneys are wearing out.”

Ans: B Feedback: In heart failure with a reduced ejection fraction, a decrease in cardiac output and renal blood flow leads to increased sodium and water retention by the kidney with a resultant increase in vascular volume and venous return to the heart and an increase in ventricular end-diastolic volume. Drinking water may increase volume but is not the physiological reason for retention of fluid. Diuretics do decrease weight as a result of diuresis, but weight loss is not the purpose for giving diuretics. The lungs are not the primary cause of heart failure.

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5. The most recent blood work of a client with a diagnosis of heart failure indicates increased levels of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP).

What is the most likely effect of these peptides on the client's physiology?

A) Water retention B) Increased tubular sodium reabsorption C) Inhibition of the renin–angiotensin–aldosterone system D) Sympathetic nervous stimulation Ans: C Feedback: The NPs inhibit the sympathetic nervous system and the renin–angiotensin–aldosterone system, in addition to decreasing tubular sodium and water reabsorption.

6. 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.

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7. 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.

8. 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.

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9. 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.

10. 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.

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11. 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.

12. 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.

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13. 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.

14. 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.

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15. 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.

16. An 86-year-old male client is disappointed to learn that he has class II heart failure despite a lifelong commitment to exercise and healthy eating. Which of the following age-related changes predisposes older adults to developing heart failure?

A) Increased vascular stiffness B) Orthostatic hypotension C) Increased cardiac contractility D) Loss of action potential Ans: A Feedback: Increased vascular stiffness in older adults causes a progressive increase in systolic blood pressure with advancing age, which in turn contributes to the development of left ventricular hypertrophy and altered diastolic filling. A loss of action potential does not typically accompany aging, and contractility tends to decrease as a result of cardiac stiffness. Orthostatic hypotension is neither a normal age-related change nor a cause of heart failure.

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17. A client has just returned from his surgical procedure. During initial vital sign measurements, the nurse notes that the client's heart rate is 111 beats/minute and the BP is 100/78 (borderline low). In this early postoperative period, the nurse should be diligently monitoring the client for the development of: A) Pulmonary embolism due to development of deep vein thrombosis B) Side effects from versed administration causing excessive vasoconstriction C) Renal failure due to an overdose of medication D) Hypovolemic shock due to acute intravascular volume loss Ans: D Feedback: Hypovolemic shock is characterized by diminished blood volume such that there is inadequate filling of the vascular compartment. Hypovolemic shock also can result from an internal hemorrhage or from third-space losses, when extracellular fluid is shifted from the vascular compartment to the interstitial space or compartment, without fluid movement in/out of the cells. Within seconds after the onset of hemorrhage or the loss of blood volume, compensatory manifestations of tachycardia, vasoconstriction, and other signs of sympathetic and adrenal medullary activity appear. There is no indication that this client has developed a pulmonary embolism, is having side effects from versed administration, or is going into renal failure due to an overdose of medication.

18. Electrical burns over a large surface area of a client's body have resulted in hypovolemic shock after the loss of large amounts of blood and plasma. Following physical assessment, which findings lead the nurse to believe the client's body is compensating for this fluid loss? Select all that apply.

A) Increased heart rate B) Vasodilation with warm extremities C) Diuresis with output of 100 mL/hour D) The client complaining of extreme thirst E) Deep, rapid respirations Ans: A, D, E Feedback: Compensatory mechanisms in hypovolemic shock include increased heart rate, peripheral vasoconstriction, and fluid and sodium retention in order to preserve vascular volume. Urine output decreases very quickly in hypovolemic shock. Thirst is an early symptom in hypovolemic shock. As shock progresses, the respirations become rapid and deep to compensate for the increased production of acid and decreased availability of oxygen.

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19. In an ICU setting, one assessment that would lead the nurse to suspect shock has resulted in decrease blood flow to vital organs is: A) Warm legs with peripheral vasodilation B) Urine output less than 20 mL/hour C) Blood pressure staying in the 98/72 range for the past hour D) Sleepiness and difficulty to arouse without using painful stimuli Ans: B Feedback: Continuous measurement of urine output is essential for assessing the circulatory status of a person in shock. Oliguria of 20 mL/hour or less indicates inadequate renal perfusion. Continuous measurement of urine output is essential for assessing the circulatory and volume status of the person in shock and monitoring the response to fluid replacement. As the shock progresses and blood flow to the brain decreases, restlessness is replaced by apathy and stupor. Sympathetic stimulation also leads to intense vasoconstriction of the skin vessels and activation of the sweat glands. As a result, the skin is cool and moist. There is an increase in heart rate, cool and clammy skin, a decrease in arterial blood pressure, and a decrease in urine output.

20. A client has arrived in the emergency department in cardiogenic shock. Which of the following assessment findings confirm this diagnosis? Select all that apply.

A) Bright red color noted in the nail beds and lips B) Less than 5 mL dark, concentrated urine in the past hour C) BP reading of 80/65 D) Difficult to arouse with changes in level of consciousness E) Diminished breath sounds in the bases, bilaterally Ans: B, C, D Feedback: The signs and symptoms of cardiogenic shock are consistent with those of end-stage heart failure. The lips, nail beds, and skin may become cyanotic because of stagnation of blood flow. Mean arterial and systolic blood pressures decrease due to poor stroke volume, and there is a narrow pulse pressure because of arterial vasoconstriction. Urine output decreases because of lower renal perfusion pressures and the increased release of aldosterone. Neurologic changes, such as alterations in cognition or consciousness, may occur because of low cardiac output and poor cerebral perfusion.

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21. A client who developed a deep vein thrombosis during a prolonged period of bed rest has deteriorated as the clot has dislodged and resulted in a pulmonary embolism. Which of the following types of shock is this client at risk of experiencing?

A) Cardiogenic shock B) Hypovolemic shock C) Obstructive shock D) Distributive shock Ans: C Feedback: Obstructive shock results from mechanical obstruction of the flow of blood through the central circulation, such as the blockage that characterizes a pulmonary embolism.

22. A family member comes rushing out of a client's room telling the nurse that the loved one can't breathe. The nurse has just left the room after hanging IV penicillin. Which of the following clinical manifestations lead the nurse to suspect the client is experiencing anaphylactic shock? Select all that apply.

A) Incontinent of urine B) Severe bronchospasm C) Wheezing sound on inspiration D) Hives over entire body E) Swelling around the lips and eyes Ans: B, C, D, E Feedback: Anaphylactic shock results from an immunologically mediated reaction in which vasodilator substances such as histamine are released into the blood. These substances cause vasodilation of arterioles and venules along with a marked increase in capillary permeability. The vascular response in anaphylaxis is often accompanied by life-threatening laryngeal edema and bronchospasm, circulatory collapse, contraction of gastrointestinal and uterine smooth muscle, and urticaria (hives) or angioedema. The onset and severity of anaphylaxis depend on the sensitivity of the person and the rate and quantity of antigen exposure. Signs and symptoms associated with impending anaphylactic shock include abdominal cramps; apprehension; warm or burning sensation of the skin, itching, and urticaria (i.e., hives); and respiratory distress such as coughing, choking, wheezing, chest tightness, and difficulty in breathing.

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23. For which of the following types of shock might intravenous antibiotic therapy be indicated?

A) Obstructive shock B) Distributive shock C) Cardiogenic shock D) Hypovolemic shock Ans: B Feedback: Septic shock is a subtype of distributive shock. The treatment of sepsis and septic shock focuses on control of the causative agent and support of the circulation and the failing organ systems. The administration of antibiotics that are specific for the infectious agent is essential. Swift and aggressive fluid administration is needed to compensate for third spacing, though which type of fluid is optimal remains controversial. Equally, aggressive use of vasopressor agents, such as norepinephrine or epinephrine, is needed to counteract the vasodilation caused by inflammatory mediators.

24. Severe shock can be followed by acute lung injury/acute respiratory distress syndrome (ALI/ARDS) characterized by: A) Hyperventilation B) Excessive surfactant C) Hyperinflated alveolar sacs D) Ventilation–perfusion mismatch Ans: D Feedback: Despite the delivery of high levels of oxygen using high-pressure mechanical ventilatory support and positive end-expiratory pressure, many persons with ALI/ARDS remain hypoxic, often with a fatal outcome. Arterial blood gas analysis establishes the presence of profound hypoxemia with hypercapnia, resulting from impaired matching of ventilation and perfusion and from the greatly reduced diffusion of blood gases across the thickened alveolar membranes. Abnormalities in the production, composition, and function of surfactant may contribute to alveolar collapse and gas exchange abnormalities.

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25. In the ICU setting, clients who develop shock need thorough head-to-toe assessments.

Which of the following clinical manifestations would alert the health care provider that the client may be developing ischemia associated with gastrointestinal redistribution of blood flow?

A) Gastric bleeding B) Nausea and vomiting C) Irritable bowel syndrome D) Copious high-volume diarrhea Ans: A Feedback: In shock, there is widespread constriction of blood vessels that supply the gastrointestinal tract, causing a redistribution of blood flow that severely diminishes mucosal perfusion. Bleeding is a common symptom of gastrointestinal ulceration caused by shock, with onset usually within 2 to 10 days after the original insult. Nausea is unrelated to ischemic damage; irritable bowel syndrome is stress related. With ischemia, the bowel ceases to function, causing a lack of peristalsis and no fecal output.

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1. Chapter 21 Which of the following clients are more than likely experiencing impairment of the mucociliary blank with cilia dysfunction? Select all that apply.

A) A smoker who smokes 2 packs of cigarettes/day and currently hospitalized with pneumonia B) A middle-aged diabetic client with bilateral neuropathy C) A military guard person stationed in Germany D) A mountain skier who spends all day outside teaching ski lessons E) A nursing home client diagnosed with H1N1 influenza with fever of 102°F Ans: A, D, E Feedback: The mucociliary blanket protects the respiratory system by entrapping foreign particles in mucus; then cilia move the mucus with trapped particles upward toward the oropharynx to be coughed out or swallowed. The function of the cilia in clearing the lower airways and alveoli is optimal at normal oxygen levels and is impaired in situations of low and high oxygen levels. It is also impaired by drying conditions, such as breathing heated but unhumidified indoor air during the winter months. Cigarette smoking slows down or paralyzes the motility of the cilia. This slowing allows the residue from tobacco smoke, dust, and other particles to accumulate in the lungs, decreasing the efficiency of this pulmonary defense system. During fever, the water vapor in the lungs increases, causing more water to be lost through the respiratory tract.

In addition, fever usually is accompanied by an increase in respiratory rate so that more air passes through the airways, withdrawing moisture from its mucosal surface. As a result, respiratory secretions thicken, preventing free movement of the cilia and impairing the protective function of the mucociliary defense system.

2. Above the glottis that opens and closes for speech, the epiglottis performs which physiologic functions during swallowing?

A) Open the epiglottis B) Cover the larynx C) Collapse the vocal cords D) Constrict the airways Ans: B Feedback: During swallowing, the free edges of the epiglottis move downward to cover the larynx, thereby preventing liquids and foods from entering. When substances other than air manage to enter the airway, the vocal folds serve as a sphincter, causing the larynx muscles to constrict and close and/or collapse the airway as a protective measure.

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3. A child with asthma is walking outside and develops a bronchospasm. The school nurse knows this bronchospasm has what effects on bronchioles with airflow? Select all that apply.

A) Narrowing of bronchioles B) Impairs airflow C) Exerts tension on the bronchiole walls D) Causes atelectasis in posterior lung segments E) Inhibits the filtering of dust particles Ans: A, B Feedback: Bronchospasm, or contraction of these muscles, causes narrowing of the bronchioles and impairs airflow. Bronchospasm does not exert tension on the walls of the bronchi, cause atelectasis, or inhibit filtering of dust particles.

4. A client with a history of emphysema from long-term cigarette smoking has loss of many alveoli. When comparing the type I alveolar cell physiologic function with the primary role of type II alveoli, the nurse would be aware that the type II alveoli are responsible for: A) Facilitation of bronchial circulation B) Production of surfactant C) Gas exchange D) Production of macrophages Ans: B Feedback: Although macrophages are present in all alveoli, only type II alveoli produce surfactant.

They do not participate directly in gas exchange or facilitate bronchial circulation.

5. Bronchial circulation differs from the pulmonary circulation by providing blood for the: A) Conducting airways B) Alveolar gas exchange C) Mediastinal and pleural space D) Intrapulmonary pressure balance Ans: A Feedback: Bronchial circulation in the lungs provides blood to the airways. Pulmonary circulation provides the blood for gas exchange and to lung tissue other than the airway tissue.

Intrapulmonary pressure is the gas pressure in the airways, which is unrelated to blood circulation.

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6. When a client with a history of asthma takes a walk outside on a windy day with high pollen counts, she may experience an asthma attack, resulting in an increase in respiration rate and wheezing. The body's response is likely related to which pathophysiological principle?

A) Parasympathetic nervous system stimulation resulting in airway constriction B) Release of catecholamines causing blood vessel constriction C) Influx of macrophages to wall of the pollen, thereby stopping the attack D) Inhibition of glandular secretions, which causes build up of mucus in the lungs Ans: A Feedback: The parasympathetic (PS) fibers are excitatory neurons that respond to acetylcholine.

Stimulation of the PSN is responsible for airway constriction, blood vessel dilation, and increased glandular secretion. The sympathetic nervous system (SNS), which responds to the catecholamines norepinephrine and epinephrine, produces airway dilation, blood vessel constriction, and inhibition of glandular secretions.

7. A client who is in a room at 1 atmosphere (760 mm Hg) is receiving supplemental oxygen therapy that is being delivered at a concentration of 50%. What is the consequent PO2?

A) 38,000 mm Hg. B) More data are needed.

C) 380 mm Hg. D) 15.2 mm Hg. Ans: C Feedback: The law of partial pressures states that the total pressure of a mixture of gases, as in the atmosphere, is equal to the sum of the partial pressures of the different gases in the mixture. If the concentration of oxygen at 760 mm Hg (1 atmosphere) is 50%, its partial pressure is 380 mm Hg (760 × 0.50).

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8. A college student is training for a marathon in the mountains. One day, she experiences a sharp pain and suddenly becomes short of breath. At the emergency room, chest x-ray reveals a spontaneous pneumothorax. The client asks the nurse to explain why this happened. The nurse states, “For unknown reasons, you lose intrapleural negative pressure.

A) You must have experienced a forced expiration against a closed glottis to cause the lung to deflate.”

B) This means your lungs collapsed and expelled its air when you lose negative pressure.”

C) You must have coughed too forcibly and your air sacs burst.”

D) You must have a genetic anomaly causing weakened alveolar sacs to rupture.”

Ans: B Feedback: The intrapleural pressure is always negative in relation to alveolar pressure in the normally inflated lung: approximately 4 mm Hg between breaths when the glottis is open and the alveolar spaces are open to the atmosphere. Although the intrapleural pressure of the inflated lung is always negative in relation to alveolar pressure, it may become positive in relation to atmospheric pressure. Although the intrapleural pressure of the inflated lung is always negative in relation to alveolar pressure, it may become positive in relation to atmospheric pressure (e.g., as during forced expiration and coughing). A spontaneous pneumothorax is a collapsed lung with loss of negative pressures.

9. A respiratory therapist has asked a client to breathe in as deeply as possible during a pulmonary function test. Inspiration is normally the result of which of the following phenomena?

A) Decreased intrapulmonary pressure B) Increased airway pressure C) Increased intrapleural pressure D) Decreased intrathoracic pressure Ans: D Feedback: During inspiration, contraction of the diaphragm and expansion of the chest cavity produce a decrease in intrathoracic pressure, causing air to move into the lungs.

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10. The client with emphysema should be educated about changes in lung tissue that may include which of the following changes? Select all that apply.

A) Loss of elastic recoil B) Difficulty exhaling due to inability to recoil C) Increased lung compliance D) Increased permeability to water E) Stiff elastin fibers Ans: A, B, C Feedback: The elastic properties of the lung involve at least three basic components: distensibility, stiffness, and elastic recoil. Distensibility is the ease with which the lungs can be inflated. Stiffness is defined as the resistance to stretch or inflation. In lung diseases such as interstitial lung disease and pulmonary fibrosis, the lungs become stiff and noncompliant as the elastin fibers are replaced with the collagen fibers of scar tissue.

Overstretching lung tissues, as occurs with emphysema, causes the elastic components of the lung to lose their recoil, making the lung more compliant and easier to inflate but more difficult to deflate because of its inability to recoil.

11. Clients who have been bed-ridden for a long time likely will experience: A) An inability to produce sufficient amounts of surfactant and may require recombinant forms B) Shallow, quiet breathing, which impairs the spreading of surfactant C) A sharp increase in surfactant levels that will require frequent suctioning D) Increase in their depth of breathing, which increases lung volumes causing more surfactant to spread out over the alveolar surfaces Ans: B Feedback: At low lung volumes, the molecules of surfactant become tightly packed, and at higher lung volumes, they spread out to cover the alveolar surface. In surgical clients and bed-ridden persons, shallow and quiet breathing often impairs the spreading of surfactant. Premature infants may require recombinant forms of surfactant to treat infant respiratory distress syndrome. Suctioning cannot be done at the alveolar level. One of the treatments for bedrest clients is cough and deep breathing exercises to enhance the spread of surfactant to prevent atelectasis.

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12. When thinking in terms of airway radius with regard to resistance, the lung structure responsible for the most airway resistance to airflow would be: A) The entire length of trachea B) The right bronchus at the bifurcation C) The bronchioles near the trachea D) A single alveolus Ans: C Feedback: The primary determinant of airway resistance to airflow is the radius of the conducting airway. Therefore, the site of most of the resistance occurs in the larger bronchioles and bronchi near the trachea, with the smallest airways contributing very little to the total airway resistance. However, although the resistance of each individual bronchiole may be relatively high, their great number results in a large total cross-sectional area, causing their total combined airway resistance to be low.

13. Completion of a client's pulmonary function study has yielded the following data: tidal volume, 500 mL; inspiratory reserve, 3100 mL; expiratory reserve, 1200 mL; residual volume, 1200 mL; functional residual capacity, 2400 mL. What is this client's inspiratory capacity?

A) 5500 mL. B) 2600 mL. C) More data are needed.

D) 3600 mL. Ans: D Feedback: Inspiratory capacity is the sum of inspiratory reserve volume and tidal volume.

14. A client with a history of chronic obstructive pulmonary disease (COPD) is undergoing pulmonary function testing. Which of the following instructions should the technician provide in order to determine the client's forced vital capacity (FVC)?

A) “I'll ask you to breathe in as deep as you can, and then blow out as much of that air as possible.”

B) “I'd like you to take a deep breath, and then blow out as much air as you can during 1 second.”

C) “I want you to breathe as normally as possible, and I'm going to measure how much air goes in and out with each breath.”

D) “Breathe normally, and then exhale as much as you possibly can when I tell you.”

Ans: A Feedback: FVC involves full inspiration to total lung capacity followed by forceful maximal expiration.

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15. Clients with chronic obstructive lung disease (COPD) may experience airway closure at the end of normal instead of low lung volumes, which result in: A) Airway constriction of the main bronchus B) Release of epinephrine, a catecholamine, which causes airway dilation C) An increase in the physiological dead space in alveoli that are perfused but not ventilated D) Trapping of large amounts of air that cannot participate in gas exchange Ans: D Feedback: The pressure needed to overcome the tension in the wall of a sphere or an elastic tube is inversely related to its radius; therefore, the small airways close first, trapping some air in the alveoli. This trapping of air may be increased in older persons and persons with chronic lung disease owing to a loss in the elastic recoil properties of the lungs. In these persons, airway closure occurs at the end of normal instead of low lung volumes, trapping larger amounts of air that cannot participate in gas exchange. It does not result in airway constriction, release of catecholamines, or an increase in the physiological dead space.

16. Respiratory movement of air that does not participate in alveolar gas exchange is known as alveolar dead space. Dead space increases when alveolar/alveoli: A) Carbon dioxide level is high.

B) Air supply exceeds blood flow.

C) Contain pulmonary edema fluid.

D) Collapse onto the capillary bed.

Ans: B Feedback: Alveolar dead space increases when ventilation exceeds perfusion, such as with an embolus obstructing blood flow to the lung area. The oxygen/CO2 gas content in the alveoli has no effect on increased dead space caused by hypoperfusion. Pulmonary edema and alveoli collapse adversely affect gas exchange but have no effect on increased dead space caused by a lack of blood flow.

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17. Generalized acute hypoxia in lung tissue, when alveolar oxygen levels drop below 60 mm Hg, causes pulmonary: A) Vasospasms B) Hypertension C) Embolus formation D) Vasoconstriction Ans: D Feedback: Vasoconstriction of pulmonary vessels is a compensatory response to generalized lung tissue hypoxia. Embolus formation causes a localized hypoxic response. Vasospasms are not involved with the hypoxia response by lung tissue. Pulmonary hypertension is the result of chronic lung tissue hypoxia.

18. Following surgery, a client had a chest x-ray that reported some opacities in the lung bases likely due to atelectasis. Which of the following pathophysiologic processes will result from this condition?

A) Compensatory vasoconstriction B) Ventilation without perfusion C) Dead air space D) Perfusion without ventilation Ans: D Feedback: With shunt, there is perfusion without ventilation, resulting in a low ventilation– perfusion ratio. This occurs in conditions such as atelectasis in which there is airway obstruction. Ventilation without perfusion (dead air space) is a consequence of impaired pulmonary circulation. Hypoxemia will result in vasodilation, not vasoconstriction.

19. Diffusion of gases in the lung is decreased, as in pulmonary edema or pneumonia, by causing an increase in alveolar: A) Gas pressure difference B) Size and surface area C) Anatomic shunting of blood D) Capillary membrane thickness Ans: D Feedback: Diffusion is adversely affected by any condition that impedes the movement of gas by thickening the capillary membrane. A decrease in gas pressure difference will slow gas exchange. Increased alveolar size and surface area and shunting will increase diffusion rate.

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20. Which of the following clients are likely experiencing a shift to the right in the dissociation curve? Select all that apply.

A) A client with respiratory influenza with a temperature of 102.6°F B) A COPD client with pneumonia with blood gas pH level of 7.31 C) A renal failure client with admitting hemoglobin level of 8.0 mg/dL D) A client having a panic attack with respiratory rate of 36 and marked decreased PCO2 levels E) A client who fell in an icy pond with admitting core body temperature of 94.1°F Ans: A, B, C Feedback: A shift to the right indicates that the affinity of hemoglobin for oxygen is decreased and the PO2 that is available to the tissues at any given level of hemoglobin saturation is increased. It usually is caused by conditions that produce an increase in tissue metabolism, such as fever or acidosis, or by an increase in PCO2. High altitude and conditions such as pulmonary insufficiency, heart failure, and severe anemia also cause the oxygen dissociation curve to shift to the right. A shift to the left indicates that the affinity of hemoglobin for oxygen is increased and the PO2 that is available to the tissues at any given level of hemoglobin saturation is decreased. It occurs in situations associated with a decrease in tissue metabolism, such as alkalosis, decreased body temperature, and decreased PCO2 levels.

21. While discussing carbon dioxide transport within the body, the instructor asks, “What enzyme helps carbon dioxide with water to form bicarbonate?” Which student response is correct?

A) Dihydrofolate reductase B) Orotidine 5'-phosphate decarboxylase C) Neuraminidase D) Carbonic anhydrase Ans: D Feedback: Most of the carbon dioxide diffuses into the red blood cells, where it either forms carbonic acid or combines with hemoglobin. Carbonic acid (H2CO3) is formed when carbon dioxide combines with water (CO2 + H2O = H+ + HCO3–). The process is catalyzed by an enzyme called carbonic anhydrase, which is present in large quantities in red blood cells. Carbonic anhydrase increases the rate of the reaction between carbon dioxide and water approximately 5000-fold. Carbonic acid readily ionizes to form bicarbonate (HCO3–) and hydrogen (H+) ions.

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22. A client arrives in the emergency department suffering a traumatic brain injury as a result of a car accident. While assessing this client, the nurse notices the client has an irregular breathing pattern consisting of prolonged inspiratory gasps interrupted by expiratory efforts. The underlying physiological principle for these signs would include: A) Damage has occurred at the connection between the pneumotaxic and apneustic centers.

B) The client's occipital lobe is no longer functioning.

C) The client must have a leak in the ventricles resulting in a decrease in spinal fluid.

D) The nerves innervating the lungs have been severed in the accident.

Ans: A Feedback: Brain injury, which damages the connections between the pneumotaxic and apneustic centers, results in an irregular breathing pattern that consists of prolonged inspiratory gasps interrupted by expiratory efforts. If the occipital lobe was not functioning, the client would have no respiratory effort and require mechanical ventilation. Leaking of spinal fluid would not cause these respiratory signs. If nerves were severed to the lungs, the client would not be able in inflate/deflate the lungs with mechanical ventilation.

23. COPD clients live with persistently elevated PCO2 levels. Therefore, which assessment finding would likely initiate a stimulus for ventilation in this client population?

A) PCO2 level of 65 mm Hg B) PO2 level of 50 mm Hg C) Arterial blood gas pH of 7.35 D) Pulse oximeter reading of 96% saturation Ans: B Feedback: The central chemoreceptors are extremely sensitive to short-term changes in blood PCO2 levels. An increase in the PCO2 of the blood produces an increase in ventilation that reaches its peak within a minute or so and then declines if the PCO 2 level remains elevated. Thus, persons with chronically elevated blood PCO2 levels no longer respond to this stimulus for increased ventilation but rely on the stimulus provided by a decrease in arterial PO2 levels that is sensed by the peripheral chemoreceptors.

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24. A client has experienced a bout of coughing after aspirating some of his secretions. The client's coughing was triggered by which of the following?

A) Sudden ventilation–perfusion mismatch B) Sudden rise in PCO2 C) Signals from receptors in the tracheobronchial wall D) Signals from central chemoreceptors Ans: C Feedback: The cough reflex is initiated by receptors located in the tracheobronchial wall; these receptors are extremely sensitive to irritating substances and to the presence of excess secretions. Blood gas changes and ventilation–perfusion mismatch do not directly initiate the cough reflex.

25. The sensation of chest tightness due to an impending asthmatic attack appears to be related to which of the following physiological causes?

A) Transmission of excessive chemoreceptor stimulation of the medullary respiratory center.

B) Uncomfortable work of breathing sensation is thought to be mediated by excessive input from stretch receptors in the chest muscles.

C) A perceived shortness of breath is a multidimensional sensation involving both the sensory intensity and unpleasantness.

D) Input from lung receptors that monitor bronchial constriction.

Ans: D Feedback: The sensation of chest tightness due to an impending asthmatic attack appears to be related to input from lung receptors that monitor bronchial constriction. Transmission of excessive chemoreceptor stimulation of the medullary respiratory center to sensory centers in the forebrain relates to air hunger. Labored breathing, an uncomfortable work of breathing sensation, is thought to be mediated by excessive input from stretch receptors in the chest muscles. A perceived shortness of breath, known as dyspnea, is a multidimensional sensation involving both the sensory intensity and unpleasantness.

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1. Chapter 22 The “cold viruses” are rapidly spread from person to person. The greatest source of spread is: A) Fingers B) Sneezing C) Plastic toys D) Eye mucosa Ans: A Feedback: Cold viruses have been found to survive for more than 5 hours on the skin and hard surfaces, such as plastic countertops. Aerosol spread of colds through coughing and sneezing is much less important than the spread by fingers picking up the virus from contaminated surfaces and carrying it to the nasal membranes and eyes. The fingers are the greatest source of spread, and the nasal mucosa and conjunctival surface of the eyes are the most common portals of entry of the virus.

2. A college student is lamenting the fact that she has developed a cold on the weekend prior to exam week. Which of the following statements shows that the student has an accurate understanding of her upper respiratory infection?

A) “I'm just going to try to rest as much as I can until these bacteria clear up.”

B) “I think I'll go to the campus clinic and see if I can get a prescription for antibiotics.”

C) “I suppose I should have been washing my hands more in the past few days.”

D) “If I can just start some antihistamines as soon as possible I bet I'll get over this faster.”

Ans: C Feedback: Handwashing remains the most effective preventative measure against the common cold. Antihistamines have been shown to have no curative value, and antibiotics are ineffective because of the viral etiology of the common cold.

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3. A client has presented to an ambulatory clinic complaining of a persistent headache.

What assessments should the clinician conduct to differentiate between rhinosinusitis and alternative health problems?

A) Take a sputum sample for culture and sensitivity.

B) Compare the client's oral, tympanic, and axillary temperatures and order a white blood cell count.

C) Palpate the client's lymph nodes and inspect the ears with an otoscope.

D) Perform transillumination and ask the client if bending forward exacerbates the headache.

Ans: D Feedback: Transillumination is performed to confirm or rule out sinusitis, and sinusitis headache usually is exaggerated by bending forward, coughing, or sneezing. The other cited assessments do not differentiate between rhinosinusitis and other health problems.

4. A distinguishing feature of viral influenza is: A) Direct contact transmission B) Abrupt-onset, profound malaise C) Constant pounding headache D) Profuse watery nasal discharge Ans: B Feedback: One distinguishing feature of influenza is the rapid onset, sometimes within minutes, of profound malaise. As with many viral respiratory tract infections, transmission is by aerosol or direct contact. In the early stages, the symptoms of influenza often are indistinguishable from other viral infections—fever, chills, malaise, muscle aching, headache, profuse watery nasal discharge, nonproductive cough, and sore throat.

Persons with chronic rhinosinusitis complain of a constant pounding headache.

5. Which of the following individuals should be prioritized for receiving a seasonal influenza vaccination?

A) An 81-year-old resident of a long-term care facility B) A 19-year-old man who was admitted to a hospital for an appendectomy C) A neonate who was born in a busy, inner-city hospital in late October D) An 86-year-old client whose flu symptoms have required hospitalization Ans: A Feedback: An older adult who lives in a nursing facility is a high-priority candidate for influenza vaccination. Infants younger than 6 months and persons who are acutely ill should not receive immunizations. Younger hospital clients may be vaccinated but are usually of lower priority than the elderly.

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6. Which of the following clients would be considered at high risk for developing pneumonia (both community and hospital setting)? Select all that apply.

A) A teenager who spends a lot of time at local coffee shops using Wi-Fi to chat with friends B) A young adult in motorcycle accident with head injury requiring tracheostomy and mechanical ventilation C) A college female who is pregnant (unplanned) who has been consuming alcohol prior to positive pregnancy test D) A HIV-positive client with a WBC count of 2000 who has been camping near a commercial farm raising chickens for food E) A school-aged child with severe asthma controlled by steroids admitted for an exacerbation Ans: B, D, E Feedback: Persons requiring intubation and mechanical ventilation are particularly at risk, as are those with compromised immune function, chronic lung disease (like asthma), and airway instrumentation, such as endotracheal intubation or tracheotomy.

Ventilator-associated pneumonia is pneumonia that develops in mechanically ventilated clients more than 48 hours after intubation. Neutropenia and impaired granulocyte function predispose to infections caused by S. aureus, Aspergillus, gram-negative bacilli, and Candida. Pneumonia in immunocompromised persons remains a major source of morbidity and mortality. The epithelial cells of critically and chronically ill persons are more receptive to binding microorganisms that cause pneumonia.

7. A family brings their elderly father to emergency department. He has been exposed to pneumococcal pneumonia at his retirement home. Today, they noted a change in his mental status. They thought he might need some oxygen. Which of the other assessment findings would correlate with this diagnosis? Select all that apply.

A) Expiratory wheezes throughout all lung fields B) Increase in chest pain with deep inspiration C) Absent breathe sounds on the entire right side of the lung D) Loss of appetite for past few days E) Purulent sputum with bloody patches Ans: B, D, E Feedback: During the initial stage, coughing brings up watery sputum and breath sounds are limited, with fine crackles. As the disease progresses, the character of the sputum changes; it may be blood tinged or rust colored to purulent. Pleuritic pain, a sharp pain that is more severe with respiratory movements, is common. Elderly persons are less likely to experience marked elevations in temperature; in these persons, the only sign of pneumonia may be a loss of appetite and deterioration in mental status. Expiratory wheezes are usually associated with asthma. Absent breath sounds on an entire lung field usually is associated with pneumothorax or respiratory failure.

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8. Which of the following clients at the clinic should be encouraged to receive the pneumococcal polysaccharide vaccine (PPSV23)? A client: Select all that apply.

A) Who is 65 years old with chronic asthma B) With a smoking history C) Who is a young adult with HIV-positive results D) Who is school-aged and has received a liver transplant E) Who is a teenager with history of kidney disease Ans: A, B Feedback: The PPSV23 vaccine consists of the 23 most common capsular serotypes that cause the most common invasive pneumococcal disease. It is recommended for all adults 65 years of age and older and for those 2 years of age and older who are at high risk for the disease. It is also recommended for adults who smoke or have asthma. The PCV13 protects against 13 types of pneumococcal bacteria. It is recommended for use in infants and young children and for all adults 50 years of age and older who have conditions that weaken the immune system such as HIV infection, organ transplantation, leukemia, lymphoma, and severe kidney disease.

9. A client is admitted to hospital to rule out Legionnaire disease following a canoe trip where he was sprayed in the face with a lot of “creek” water. Which of the following manifestations are characteristic of Legionnaire pneumonia? Select all that apply.

A) Temperature of 103.5°, pulse 80 B) “Talking but not making a lot of sense” (confusion) C) Decreased abdominal bowel sounds D) Productive cough with thick, yellow secretions E) Chest x-ray that reveals areas of consolidation suggestive of pneumonia Ans: A, B, E Feedback: Legionella pneumonia typically presents acutely with malaise, weakness, lethargy, fever, and dry cough. Other manifestations include disturbances of central nervous system function and elevation in body temperature, sometimes to more than 104°F (40°C). The presence of pneumonia along with diarrhea, hyponatremia, and confusion is characteristic of Legionella pneumonia. The disease causes consolidation of lung tissues and impairs gas exchange. Another characteristic of the disease is a lack of a normal pulse–temperature relationship in which a fever is not accompanied by an appropriate rise in heart rate. For example, a temperature of 102°F is normally accompanied by a heart rate of 110 beats/minute; in Legionella pneumonia it is often less than 100 beats/minute.

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10. The pathogenic capacity of the tubercle bacillus is related to: A) Formation of a Ghon focus lesion B) Its inherent destructive capabilities C) Rapid viral replication in host cells D) The initiation of a cell-mediated immune response Ans: D Feedback: The pathogenesis of tuberculosis, in previously unexposed immunocompetent people, is a cell-mediated immune response that confers resistance to the organism and development of hypersensitivity to the tubercular antigens. Pathologic manifestations of tuberculosis, such as caseating granuloma and cavitation, are the result of the hypersensitivity reaction rather than its inherent destructive capabilities. In persons with intact cell-mediated immunity, the cell-mediated immune response results in the development of a granulomatous lesion, called a Ghon focus, that contains the tubercle bacilli, modified macrophages, and other immune cells.

11. A nurse who provides weekly care in a homeless shelter has unknowingly inhaled airborne Mycobacterium tuberculosis and has subsequently developed latent tuberculosis infection. Which of the following is true of this nurse?

A) The nurse is likely asymptomatic.

B) The nurse is now immune to more severe tuberculosis infection.

C) The nurse can spread tuberculosis to others.

D) The nurse has active tuberculosis infection.

Ans: A Feedback: Latent TB infection is not an active form of TB, and affected individuals are asymptomatic and cannot pass on the disease to others. It does not confer immunity.

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12. While administering a tuberculin (TB) skin test, a client who is HIV positive asks, “I heard from my friends, this test may not work on me since I have HIV.” The health care provider's best response would be: A) “This test is 99.9% specific, so it will give us an accurate result.”

B) “Sometimes immunocompromised clients will have negative results if you are unable to mount a normal immune reaction.”

C) “Most of the time, with HIVpositive clients, we see more false-positive results since you may have a similar infection in your body.”

D) “If your test comes back positive, we will send a blood test off to a special lab to confirm you really have TB before we start treatment.”

Ans: B Feedback: Hypersensitivity response to the tuberculin test depends on cell-mediated immunity.

Inherent anergy in persons with HIV infection and other immunocompromised states causes a false-negative test result, which can mean that the person has a true lack of exposure to tuberculosis or is unable to mount an immune response to the test.

False-positive results can also occur—for example, in persons who have nontuberculosis mycobacterial infection or who have received the Bacillus Calmette-Guérin (BCG) vaccine for tuberculosis prevention.

13. Following a dust storm in Arizona, several clients have presented to the clinic complaining of productive cough, fever, and night sweats. The health care provider suspects a fungal infection related to breathing dust. One particular client is critical.

They suspect the infection has progressed outside the lung when they observe the client has: Select all that apply.

A) Generalized lymph node enlargement B) Urine output decreased to 40 mL/hour C) Requires guaifenesin to cough up sputum D) An enlarged liver via palpation E) Copious bleeding at the site where the lab technician drew some blood Ans: A, D, E Feedback: The most common manifestations of fungal infections in the lungs are productive cough, fever, night sweats, and weight loss. Characteristically, disseminated disease presents with a high fever, generalized lymph node enlargement, hepatosplenomegaly, muscle wasting, anemia, leukopenia, and thrombocytopenia. Urine output of 40 mL/hour is normal. Guaifenesin is an expectorant used in many lung diagnoses to liquefy secretions. It is not specific to fungal infections.

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14. A client with newly diagnosed squamous cell carcinoma of the lung asks, “So how do we treat this cancer?” Which response from the health care provider is most accurate?

Select all that apply.

A) Surgery to remove tumor B) Radiation therapy C) Chemotherapy D) Stem cell transplant E) Monoclonal antibody Ans: A, B, C Feedback: Although all forms of lung cancer are serious and potentially fatal diagnoses, individuals with small cell lung cancer, adenocarcinoma, and large cell lung cancer often face prognoses that are worse than those associated with squamous cell lung cancer. Treatment methods for NSCLC include surgery, radiation therapy, and systemic chemotherapy. These treatments may be used singly or in combination. Stem cell transplant is not utilized in lung cancer. New trials are exploring the use of monoclonal antibodies but have not been approved by the FDA at this time.

15. A client with an 80-pack-year history of tobacco smoking has presented to the clinic complaining of “bronchitis” cough for the past 5 months, weight loss, and shortness of breath. Today, this client “got scared” when he coughed up blood in his sputum. The health care provider is concerned this client may have which of the following possible diagnoses?

A) Small cell lung cancer due to smoking history B) Tuberculosis due to long period of coughing C) Pulmonary embolism due to blood in sputum D) Pneumothorax related to chronic lung infection weakening the alveoli Ans: A Feedback: Small cell lung cancer has the strongest association with cigarette smoking and is rarely observed in someone who has not smoked; brain metastasis is common. The earliest symptoms (of lung cancer) usually are chronic cough, shortness of breath, and wheezing because of airway irritation and obstruction. Hemoptysis (i.e., blood in the sputum) occurs when the lesion erodes into blood vessels. There is no indication the client has risk factors for TB. Pulmonary emboli result from blood clots traveling to the lungs.

Pneumothorax would cause different symptoms and be an acute, abrupt onset.

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16. A nurse runs into an old high school friend after 20 years. She notes her friend continues to smoke after all these years. The friend asks, “Do you think I sound hoarse?” Upon further assessment, the nurse/friend notes her friend has several warning signs of cancer.

Which manifestations would lead to this conclusion? Select all that apply.

A) “I seem to have some difficulty swallowing food… this is new for me.”

B) “I seem to have more trouble holding my urine than I use to.”

C) “Can you feel how large my lymph nodes are on my neck and armpits (axillae)?”

D) Pericardial friction rub heard on auscultation.

E) Feels subcutaneous emphysema in upper chest area.

Ans: A, C Feedback: Tumors that invade the mediastinum may cause hoarseness because of the involvement of the recurrent laryngeal nerve and cause difficulty in swallowing because of compression of the esophagus. An uncommon complication called the superior vena cava syndrome occurs in some persons with mediastinal involvement. Interruption of blood flow in this vessel usually results from compression by the tumor or involved lymph nodes. Urinary incontinence, pericardial friction rub, and subcutaneous emphysema are not related to this cancer but can occur as complications from treatments.

17. Which of the following individuals is most clearly in need of diagnostic testing for lung cancer?

A) A client who has required hospitalization with a fever and the production of copious lung secretions B) A client with a history of secondary tuberculosis who failed to complete his prescribed course of antibiotics C) A woman who complains of recurrent lower respiratory infections and who has sought care for increasing shortness of breath D) A man who demonstrates wasting of the pelvic and shoulder muscles combined with signs of hypercalcemia Ans: D Feedback: Hypercalcemia and wasting of the proximal muscles of the pelvic and shoulder girdles are indicative of the paraneoplastic manifestations of lung cancer. The other cited respiratory conditions warrant follow-up and treatment but are not particularly suggestive of a neoplastic etiology.

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18. Increased upper airway resistance and decreased airflow into the lungs in neonates (0 to 4 weeks of age) can result from: A) Frequent crying B) Sleeping supine C) Nasal congestion D) Productive coughing Ans: C Feedback: The neonate (0 to 4 weeks of age) breathes predominantly through the nose and does not adapt well to mouth breathing. Any obstruction of the nose or nasopharynx may increase upper airway resistance and increase the work of breathing. While sleeping, the neonate's face should remain away from any surface or cloth in order to maintain an open nasal airway.

19. Which of the following characteristics of the lungs of infants and small children creates an increased risk of respiratory disorders?

A) Type II alveoli in children may overproduce surfactant.

B) Smaller airways create a susceptibility to changes in airway resistance and airflow.

C) The pneumotaxic center in the pons is underdeveloped until 8 years of age.

D) There are fewer chemoreceptors in the young medulla.

Ans: B Feedback: Because the resistance to airflow is inversely related to the fourth power of the radius (resistance = 1/radius), relatively small amounts of mucus secretion, edema, or airway constriction can produce marked changes in airway resistance and airflow. Surfactant production is low early in life, and the respiratory center and chemoreceptors are present and functional in infants and children.

20. Most respiratory disorders in infants produce a decrease in: A) Lung compliance B) Airway resistance C) Oxygen demand D) Respiratory rate Ans: A Feedback: Most respiratory disorders in infants produce a decrease in lung compliance or an increase airway resistance. Respiratory disorders increase the cellular demand for oxygen because the alveolar–capillary membrane is often impaired by the disease process. A compensatory tachypnea is an attempt to deliver more oxygenated blood to hypoxic lung tissue.

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21. A 6-hour-old newborn develops a critical respiratory problem and is rushed to the ICU. The ICU nurses suspect the infant has respiratory distress syndrome (RDS) based on which findings? Select all that apply.

A) Bluish discoloration of the skin and mucous membranes (central cyanosis) B) Substernal retractions with each breathe C) Periorbital edema D) Clubbed fingers E) Expiratory grunting Ans: A, B, E Feedback: Infants with RDS present with multiple signs of respiratory distress, usually within the first 24 hours of birth. Central cyanosis is a prominent sign. Breathing becomes more difficult, and retractions occur as the infant's soft chest wall is pulled in as the diaphragm descends. Grunting sounds accompany expiration. Periorbital edema is usually associated with kidney disease in infants. Clubbed fingers occur over a long period of time (years) in clients with COPD. 22. A mother rushes her toddler into the emergency department stating, “My baby can't breathe.” Initial assessment reveals the child is struggling to breathe in an upright position. He has both inspiratory and expiratory stridor and is using his chest muscles to breath. The nurse suspects the child has which of the following acute respiratory infections?

A) Croup B) Asthma C) Epiglottitis D) Bronchiolitis Ans: C Feedback: Epiglottitis typically presents with an acute onset of sore throat and fever. The child appears pale, toxic, and lethargic and assumes a distinctive position—sitting up with the mouth open and the chin thrust forward. Symptoms rapidly progress to difficulty swallowing, a muffled voice, drooling, and extreme anxiety. Moderate to severe respiratory distress is evident. There are inspiratory and sometimes expiratory stridor, flaring of the nares, and inspiratory muscle retractions. Croup or acute laryngotracheobronchitis is a viral infection that affects the larynx, trachea, and bronchi.

Acute bronchiolitis is a viral infection of the lower airways, most commonly caused by the respiratory syncytial virus. Asthma is a reactive airway disease rather than an infection.

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23. A child is brought to the emergency department with a respiratory infection. The child is struggling to breath and is very anxious. The health care providers suspect epiglottitis.

Which of the following interventions would be a priority?

A) Have parents help hold the child down so blood work can be drawn and sent to lab so WBC count can be reviewed.

B) Try to get the child to open his mouth so you can put a tongue blade in the back of the throat to look for swelling or pustules.

C) Place the child upright in bed and begin preparing for a tracheostomy placement.

D) Administer the first dose of an antibiotic vial liquid suspension as soon as possible to begin fighting the infection.

Ans: C Feedback: Epiglottitis is a medical emergency, and immediate establishment of an airway by endotracheal tube or tracheostomy is usually needed. If epiglottitis is suspected, the child should never be forced to lie down because this causes the epiglottis to fall backward and may lead to complete airway obstruction. Examination of the throat with a tongue blade may cause airway spasm and cardiopulmonary arrest and should be done only by medical personnel experienced in intubation of small children. It also is unwise to attempt any procedure, such as drawing blood, which would heighten the child's anxiety because this also could precipitate airway spasm and cause death.

24. A 6-month-old infant has been hospitalized with acute bronchiolitis. Which of the following treatments should be prioritized in the infant's care?

A) Supplementary oxygen therapy B) Intravenous antibiotics C) Transfusion of fresh frozen plasma D) Tracheotomy Ans: A Feedback: Bronchiolitis necessitates supplementary oxygen therapy. Antibiotics are ineffective due to the viral etiology. Recovery usually occurs within several days, and tracheotomy is necessary only in the event of severe complications. Plasma transfusion is not a relevant treatment modality.

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25. A 2-year-old child is admitted to pediatric unit with bronchiolitis. The nurse calls the physician fearing the child is going into respiratory failure based on which of the following assessment findings? Select all that apply.

A) Increased respiratory rate to 44 breaths/minute B) Substernal retractions becoming more pronounced C) New-onset expiratory grunting D) Productive cough with white secretions E) Faint wheezes noted in the posterior lung base Ans: A, B, C Feedback: Children with impending respiratory failure due to airway or lung disease have rapid breathing; exaggerated use of the accessory muscles; retractions, which are more pronounced in the child than in the adult because of higher chest compliance; nasal flaring; and grunting during expiration.

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1. Chapter 23 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.

2. 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.

3. 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.

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4. 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.

5. A motor vehicle accident has resulted in critical injury for the driver of the car. The driver has hit the steering wheel with his chest and fractured his sternum and some ribs.

Which of the following manifestations would lead the staff to suspect the driver has developed a tension pneumothorax? Select all that apply.

A) Audible friction rub over the affected lung B) Mediastinal shift of the trachea toward one side C) Marked peripheral edema in lower limbs and ascites D) Atrial fibrillation noted on ECG printout E) Subcutaneous emphysema palpated in the upper chest/neck region Ans: B, E Feedback: With tension pneumothorax, the structures in the mediastinal space shift toward the opposite side of the chest. There may be distention of the neck veins, subcutaneous emphysema (i.e., presence of air in the subcutaneous tissues of the chest and neck), and clinical signs of shock. Pneumothoraces do not typically cause a friction rub or dysrhythmias. Marked peripheral edema is associated with right-sided heart failure.

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6. 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.

7. 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.

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8. 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.

9. 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.

10. 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.

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11. Which of the following medications helps treat the inflammatory reaction of asthma clients diagnosed with late-phase asthma response?

A) Anticholinergic agents B) Systemic corticosteroids C) Long-acting 2-agonists D) Phosphodiesterase inhibitors Ans: B Feedback: A short course of systemic corticosteroids, administered orally or parenterally, may be used for treating the inflammatory reaction associated with the late-phase response. The anticholinergic agents block cholinergic receptors and reduce intrinsic vagal tone that causes bronchoconstriction. The long-acting 2 agonists, available for administration by the inhaled or oral routes, act by relaxing bronchial smooth muscle. Theophylline, a phosphodiesterase inhibitor, is a bronchodilator that acts by relaxing bronchial smooth muscle.

12. A toddler seems to have a little “cold” and runny nose. At bedtime, he appears to be OK. A few hours later, parents awaken hearing a “tight” coughing sound. They recognize the child is not breathing well, so they rush to the emergency department. On arrival, the nurses suspect bronchial asthma based on which of the following assessment data? Select all that apply.

A) Audible wheezing B) “Crowing sound with inspiration” C) Respiratory rate—44 with prolonged exhalation D) Coughing up blood-tinged sputum E) Sitting upright, leaning forward, and using accessory muscles to breathe Ans: A, C, E Feedback: Bronchial asthma represents a reversible form of obstructive airway disease caused by narrowing of airways due to bronchospasms, inflammation, and increased airway secretions. Healthy children develop what may seem to be a cold with rhinorrhea, rapidly followed by irritability, a tight and nonproductive cough, wheezing, tachypnea (respiratory rate—44), dyspnea with prolonged expiration, and use of accessory muscles of respiration. Cyanosis, hyperinflation of the chest, and tachycardia indicate increasing severity of the asthma attack. Croup is characterized by inspiratory stridor or a barking cough. The British use the term croup to describe the cry of the crow or raven, and this is undoubtedly how the term originated. Hemoptysis (blood in the sputum) is usually associated with pulmonary emboli or lung cancers to name a few.

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13. While lecturing on COPD, the instructor mentions emphysema. The instructor asks the students, “If the client is a smoker, explain the physiology behind cellular changes occurring in the lung which allow destruction of the alveoli.” Which students have an accurate response? Select all that apply.

A) “Antiprotease production and release is not adequate to neutralize the excess protease production.”

B) “The capillary beds can no longer bring the cells to the lung to fight off the infection since they are blocked by fatty plaque.”

C) “There is 1-antitrypsin deficiency, so this enzyme can't protect the lung from damage.”

D) “The alveolar tissue is being digested by enzymes; therefore, they can't grow back to restore normal ventilation.”

Ans: A, C Feedback: Emphysema is characterized by a loss of lung elasticity and abnormal enlargement of the air spaces distal to the terminal bronchioles, with destruction of the alveolar walls.

One of the recognized causes of emphysema is an inherited deficiency of 1-antitrypsin, an antiprotease enzyme that protects the lung from injury. Cigarette smoke stimulates the movement of inflammatory cells into the lungs, resulting in increased release of elastase and other proteases. In smokers in whom COPD develops, antiprotease production and release may be inadequate to neutralize the excess protease production such that the process of elastic tissue destruction goes unchecked.

14. A 51-year-old man has been diagnosed with chronic bronchitis after a long history of recurrent coughing. Which of the man's following statements demonstrates a sound understanding of his new diagnosis?

A) “If I had quit smoking earlier than I did, I think I could have avoided getting bronchitis.”

B) “I'm pretty sure that I first caught bronchitis from the person who has the cubicle next to mine at work.”

C) “I read on the Internet that I might have got bronchitis because I was born with an enzyme deficiency.”

D) “I think that I probably could have prevented this if I had got in the habit of exercising more when I was younger.”

Ans: A Feedback: Smoking is frequently implicated in the etiology of chronic bronchitis. Infections do not typically initiate the disease, and exercise is not noted to have preventative value.

Enzyme deficiency is associated with emphysema, but not bronchitis.

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15. When evaluating the pulmonary function test results for a COPD client, which one correlates to the mismatch of ventilation and perfusion associated with this diagnosis?

A) Forced vital capacity (FVC) is elevated.

B) Forced expiratory volume (FEV) is decreased.

C) Total lung capacity (TLC) is decreased.

D) Marked decrease in residual volume (RV).

Ans: B Feedback: In clients with chronic lung disease, the FVC is decreased, the FEV1.0 is decreased, and the ratio of FEV1.0 to FVC is decreased. Lung volume measurements reveal a marked increase in RV, an increase in TLC, and elevation of the RV-to-TLC ratio.

16. A 25-year-old cystic fibrosis client presents to the clinic in obvious respiratory distress.

Following physical exam, the health care provider suspects bronchiectasis based on which of the following findings? Select all that apply.

A) Crushing, substernal chest pain B) Copious amounts of foul-smelling purulent sputum C) Neck vein distention D) Blood-tinged sputum E) Wheezing throughout the lung fields Ans: B, D, E Feedback: Bronchiectasis is usually manifested by a chronic productive cough, often with several 100 mL of foul-smelling, purulent sputum a day. Hemoptysis is common. Dyspnea and wheezing occur in about 75% of clients. Crushing substernal chest pain and next vein distention are more suggestive of pulmonary emboli or myocardial infarction with right-sided heart failure.

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17. A teenaged cystic fibrosis client presents to the clinic. The health care provider (HCP) knows that cystic fibrosis (CF) causes severe chronic respiratory disease in children. In addition, the HCP should also focus his or her assessment on which of the other body systems affected by CF? A) Renal B) Pancreatic C) Cardiac D) Central nervous system Ans: B Feedback: Cystic fibrosis (CF) is manifested by pancreatic exocrine deficiency and elevation of sodium chloride in the sweat. Cystic fibrosis (CF) is an inherited disorder involving fluid secretion by the exocrine glands in the epithelial lining of the respiratory, gastrointestinal, and reproductive tracts. Excessive loss of sodium in the sweat predisposes young children to salt depletion episodes. Respiratory manifestations are caused by an accumulation of viscid mucus in the bronchi, impaired mucociliary clearance, lung infections, bronchiectasis, and dilatation. The renal, cardiac, and CNS are usually not involved with CF manifestation.

18. Which of the following individuals is experiencing an immunologic lung disorder affecting ventilation that has caused the formation of a granuloma on chest x-ray?

A) A 30-year-old African American man who has been diagnosed with sarcoidosis B) An infant whose routine screening is suggestive of cystic fibrosis C) An elderly, lifelong smoker who has been admitted to hospital with emphysema exacerbation D) A 16-year-old girl who must limit her physical activity to prevent the onset of acute asthmatic attacks Ans: A Feedback: Sarcoidosis is an example of restrictive lung disease, whereas cystic fibrosis (CF), emphysema, and asthma are considered obstructive.

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19. Soon after delivery, the mother grabs the nurses arm and states, “Something's wrong…I can't get my breath.” Which of the following assessments lead the nurse to suspect the client has had an amniotic emboli travel to the lungs? Select all that apply.

A) BP 90/65; pulse 130, irregular; respiratory rate 35, shallow.

B) Intercostal traction noted on inspiration.

C) +3 pitting edema in lower extremities.

D) Trachea has shifted and is no longer midline.

E) Productive cough with blood-streaked sputum.

Ans: A, E Feedback: The embolism may consist of amniotic fluid that has entered the maternal circulation during childbirth. Persons with moderate-sized emboli often present with breathlessness accompanied by pleuritic pain, apprehension, slight fever, and cough productive of blood-streaked sputum. Tachycardia often occurs to compensate for decreased oxygenation, and the breathing pattern is rapid and shallow. Intercostal traction is usually associated with atelectasis; pitting edema is a sign of right-sided heart failure; trachea shift is a classic sign of a tension pneumothorax.

20. Which of the following clients is at risk for developing a preventable disorder related to prolonged immobility?

A) A middle-aged adult male diagnosed with bronchitis related to chronic smoking B) A young adult female diagnosed with sarcoidosis requiring corticosteroids to return her to remission C) A postsurgical client who is refusing to get out of bed and walk and will not wear those “uncomfortable elastic stocking” D) A sleep apnea client related to a history of smoking who utilizes a C-PAP machine every night at bedtime to maintain airway Ans: C Feedback: A lack of mobility can result in secondary atelectasis (through incomplete lung expansion) and pulmonary embolism (from deep vein thrombosis). This is not the case with the other listed disorders of ventilation and gas exchange.

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21. As a result of hypoxemia and polycythemia, persons with chronic obstructive bronchitis are prone to: A) Breakdown of elastin B) Left-sided heart failure C) Pulmonary hypertension D) Expiratory airway collapse Ans: C Feedback: Hypoxemia causes reflex vasoconstriction of the pulmonary vessels and further impairment of gas exchange in the lung. Hypoxemia also stimulates red blood cell production, causing polycythemia. As a result, persons with chronic obstructive bronchitis may develop pulmonary hypertension and right-sided heart failure. With breakdown and loss of lung elasticity and hyperinflation of the lungs with emphysema, the airways often collapse during expiration.

22. A young, male child is born with severe respiratory failure. Over the course of months, the parents note his body looks swollen. They ask, “Is our baby's kidneys not working right? Why is he so swollen?” The nurse bases his or her reply on which of the following physiological principles?

A) “The right side of his heart (cor pulmonale) is not pumping effectively. Blood is backlogging in his body, which is why he is so swollen.”

B) “We just need to call the physician and ask him to give you a prescription for more water pills.”

C) “Once we get his oxygenation level back to normal, then maybe his kidneys will receive enough oxygenated blood to filter better.”

D) “This happens when he has so many secretions in his lungs. Maybe we should try some expectorant to thin his secretions so he can cough them out.”

Ans: A Feedback: The term cor pulmonale refers to right heart failure resulting from primary lung disease or pulmonary hypertension. The increased pressures and work result in hypertrophy and eventual failure of the right ventricle. The manifestations of cor pulmonale include signs of right-sided heart failure, which include venous congestion, peripheral edema, shortness of breath, and a productive cough, which becomes worse during periods of heart failure. None of the other statements are applicable to these parents' questions.

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23. With acute respiratory distress syndrome (ARDS), a client progressively increases his work of breathing. The physiological principle behind this respiratory distress is related to: A) Increases in left atrial pressure causing thickening of the lining of the pulmonary arteries B) The elevation of pulmonary venous pressure C) Structural abnormalities of pulmonary vessels with proliferation of the vessel intima D) The stiffening of the lung, making it more difficult to inflate Ans: D Feedback: As the disease (ARDS) progresses, the work of breathing becomes greatly increased as the lung stiffens and becomes more difficult to inflate. There is increased intrapulmonary shunting of blood, impaired gas exchange, and hypoxemia despite high supplemental oxygen therapy. With pulmonary hypertension, there are continued increases in left atrial pressure, which can lead to medial hypertrophy and intimal thickening of the small pulmonary arteries, causing sustained hypertension. Pulmonary hypertension also causes an elevation of pulmonary venous pressure.

24. Which of the following clients is at risk for developing acute respiratory failure?

A) A middle-aged male diagnosed with amyotrophic lateral sclerosis (ALS) who has pneumonia with low O2 saturation B) An elderly female living in senior housing who has been exposed to a “cold” while her grandchildren visited C) A teenager in a high school that has had an increase in student absences due to an outbreak of strep throat D) A toddler in daycare who has been sharing toys with peers before the staff could sanitize properly Ans: A Feedback: Acute respiratory failure may occur in previously healthy persons as the result of acute disease or trauma involving the respiratory system, or it may develop in the course of a chronic neuromuscular or lung disease. ALS is a neurodegenerative disease with various causes. It is characterized by rapidly progressive weakness due to muscle atrophy and muscle spasticity and difficulty in speaking (dysarthria), swallowing (dysphagia), and breathing (dyspnea). A common cold, strep throat, or sharing toys in daycare will not necessarily place one at risk for respiratory failure.

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25. A newly admitted critical head injury client presents to the neuro-ICU. The client is unresponsive to painful stimuli but able to breathe on his own. As the shift progresses, the nurses note a decrease in the client's respiratory effort. The client cannot maintain his O2 saturation above 70%. The nurses should anticipate assisting in beginning what type of pulmonary support?

A) Increase oxygen level to 10 L/min.

B) Begin Bi-PAP. C) Call respiratory therapy to suction the client.

D) Prepare for mechanical ventilation.

Ans: D Feedback: When alveolar ventilation is inadequate to maintain PO 2 or PCO2 levels because of respiratory or neurologic failure, mechanical ventilation may be lifesaving. Usually a nasotracheal, orotracheal, or tracheotomy tube is inserted into the trachea to provide the client with the airway needed for mechanical ventilation.

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1. Chapter 24 Protein and blood cell leakage into the filtrate that occurs in many forms of glomerular disease is a result of changes in the structure and function of the glomerular: A) Renal corpuscle B) Bowman capsule C) Peritubular network D) Basement membrane Ans: D Feedback: The basement membrane is a meshwork of collagen fibers, with slit pores between the fibers creating size-dependent permeability that (normally) does not allow large molecules, such as protein and blood cells through. The renal corpuscle contains the Bowman capsule and capillaries surrounding it. Peritubular capillary network is a low-pressure reabsorptive system that permits rapid fluid/solute transfer to/from the tubules.

2. While studying for renal test in pathophysiology class, a student helps a peer by reviewing facts about the cells of the proximal tubule. Which of the following functions should they include in this discussion? Select all that apply.

A) Aids in reabsorption B) Location for high-pressure capillary filtration C) Rich in mitochondria D) Plays a role in the medullary collecting tubule E) Supports active transport processes Ans: A, C, E Feedback: The cells of the proximal tubule have a fine, villous structure that increases the surface area for reabsorption; they also are rich in mitochondria, which support active transport processes. The epithelial layer thins in segments of the loop of Henle and has few mitochondria, indicating minimal metabolic activity and reabsorptive function.

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3. In the intensive care unit (ICU), the nurse is caring for a trauma client who has abdominal injuries is beginning to have a decrease in BP and increased pulse rate and is pale with diaphoretic skin. The nurse is assessing the client for hemorrhagic shock. If the client is in shock, the nurse would expect to find: A) Excess output of blood-tinged urine B) Complaints of flank pain rotating around the abdominal muscles C) Significant decrease in urine output due to decrease in renal blood flow D) An increase in GFR due to relaxation of the afferent arterioles Ans: C Feedback: During periods of strong sympathetic stimulation, such as shock, constriction of the afferent arteriole causes a marked decrease in renal blood flow and thus glomerular filtration pressure. Consequently, urine output can fall almost to 0. Unless the injury is specific to the kidney, the client will not have blood in urine and urine production will not be excessive. Flank pain is associated with obstruction due to stone formation. The GFR will decrease rather than increase.

4. When explaining to a CKD client how urea is absorbed, which of the following transport mechanisms will be mentioned?

A) Primary active transport B) Secondary active transport C) Passive transport D) Active sodium transport Ans: C Feedback: The mechanisms of transport across the tubular cell membrane are similar to those of other cell membranes in the body and include active and passive transport mechanisms.

Water and urea (a by-product of protein metabolism) are passively absorbed along concentration gradients. Sodium (Na+), other electrolytes, as well as urate, glucose, and amino acids, are reabsorbed using primary or secondary active transport mechanisms to move across the tubular membrane. The bulk of energy used by the kidney is for active sodium transport mechanisms that facilitate sodium reabsorption and cotransport of other electrolytes and substances such as glucose and amino acids.

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5. An automobile accident client is brought to the emergency department in hypovolemic shock from internal bleeding. Nurses are closely monitoring urine output since a significant decrease signifies that: A) The kidneys are probably injured.

B) Renal arteries are clogged with blood.

C) The SNS has caused afferent arteries to constrict to decrease blood flow.

D) Vagus nerve has caused bradycardia, which decreases amount of blood reaching kidneys.

Ans: C Feedback: The afferent and the efferent arterioles are innervated by the sympathetic nervous system and are sensitive to vasoactive hormones, such as angiotensin II. During periods of strong sympathetic stimulation, such as shock, constriction of the afferent arteriole causes a marked decrease in renal blood flow and thus glomerular filtration pressure.

Consequently, urine output can fall almost to 0. There is no enough information to conclude the kidneys are injured, the renal arteries are clotted, or the vagus nerve has been innervated.

6. While explaining the tubular role in reabsorption, the nurse will stress that a diet high in sodium intake will result in sodium reabsorption in which of the following renal locations?

A) Descending limb of the loop of Henle B) Ascending limb of the loop of Henle C) Bowman capsule D) Proximal convoluted tubule Ans: D Feedback: Approximately 65% of all reabsorptive and secretory processes that occur in the tubular system take place in the proximal tubule. Electrolytes, such as Na +, K+, Cl–, and bicarbonate (HCO3–), are 65% to 80% reabsorbed in this location.

7. When the glomerular transport maximum for a substance such as blood glucose is exceeded and its renal threshold has been reached, the substance will: A) Reabsorb quickly B) Spill into the urine C) Countertransport sodium D) Attach to protein carriers Ans: B Feedback: When the substance (such as blood glucose) exceeds the number of carrier proteins available for transport, the transport maximum has been exceeded, the renal threshold is reached, and the substance will spill (not reabsorb) into the urine. Sodium cotransport helps to move the substance back into the tubule.

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8. A client who has been diagnosed with Addison disease will likely experience which of the following lab results related to the absence of aldosterone?

A) Serum potassium levels elevated B) Increased serum sodium levels C) Elevated creatinine levels D) Decreased serum chloride levels Ans: A Feedback: Aldosterone exerts a strong influence on potassium secretion in the distal and collecting tubules. In the absence of aldosterone, as occurs in Addison disease, potassium secretion is markedly decreased, causing blood levels to increase. In the presence of aldosterone, almost all the sodium in the distal tubular fluid is reabsorbed, and the urine essentially becomes sodium free. In the absence of aldosterone, virtually no sodium is reabsorbed from the distal tubule, and excessive amounts of sodium are lost in the urine.

9. A client has been prescribed hydrochlorothiazide, a thiazide diuretic, to control high blood pressure. While educating the client about the actions of the medication, the nurse will mention which of the following actions? Select all that apply.

A) Blocks Na+ reabsorption in distal tubules B) Establishes a high concentration of osmotically active particles C) Increases active reabsorption of Ca++ into the blood D) Juxtamedullary vasoconstriction, which controls water movement E) Establishes a high concentration of K+ within the cell Ans: A, C Feedback: The thiazide diuretics, which are widely used to treat disorders such as hypertension, exert their action by blocking sodium reabsorption in this segment of the renal tubules, while enhancing the active reabsorption of calcium into the blood via the calcium– sodium exchange transport mechanism. For this reason, thiazide diuretics have proved useful in reducing the incidence of calcium kidney stones in persons with hypercalciuria. ATPase pump maintains a low sodium concentration inside the cell by moving sodium down its concentration into the cell through special sodium channels.

The pump also establishes a high concentration of potassium within the cell, causing it to diffuse down its concentration gradient across the luminal membrane into the tubular fluid.

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10. An athlete has become dehydrated during a long race in hot weather. Which of the following physiologic processes will occur in an attempt to protect the athlete's extracellular fluid volume?

A) Dilation of the afferent and efferent arterioles B) Release of ADH from the posterior pituitary C) Increased water reabsorption in the ascending limb of the loop of Henle D) Increased water reabsorption in the distal convoluted tubule Ans: B Feedback: ADH assists in the maintenance of the extracellular fluid volume by controlling the permeability of the medullary collecting tubules. Osmoreceptors in the hypothalamus sense an increase in osmolality of extracellular fluids and stimulate the release of ADH from the posterior pituitary gland. In exerting its effect, ADH, also known as vasopressin, binds to receptors on the basolateral side of the tubular cells. Binding of ADH to the vasopressin receptors causes water channels, known as aquaporin-2 channels, to move into the luminal side of the tubular cell membrane, producing a marked increase in water permeability. The ascending limb of the loop of Henle and the distal convoluted tubule are largely impermeable to water, and arteriole dilation does not directly increase the amount of water reabsorbed from glomerular filtrate.

11. Which of the following factors is likely to result in decreased renal blood flow?

A) Action of dopamine B) Release of nitric oxide C) Action of prostaglandins D) Sympathetic nervous system stimulation Ans: D Feedback: Sympathetic nervous system (SNS) stimulation results in decreased renal blood flow by vasoconstriction. Dopamine, nitric oxide, and prostaglandins are all vasodilators.

12. Nitric oxide, a vasodilator produced by the vascular endothelium, is important in renal control by: Select all that apply.

A) Preventing excessive vasoconstriction B) Regulating renal blood flow C) Inhibiting prostaglandin synthesis D) Allowing normal excretion of sodium and water Ans: A, D Feedback: Nitric oxide, a vasodilator produced by the vascular endothelium, appears to be important in preventing excessive vasoconstriction of renal blood vessels and allowing normal excretion of sodium and water. Prostaglandins do not appear to play a major role in regulating renal blood flow. Some medications like aspirin and NSAIDs inhibit prostaglandin synthesis.

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13. Which of the following aspects of kidney function is performed by the juxtaglomerular apparatus?

A) Regulating urine concentration B) Facilitating active transport to reabsorb electrolytes C) Regulating sodium and potassium elimination D) Matching changes in GFR with renal blood flow Ans: D Feedback: The juxtaglomerular apparatus is thought to represent a feedback control system that links changes in the glomerular filtration rate (GFR) with renal blood flow.

14. A client is admitted with worsening heart failure. The client is complaining about having to urinate frequently. The nurse knows that the physiology behind the body's response to decrease vascular volume by increasing urine output is due to: A) Release of atrial natriuretic peptide (ANP) from overstretched atria B) Renin secretion, resulting in angiotensin II formation C) Reabsorption of potassium from the proximal tubule D) Aldosterone secretion by the adrenal gland, which inhibits sodium absorption Ans: A Feedback: ANP is believed to play an important role in salt and water excretion by the kidney. It is synthesized by muscle cells in the atria of the heart and released when the atria are stretched. Increased levels of this peptide directly inhibit the reabsorption of sodium and water in the renal tubules. ANP also inhibits renin secretion and therefore angiotensin II formation, which in turn reduces reabsorption of sodium. The decrease in sodium reabsorption increases urine output and helps return blood volume to normal. ANP levels, which become elevated when the atria are stretched in HF, help to decrease vascular volume by increasing urine output. Potassium reabsorption is not responsible for water excretion. Aldosterone secretion by the adrenal gland functions in the regulation of sodium and potassium elimination by the principal cells in the distal and collecting tubules.

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15. When explaining the body's compensatory mechanisms to maintain a normal pH, the health care provider knows that the renal system: A) Works slower than the respiratory system, going into action 1 to 2 days after H+ remain elevated B) Will absorb more bile acids to try to normalize elevated H+ levels C) Will absorb more Na+ and water to dilute the elevated H+ in an effort to normalize pH D) Waits until the lungs have increased the respiratory rate to try to blow off excess CO2 Ans: A Feedback: Only the kidney can eliminate hydrogen from the body. Virtually all the excess H + excreted in the urine are secreted into the tubular fluid by means of tubular secretory mechanisms. The ability of the kidneys to excrete large amounts of H + in the urine is accomplished by combining the excess ions with buffers in the urine. The three major urine buffers are HCO3–, phosphate (HPO42–), and ammonia (NH3). An important aspect of this buffer system is that the deamination process increases whenever the body's hydrogen ion concentration remains elevated for 1 to 2 days.

16. Which of the following medications may be responsible for a client developing increased uric acid levels by decreasing ECF volume?

A) Vitamin C B) Thiazide diuretics C) Penicillin antibiotics D) Maalox products Ans: B Feedback: Because of its effect on uric acid secretion, aspirin is not recommended for treatment of gouty arthritis. Thiazide and loop diuretics also can cause hyperuricemia and gouty arthritis, presumably through a decrease in ECF volume and enhanced uric acid reabsorption.

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17. A client's most recent blood work reveals a blood urea nitrogen (BUN) level of 36 mg/dL (normal range 8 to 25 mg/dL). Which of the following factors may have contributed to this finding?

A) Increased salt intake B) Action of ADH C) Dehydration D) Parasympathetic nervous system stimulation Ans: C Feedback: During periods of dehydration, the blood volume and glomerular filtration rate (GFR) drop, and BUN levels increase. Increased salt intake, parasympathetic stimulation, and the action of ADH do not normally result in an increase in BUN.

18. Which of the following physiologic processes is performed by the kidneys and contributes to increased blood pressure?

A) Catalysis of the conversion of angiotensin I to angiotensin II B) Production and release of renin C) Secretion of aldosterone D) Conversion of aldosterone to angiotensin Ans: B Feedback: Renin, an enzyme that is synthesized and stored in the juxtaglomerular cells of the kidney, enzymatically converts angiotensinogen to angiotensin I. Angiotensin I is converted to angiotensin II, a potent vasoconstrictor, in the lungs. Aldosterone is secreted by the adrenal glands and does not convert to angiotensin.

19. Which of the following clients is benefiting from the renin–angiotensin–aldosterone mechanism?

A) A teenager who received an injury to the flank area during football practice B) A toddler who was recently diagnosed with cystic fibrosis C) A college student admitted to the neurotrauma unit following traumatic brain injury requiring surgery to evacuate a large hematoma D) A middle-aged adult with osteoarthritis requiring arthroscopic knee surgery to repair a torn meniscus Ans: C Feedback: The kidney releases renin, which enters the blood stream to convert angiotensinogen to angiotensin I. The angiotensin I travels to the lungs, where it is converted to angiotensin II. Angiotensin II acts directly on the kidneys. Renin functions by means of angiotensin II to produce intrarenal vasoconstriction. This helps to regulate blood pressure, which could be a problem for the client having bleeding (hematoma) inside the brain.

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20. A client has a diagnosis of chronic renal failure secondary to diabetic nephropathy.

Which of the following hematologic changes may result from this client's kidney disorder?

A) Anemia B) Leukocytosis C) Thrombocytopenia D) Leukopenia Ans: A Feedback: Erythropoietin is a polypeptide hormone that regulates the differentiation of RBCs in the bone marrow. Between 89% and 95% of erythropoietin is formed in the kidneys. The synthesis of erythropoietin is stimulated by tissue hypoxia, which may be brought about by anemia, residence at high altitudes, or impaired oxygenation of tissues due to cardiac or pulmonary disease. Persons with chronic kidney disease often are anemic because of an inability of the kidneys to produce erythropoietin. Changes in platelet or white blood cell levels are not likely to result directly from renal failure.

21. Clients with CKD are at risk for demineralization of their bones since they are no longer able to: A) Transform vitamin D to its active form B) Excrete bicarbonate effectively C) Stimulate bone osteoclastic production D) Synthesize erythropoietin Ans: A Feedback: The kidneys aid in calcium metabolism by activating vitamin D, after it is chemically converted by the liver. Bicarbonate buffering is unrelated to activation of vitamin D. Bone marrow is stimulated by the synthesis of erythropoietin to form red blood cells, which is unrelated to calcium levels.

22. Which one of the following blood tests reflects the glomerular filtration rate (GFR) and is used to estimate renal function?

A) Blood protein B) Serum creatinine C) Serum ammonia D) Blood urea nitrogen Ans: B Feedback: Serum creatinine level is used to estimate functional capacity of the kidneys. Increased creatinine level indicates decreased GFR and renal function. Blood urea nitrogen (BUN) levels are influenced by hydration status, protein intake, and bleeding, in addition to renal function. Serum ammonia is a metabolic by-product of urea and can be influenced by multiple factors unrelated to kidney function.

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23. A client has provided a routine urine sample during a scheduled visit to his primary care provider. Which of the following results is an expected finding in a healthy individual?

A) Low to moderate amount of glucose in the urine B) Urine specific gravity of 1.020 C) Presence of moderate amounts of albumin with absence of other proteins D) Presence of urinary casts Ans: B Feedback: Normal urine specific gravity ranges from 1.010 to 1.025. Glucose and casts are normally absent, and albumin is normally present in only scant amounts.

24. When explaining urinalysis results that show the presence of cast cells, the nurse informs the client that casts cells develop when the client has: Select all that apply.

A) A high protein concentration of the urine B) An elevated urine pH C) High urine osmolality D) More than one bacteria present in the urine Ans: A, C Feedback: Casts are molds of the distal nephrons' lumen. A gel-like substance (Tamm-Horsfall mucoprotein) is formed in the tubular epithelium and is the major protein constituent of urinary casts. Casts composed of this gel but devoid of cells are called hyaline casts.

These casts develop when the protein concentration of the urine is high, urine osmolality is high, and urine pH is low.

25. The nurse should anticipate that a client who collapsed while running his or her first marathon and has a urine specific gravity of 1.035 is experiencing: A) Frostbite B) Sun stroke C) Dehydration D) Exhaustion Ans: C Feedback: The usual range of specific gravity is 1.010 to 1.025 with normal fluid intake. Healthy kidneys can produce concentrated urine with specific gravity of 1.030 to 1.040 during periods of dehydration and dilute urine with a specific gravity that approaches 1.000 during periods of too much fluid intake. Frostbite, sunstroke, and exhaustion do not change urine specific gravity if fluid volume is normal.

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1. Chapter 25 An adult client has been diagnosed with polycystic kidney disease. Which of the client's following statements demonstrates an accurate understanding of this diagnosis?

A) “I suppose I really should have paid more attention to my blood pressure.”

B) “I've always been prone to getting UTIs, and now I know why.”

C) “I suppose I should be tested to see if my children might inherit this.”

D) “I had a feeling that I was taking too many medications, and now I know the damage they can do.”

Ans: C Feedback: Autosomal dominant polycystic kidney disease is the most common of all inherited kidney diseases. The disorder is characterized by multiple expanding cysts of both kidneys that ultimately destroy the surrounding kidney structures and cause renal failure. The etiology of polycystic kidney disease (PKD) is not infective, and it is not caused by nephrotoxic drugs or uncontrolled hypertension.

2. While taking a client history, which of the following assessments lead the nurse to suspect the client may have polycystic kidney disease? Select all that apply.

A) Massive proteinuria on dipstick urine specimen B) Renal colic with flank pain C) Bright red blood in urine sample D) Elevated blood pressure of 180/94 E) Shortness of breath (SOB) with loud rhonchi and wheezes heard on auscultation Ans: B, C, D Feedback: The manifestations of ADPKD include pain from the enlarging cysts that may reach debilitating levels, episodes of gross hematuria from bleeding into a cyst, infected cysts from ascending UTIs, and hypertension resulting from compression of intrarenal blood vessels with activation of the renin–angiotensin mechanism. Renal colic caused by nephrolithiasis, or kidney stones, occurs in about 20% of persons with ADPKD. One type of pain associated with kidney stones is renal colic, described as colicky pain that accompanies stretching of the collecting system or ureter. Nephrotic syndrome is characterized by massive proteinuria. SOB with abnormal respiratory sounds is not usually associated with ADPKD.

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3. Which of the following statements about the use of angiotensin-converting enzyme inhibitor medications and autosomal recessive polycystic kidney disease (ARPKD) is accurate?

A) The use of ACE inhibitors will increase the vasopressin levels.

B) ACE inhibitors may interrupt the renin–angiotensin–aldosterone system to reduce renal vasoconstriction.

C) The ACE inhibitors have been shown to shrink the size of the cysts inside the kidneys.

D) ACE inhibitors should be used strictly in those clients who also have an underlying cardiac history.

Ans: B Feedback: In addition to increasing water intake to decrease vasopressin levels, the angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) may be used to interrupt the renin–angiotensin–aldosterone system as a means of reducing intraglomerular pressure and renal vasoconstriction. Although not approved by the Food and Drug Administration (FDA), there has been recent interest in the use of vasopressin receptor antagonists (vaptans) to decrease cyst development.

4. An infant has been diagnosed with autosomal recessive polycystic kidney disease (ARPKD). Which of the following treatment goals would be considered the priority in the care of this child?

A) Rehydration therapy B) Total parenteral nutrition C) Prophylactic antibiotics D) Respiratory support Ans: D Feedback: Aggressive ventilatory support is often necessary for neonates with ARPKD, due to the presence of pulmonary hypoplasia and hypoventilation. Hydration, nutrition, and infection prevention are relevant aspects of care, but respiratory interventions are the priority.

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5. Glomerulonephritis is usually caused by: A) Vesicoureteral reflux B) Catheter-induced infection C) Antigen–antibody complexes D) Glomerular membrane viruses Ans: C Feedback: Two types of immune mechanisms have been implicated in the development of glomerular disease: injury resulting from antibodies reacting with fixed glomerular antigens and injury resulting from circulating antigen–antibody complexes that become trapped in the glomerular membrane. Reflux, which is the most common cause of chronic pyelonephritis, results from superimposition of infection on congenital vesicoureteral reflux or intrarenal reflux. Urinary catheters provide a means for microorganisms to ascend into the urinary tract to cause bladder infections or pyelonephritis.

6. A client has been given the diagnosis of diffuse glomerulonephritis. They ask the nurse what diffuse means. The nurse responds: A) Only some of the glomeruli are affected.

B) Only one segment of each glomerulus is involved.

C) That the mesangial cells are being affected.

D) All glomeruli and all parts of the glomeruli are involved.

Ans: D Feedback: Glomerular changes can be diffuse, involving all glomeruli and all parts of the glomeruli; focal, meaning only some of the glomeruli are affected; segmental, involving only a certain segment of each glomerulus; and mesangial, affecting only mesangial cells.

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7. A child is recovering from a bout with group A -hemolytic Streptococcus infection.

They return to the clinic a week later complaining of decrease in urine output with puffiness and edema noted in the face and hands. The health care provider suspects the child has developed: A) Autosomal recessive polycystic kidney disease B) Adult-onset medullary cystic disease C) Acute postinfectious glomerulonephritis D) Acute nephritic syndrome Ans: C Feedback: The classic case of poststreptococcal glomerulonephritis follows a streptococcal infection by approximately 7 to 12 days—the time needed for the development of antibodies. Oliguria, which develops as the GFR decreases, is one of the first symptoms.

Proteinuria and hematuria follow because of increased glomerular capillary wall permeability. Sodium and water retention gives rise to edema (particularly of the face and hands) and hypertension. Adults with medullary cystic kidney disease present first with polyuria, polydipsia, and enuresis (bed-wetting), which reflect impaired ability of the kidneys to concentrate urine. The typical infant with ARPKD presents with bilateral flank masses, accompanied by severe renal failure, signs of impaired lung development, and variable degrees of liver fibrosis and portal hypertension. Acute nephritic syndrome is characterized by sudden onset of hematuria, variable degrees of proteinuria, diminished glomerular filtration rate (GFR), oliguria, and signs of impaired renal function.

8. Following an episode of strep throat, the school nurse notices the fourth grade child has not recovered from this illness a week later. Upon further investigation, the nurse notices that the child has developed water retention. Which of the following assessments support this conclusion? Select all that apply.

A) Periorbital edema B) BP 100/70 C) Swelling of the hands and fingers D) Vomiting after intake of any solid food E) Dizziness and right ear pain Ans: A, B Feedback: Generalized edema, a hallmark of nephrosis, results from salt and water retention and a decrease in plasma colloid osmotic pressure due to loss of albumin in the urine.

Glomerulonephritis is characterized by sodium and water retention that causes edema, particularly of the face and hands. Fluid retention usually results in an elevated BP, not a normal one. Vomiting and dizziness are not associated with this diagnosis.

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9. Which of the following assessment findings would lead the nurse to suspect the client has nephrotic syndrome?

A) Hematuria and anemia B) Proteinuria and generalized edema C) Renal colic and increased serum sodium D) Increased creatinine with normal blood urea nitrogen Ans: B Feedback: The nephrotic syndrome is characterized by massive proteinuria and lipiduria, along with an associated hypoalbuminemia, generalized edema, and hyperlipidemia.

10. Following the diagnosis of nephrotic syndrome, the nurse knows the clinical manifestations occur as a result of a decreased plasma colloidal osmotic pressure.

Therefore, the nurse should assess the client for: Select all that apply.

A) Moist crackles in both lung fields B) Areas of diminished breath sounds due to pleural effusions C) Liver enlargement D) Kidneys palpable to deep palpation E) Increased circumference in the abdomen related to fluid excess Ans: A, B, E Feedback: Generalized edema, which is a hallmark of the nephrotic syndrome, results from a decrease in the plasma colloidal osmotic pressure due to the hypoalbuminemia that develops as albumin is lost from the vascular compartment. Initially, the edema presents in dependent parts of the body such as the lower extremities, but becomes more generalized as the disease progresses. Dyspnea due to pulmonary edema, pleural effusions, and diaphragmatic compromise due to ascites (increase fluid in the abdominal cavity) can develop in persons with nephrotic syndrome. Live enlargement is not associated with nephrotic syndrome, but increased synthesis of lipoproteins in the liver secondary to a compensatory increase in albumin production may occur. Palpable kidney mass is associated with cancer.

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11. 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.

12. 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.

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13. 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.

14. 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.

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15. 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.

16. A client with a history of chronic pyelonephritis has been admitted several times with recurrent bacterial infection of the urinary tract. The nurse should anticipate educating this client with regard to which common treatment regimen?

A) Increase intake of cranberry juice to 2 L/day.

B) Continue taking antibiotics for full 10 to 14 days even if symptoms of infection disappear.

C) Force micturition every 2 hours while awake.

D) Take prescribed diuretics early in the day to avoid having to get up during the night.

Ans: B Feedback: Chronic pyelonephritis involves a recurrent or persistent bacterial infection superimposed on urinary tract obstruction, urine reflux, or both. Chronic obstructive pyelonephritis can be bilateral, caused by conditions that obstruct bladder outflow; or unilateral, such as occurs with ureteral obstruction. Cranberry juice, forced micturition, and diuretics are not standard treatments for chronic pyelonephritis.

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17. Prior to undergoing diagnostic testing with contrast, it is recommended that older adult clients have their creatinine level checked. The rationale for this is to ensure the client: A) Is not allergic to shell fish or iodine B) Will not undergo an acute kidney injury by decreasing renal blood flow C) Does not have a kidney stone obstructing the urethra D) Is in good enough health to withstand a walking on a treadmill Ans: B Feedback: Some drugs, such as diuretics, high molecular weight radiocontrast media, the immunosuppressive drugs cyclosporine and tacrolimus, and the nonsteroidal anti-inflammatory drugs (NSAIDs), can cause acute kidney injury by decreasing renal blood flow. Checking creatinine levels do not predict the client's allergies, a kidney stone, or tolerance for stress testing.

18. The most damaging effects of urinary obstruction are the result unrelieved obstruction of urine outflow and: A) Urinary stasis B) Concentrated urine C) Kidney hyperplasia D) Renal hypertension Ans: A Feedback: The most damaging effects of urinary obstruction are stasis of urine, which predisposes to infection and stone formation, and unrelieved obstruction of urine outflow. Most commonly, the person has pain, signs, and symptoms of urinary tract infection (UTI) and manifestations of renal dysfunction, such as an impaired ability to concentrate urine.

Progressive atrophy of the kidney is caused by obstruction of the outflow of urine.

Hypertension is an occasional complication of urinary tract obstruction, since urine flow is obstructed rather than renal blood flow.

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19. The physician suspects that a client with kidney stones has developed magnesium ammonium phosphate (struvite) stones based on which of the following urinalysis results? Select all that apply.

A) Elevated uric acid levels B) Alkaline urine pH C) High urine phosphate level D) High bacterial count E) Presence of cystine particles Ans: B, C, D Feedback: Magnesium ammonium phosphate stones, also called struvite stones, form only in alkaline urine and in the presence of bacteria that possess an enzyme called urease, which splits the urea in the urine into ammonia and carbon dioxide. The ammonia that is formed takes up a hydrogen ion to become an ammonium ion, increasing the pH of the urine so that it becomes more alkaline. Because phosphate levels are increased in alkaline urine and because magnesium always is present in the urine, struvite stones form. Uric acid stones develop in conditions of gout and high concentrations of uric acid in the urine. Cystine stones account for less than 1% of kidney stones overall but represent a significant proportion of childhood calculi. They are seen in cystinuria, which results from a genetic defect in renal transport of cystine.

20. An obese, male client with a history of gout and a sedentary lifestyle has been advised by his primary care provider to avoid organ meats, certain fish, and other foods that are high in purines. The care provider is demonstrating an awareness of the client's susceptibility to which of the following types of kidney stones?

A) Calcium stones B) Magnesium ammonium phosphate stones C) Uric acid stones D) Cystine stones Ans: C Feedback: Uric acid stones develop in conditions of gout and when high concentrations of uric acid in the urine. Unlike radiopaque calcium stones, uric acid stones are not visible on x-ray films. According to Table 25-2, these stones develop in clients who eat a high-purine diet like Atkins.

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21. If a client with a kidney stone has the “classic” ureteral colic, the client will describe his pain as: Select all that apply.

A) Acute, intermittent B) Diffuse over the entire lower back and legs C) Excruciating D) In the flank and upper outer quadrant of the abdomen Ans: A, C, D Feedback: The symptoms of renal colic are caused by stones 1 to 5 mm in diameter that can move into the ureter and obstruct flow. Classic ureteral colic is manifested by acute, intermittent, and excruciating pain in the flank and upper outer quadrant of the abdomen on the affected side. The pain may radiate to the lower abdominal quadrant, bladder area, perineum, or scrotum in the man. The pain is usually not described as diffuse and over the entire low back and legs.

22. A client has recently undergone successful extracorporeal shock wave lithotripsy (ESWL) for the treatment of renal calculi. Which of the following measures should the client integrate into his lifestyle to reduce the risk of recurrence?

A) Increased fluid intake and dietary changes B) Weight loss and blood pressure control C) Regular random blood glucose testing D) Increased physical activity and use of over-the-counter diuretics Ans: A Feedback: Depending on the type of stone that was present, many clients benefit from increased fluid intake and changes in diet. Weight loss, blood sugar and pressure control, and exercise are not central preventative measures. It would likely be inappropriate to recommend the use of over-the-counter diuretics as a preventative measure.

23. A young child has been diagnosed with Wilms tumor after his mother discovered an unusual mass, prompting a diagnostic workup. Which of the following characteristics is typical of Wilms tumor? The tumor is usually: A) Asymptomatic B) Self-limiting C) A secondary neoplasm D) Encapsulated Ans: D Feedback: Wilms tumor usually is a solitary mass that occurs in any part of the kidney. It usually is sharply demarcated and variably encapsulated. It is not a self-limiting health problem, and chemotherapy, radiotherapy, and/or surgery may be utilized. Symptoms include hypertension, abdominal pain, and vomiting.

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24. While taking a history from an adult client newly diagnosed with renal cell cancer, the nurse can associate which of the following high-risk factors with the development of this cancer?

A) Heavy smoking B) Inherited renal disease C) Adrenal medulla tumors D) Anorexia/bulimia disorder Ans: A Feedback: Epidemiologic evidence suggests a correlation between heavy smoking and kidney cancer. Obesity also is a risk factor; particularly in women. The risk of renal cell carcinoma also is increased in persons with acquired cystic kidney disease associated with chronic renal insufficiency. Although the adrenal gland is adjacent to the kidney, primary adrenal tumors are unrelated to renal cell disease.

25. Which of the following client clinical manifestations most clearly suggests a need for diagnostic testing to rule out renal cell carcinoma?

A) Urinary urgency B) Hematuria C) Oliguria D) Cloudy urine Ans: B Feedback: Presenting features of renal cancer include hematuria, flank pain, and presence of a palpable flank mass. Gross or microscopic hematuria, which occurs in more than 50% of cases, is an important clinical clue. Urgency, oliguria, and cloudy urine are not as closely associated with renal carcinoma.

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1. Chapter 26 A diabetic client with a history of hypertension may receive a prescription for which medication to provide a renal protective effect by reducing intraglomerular pressure?

Select all that apply.

A) Loop diuretics B) ACE inhibitors C) Angiotensin receptor blockers D) Calcium channel blockers E) A digitalis preparation Ans: B, C Feedback: The ACE inhibitors and ARBs reduce the effects of angiotensin II on renal blood flow.

They also reduce intraglomerular pressure and may have a renal protective effect in persons with hypertension or type 2 diabetes. However, when combined with diuretics, they may cause prerenal injury in persons with decreased blood flow due to large-vessel or small-vessel kidney disease. Calcium channel blockers are vasodilators.

2. An 86-year-old female client has been admitted to the hospital for the treatment of dehydration and hyponatremia after she curtailed her fluid intake to minimize urinary incontinence. The client's admitting laboratory results are suggestive of prerenal failure.

The nurse should be assessing this client for which of the following early signs of prerenal injury?

A) Sharp decrease in urine output B) Excessive voiding of clear urine C) Acute hypertensive crisis D) Intermittent periods of confusion Ans: A Feedback: Dehydration and its consequent hypovolemia can result in acute renal failure that is prerenal in etiology. The kidney normally responds to a decrease in GFR with a decrease in urine output. Thus, an early sign of prerenal injury is a sharp decrease in urine output. Postrenal failure is obstructive in etiology, and intrinsic (or intrarenal) renal failure is reflective of deficits in the function of the kidneys themselves.

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3. A client had excessive blood loss and prolonged hypotension during surgery. His postoperative urine output is sharply decreased, and his blood urea nitrogen (BUN) is elevated. The most likely cause for the change is acute: A) Prerenal inflammation B) Bladder outlet obstruction C) Tubular necrosis D) Intrarenal nephrotoxicity Ans: C Feedback: Ischemic acute tubular necrosis (ATN) occurs most frequently in persons who have major surgery with prolonged renal hypoperfusion—this directly damages the tubular epithelial cells with acute suppression of renal function. Nephrotoxic ATN is caused by toxic agents or drugs. Prerenal vasoconstriction is associated with acute-onset loss of renal output. Bladder (postrenal) obstruction would not affect the BUN, since it rarely causes renal failure.

4. A client with significant burns on his lower body has developed sepsis on the 3rd day following his accident. Which of the following manifestations would the nurse anticipate for an ischemic acute tubular necrosis rather than prerenal failure? The client: A) Exhibits pulmonary and peripheral edema B) GFR does not increase after restoration of renal blood flow C) Undergoes emergent hemodialysis that does not result in decreased BUN and creatinine D) Exhibits oliguria and frank hematuria Ans: B Feedback: In contrast to prerenal failure, the glomerular filtration rate (GFR) does not improve with the restoration of renal blood flow in acute renal failure caused by ischemic acute tubular necrosis. Edema, oliguria, and hematuria are not diagnostic of acute tubular necrosis (ATN), and hemodialysis does not normally fail to achieve a reduction in blood urea nitrogen (BUN) and creatinine.

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5. A drug abuser was found unconscious after shooting up heroin 2 days prior. Because of the pressure placed on the hip and arm, the client has developed rhabdomyolysis. The nurse knows this can: A) Obstruct the renal tubules with myoglobin and damage tubular cells B) Be cured by administering an anticoagulant immediately C) Cause the kidney to develop renal stones due to stasis D) Cause compartment syndrome in the lower extremities Ans: A Feedback: Myoglobin normally is not found in the serum or urine. It has a low molecular weight; if it escapes into the circulation, it is rapidly filtered in the glomerulus. A life-threatening condition known as rhabdomyolysis occurs when increasing myoglobinuria levels cause myoglobin to precipitate in the renal tubules, leading to obstruction and damage to surrounding tubular cells. Myoglobinuria most commonly results from muscle trauma but may result from exertion, hyperthermia, sepsis, prolonged seizures, and alcoholism or drug abuse. Rhabdomyolysis is not cured with anticoagulation administration nor does it cause kidney stones. Compartment syndrome occurs when there is insufficient blood supply to muscles and nerves due to increased pressure within one of the body's compartments.

6. A client is beginning to recover from acute tubular necrosis. The nurse would likely be assessing which of the following manifestations of the recovery phase of ATN? A) Edema B) Diuresis C) Proteinuria D) Hypokalemia Ans: B Feedback: The recovery phase is first noticed as increased/excessive output (diuresis) of dilute urine and a fall in serum creatinine, indicating that the nephrons have recovered to the point at which urine excretion is possible. Potassium will remain elevated or continue to rise, since the diuresis occurs before renal function fully returns to normal. Edema/fluid retention is characteristic of the maintenance phase. Proteinuria is characteristic of glomerular disease and/or chronic kidney disease.

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7. When acute tubular necrosis (ATN) is suspected, the nurse will likely see which of the following laboratory findings on the urinalysis report? Select all that apply.

A) Protein B) Glucose C) Red blood cells D) Sodium excess E) Cast cells Ans: A, C, E Feedback: Nephron damage allows the larger protein cells to pass through the membrane and into the urine (normally, urine has very few proteins present). Further diagnostic information that can be obtained from the urinalysis includes hemoglobinuria (blood in the urine) and casts or crystals in the urine. Glucosuria in the urine is an indirect indication of extreme hyperglycemia, often unrelated to renal disease. Urine sodium concentration is maintained with prerenal azotemia; urine sodium decreases with renal tubule damage.

Urine calcium is not diagnostic for ATN.

8. Which of the following individuals likely faces the greatest risk for the development of chronic kidney disease?

A) A first-time mother who recently lost 1.5 L of blood during a postpartum hemorrhage B) A client whose diagnosis of thyroid cancer necessitated a thyroidectomy C) A client who experienced a hemorrhagic stroke and now has sensory and motor deficits D) A client with a recent diagnosis of type 2 diabetes who does not monitor his blood sugars or control his diet Ans: D Feedback: Chronic kidney disease (CKD) is a pathophysiologic process that results in the loss of nephrons and a decline in renal function that has persisted for more than 3 months. CKD can result from diabetes, hypertension, glomerulonephritis, lupus (SLE), and polycystic kidney disease. The prevalence and incidence of CKD continue to grow, reflecting the growing elderly population and the increasing number of people with diabetes and hypertension. Hemorrhage may result in acute renal failure, but it is not associated with chronic kidney disease. Stroke and loss of the thyroid gland are not noted to underlie cases of chronic kidney disease.

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9. The primary care provider for a newly admitted hospital client has added the glomerular filtration rate (GFR) to the blood work scheduled for this morning. The client's GFR results return as 50 mL/minute/1.73 m2. The nurse explains to the client that this result represents: A) A need to increase water intake B) The kidneys are functioning normally C) A loss of over half the client's normal kidney function D) Concentrated urine Ans: C Feedback: In clinical practice, GFR is usually estimated using the serum creatinine concentration.

A GFR below 60 mL/minute/1.73 m2 represents a loss of one half or more of the level of normal adult kidney function. The GFR is not diagnostic for concentrated urine or the need to drink more water.

10. As chronic kidney disease progresses, the second stage (renal insufficiency) is identified by: A) Decrease in GFR of 60 to 89 mL/minute/1.73 m2 B) Decrease in GFR to 30 to 59 mL/minute/1.73 m2 C) GFR decrease to 15 to 29 mL/minute/1.73 m2 D) Diminished GFR to less than 15 mL/minute/1.73 m2 Ans: A Feedback: Diminished renal reserve is characteristic of renal insufficiency, when labs remain normal but there is renal insufficiency. Only the second stage, formerly known as renal insufficiency, is characterized by a decrease in GFR of 60 to 89 mL/minute/1.73 m 2.

The other choices represent stage 3, 4, and 5, respectfully.

11. As nitrogenous wastes increase in the blood, the CKD client may exhibit which of the following clinical manifestations? Select all that apply.

A) Numbness in lower extremities B) Photophobia C) Extremely low platelet counts D) Restless leg syndrome E) Pruritis Ans: A, D, E Feedback: The uremic state is characterized by signs and symptoms of altered neuromuscular function (e.g., fatigue, peripheral neuropathy, restless leg syndrome, sleep disturbances, uremic encephalopathy); gastrointestinal disturbances such as anorexia and nausea; white blood cell and immune dysfunction, and dermatologic manifestations such as pruritus. Photophobia and thrombocytopenia are usually not associated with CKD.

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12. A client with a diagnosis of chronic kidney disease (CKD) may require the administration of which of the following drugs to treat coexisting conditions that carry a high mortality?

A) Antihypertensive medications B) Antiarrhythmic medications C) Opioid analgesics D) Nonsteroidal anti-inflammatory drugs (NSAIDs) Ans: A Feedback: Hypertension is a common result of CKD, and the mechanisms that produce hypertension in CKD include increased vascular volume, elevation of peripheral vascular resistance, decreased levels of renal vasodilator prostaglandins, and increased activity of the renin–angiotensin–aldosterone system. NSAIDs, opioids, and antiarrhythmics are not as frequently indicated for the treatment of CKD.

13. The nurse is providing care for a client who has a diagnosis of kidney failure. Which of the following laboratory findings is consistent with this client's diagnosis?

A) Elevation in vitamin D levels B) Hypophosphatemia C) Hypocalcemia D) Hypokalemia Ans: C Feedback: Diagnostic findings that are congruent with a diagnosis of kidney failure include hyperphosphatemia, hypocalcemia, a decrease in active vitamin D levels, and secondary hyperparathyroidism.

14. A chronic kidney disease client who has renal osteodystrophy should be assessed for which of the following complications? Select all that apply.

A) Muscle weakness B) Kidney stones C) Bone pain D) Stress fractures E) Urosepsis Ans: A, C, D Feedback: Both types of renal osteodystrophy are manifested by abnormal absorption and defective bone remodeling. Renal osteodystrophy is typically accompanied by reductions in bone mass, alterations in bone microstructure, bone pain, and skeletal fracture. There are changes in bone turnover, mineralization, and bone volume, accompanied by bone pain and muscle weakness, risk of fractures, and other skeletal complications. Kidney stones and urosepsis are not associated with renal osteodystrophy.

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15. A client who has developed stage 3 renal failure has been diagnosed with high phosphate levels. To avoid the development of osteodystrophy, the physician may prescribe a phosphate-binding agent that does not contain: A) Aluminum B) Calcium carbonate C) Calcium acetate D) Sevelamer hydrochloride Ans: A Feedback: Aluminum-containing antacids can contribute to the development of osteodystrophy, whereas calcium-containing phosphate binders can lead to hypercalcemia, thus worsening soft tissue calcification, especially in persons receiving vitamin D therapy.

Sevelamer hydrochloride is a newer phosphate-binding agent that does not contain calcium or aluminum.

16. A client with a long-standing diagnosis of chronic kidney disease has been experiencing increasing fatigue, lethargy, and activity intolerance in recent weeks. His care team has established that his GFR remains at a low, but stable, level. Which of the following assessments is most likely to inform a differential diagnosis?

A) Blood work for white cells and differential B) Cystoscopy and ureteroscopy C) Assessment of pancreatic exocrine and endocrine function D) Blood work for hemoglobin, red blood cells, and hematocrit Ans: D Feedback: Anemia is a frequent, and debilitating, consequence of CKD. The anemia may be due to chronic blood loss, hemolysis, bone marrow suppression due to retained uremic factors, and decrease in red cell production due to impaired production of erythropoietin and iron deficiency. Pancreatic function is not typically affected by CKD, and endoscopic examination is less likely to reveal a cause of fatigue. An infectious etiology is possible and would be informed by white cell assessment, but this is less likely than anemia given the client's complaints.

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17. Impaired skin integrity and skin manifestations are common in persons with chronic kidney disease. Pale skin and subcutaneous bruising are often present as a result of: A) Thrombocytopenia B) Anticoagulant therapy C) Decreased vascular volume D) Impaired platelet function Ans: D Feedback: Bruising and pale skin are present with chronic kidney disease because platelet function is impaired. Adequate platelets are available, but the function is abnormal. Renal clients do not routinely receive anticoagulant therapy, since they already have bleeding tendencies. Increased vascular volume is associated with renal disease.

18. If a CKD client is developing uremic encephalopathy, the earliest manifestations may include: Select all that apply.

A) Decreased alertness B) Delirium and hallucinations C) New-onset seizures D) Diminished awareness Ans: A, D Feedback: Reductions in alertness and awareness are the earliest and most significant indications of uremic encephalopathy. Late in the disease process, the client may develop delirium, coma, and seizures.

19. A chronic kidney disease (CKD) client asks the nurse, “Why do I itch all the time?” The nurse bases her response on which of the following integumentary physiologic factors that causes pruritis? Select all that apply.

A) Too harsh of soap while bathing B) Decrease in perspiration C) Limited sodium intake D) Enlarged size of sweat glands E) Elevated serum phosphate levels Ans: B, E Feedback: Dry, itchy skin is a common consequence of CKD. Pruritus is common; it results from the high serum phosphate levels and the development of phosphate crystals that occur with hyperparathyroidism. Harsh soap (may dry the skin), limited Na+ intake, and enlarged sweat glands are not noted to accompany or result in pruritus.

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20. A client with a recent diagnosis of renal failure who will require hemodialysis is being educated in the dietary management of the disease. Which of the client's following statements shows an accurate understanding of this component of treatment?

A) “I've made a list of high-phosphate foods, so that I can try to avoid them.”

B) “I'm making a point of trying to eat lots of bananas and other food rich in potassium.”

C) “I'm going to try to maintain a high-fiber, low-carbohydrate diet.”

D) “I don't think I've been drinking enough, so I want to include 8 to 10 glasses of water each day.”

Ans: A Feedback: Persons with chronic kidney disease (CKD) are usually encouraged to limit their dietary phosphorus as a means of preventing secondary hyperparathyroidism, renal osteodystrophy, and metastatic calcification. Excessive potassium and fluids are likely contraindicated in kidney disease individuals require hemodialysis. The amount of dietary fiber intake is not a priority when looking at primary needs of a CKD patient's food intake.

21. Client and family education regarding peritoneal dialysis should include assessing the client for: A) Bleeding around the arteriovenous fistula or an external arteriovenous shunt B) Signs and symptoms of hypoglycemia such as weakness, irritability, and shakiness C) Dehydration that may appear as dry mucous membranes or poor skin turgor D) Muscle cramps associated with hypoparathyroidism Ans: C Feedback: Potential problems with peritoneal dialysis include infection, catheter malfunction, dehydration caused by excessive fluid removal, hyperglycemia, and hernia. The most serious complication is infection, which can occur at the catheter exit site, in the subcutaneous tunnel, or in the peritoneal cavity. In peritoneal dialysis, a sterile dialyzing solution is instilled through a catheter over a period of approximately 10 minutes. Then the solution is allowed to remain in the peritoneal cavity for a prescribed amount of time. Shunts, fistulas, and artificial dialyzers are associated with hemodialysis, which is usually performed three times weekly.

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22. While assessing a peritoneal dialysis client in his or her home, the nurse notes that the fluid draining from the abdomen is cloudy, is white in color, and contains a strong odor.

The nurse suspects this client has developed a serious complication known as: A) Peritonitis B) Bowel perforation C) Too much sugar in the dialysis solution D) Bladder erosion Ans: A Feedback: Potential problems with peritoneal dialysis include infection, catheter malfunction, dehydration, hyperglycemia, and hernia. Bowel perforation can occur, but the fluid would be stool colored. The client may develop hyperglycemia; however, this will not cause the fluid to be cloudy. If bladder erosion had occurred, the fluid would look like urine and not be cloudy and white.

23. Regardless of the cause, chronic kidney disease results in progressive permanent loss of nephrons and glomerular filtration, and renal: A) Tubule dysplasia B) Vascular pressure C) Endocrine functions D) Hypophosphatemia Ans: C Feedback: Chronic kidney disease results in loss of nephrons, tubule, and endocrine functions such as erythropoietin production. Systemic and renal hypertension is commonly an early manifestation of chronic kidney disease, caused by resistance to blood flow through the constricted renal vessels. Tubule hypertrophy is a compensatory response for those destroyed—when the few remaining nephrons are destroyed, renal failure is apparent.

Phosphate accumulates in the blood; since it is inversely related to calcium, the levels of which remain chronically low.

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24. Manifestations of childhood renal disease are varied and may differ from adult-onset renal failure. A school-aged child with chronic kidney disease may exhibit: A) Low IQ level with borderline retardation B) Developmental delays such as uncoordinated gait and minimal fine motor skills C) Inability to control bladder, resulting in incontinence D) Frequent, uncontrolled rolling of the tongue and opening mouth extremely wide Ans: B Feedback: Childhood chronic kidney disease is manifested by growth and developmental delays and late onset sexual maturity as a result of the uremic effects on endocrine function, bone abnormalities, and development of psychosocial problems. Renal failure is unrelated to the ability of children to have control of urine or bowel elimination.

Intelligence is not affected by renal failure, although renal encephalopathy may affect behavior.

25. Reduced glomerular filtration rate (GFR), with a serum creatinine level that remains in the normal range, is associated with aging because elderly persons tend to have reduced: A) Calcium intake B) Muscle mass C) Drug tolerance D) Renal perfusion Ans: B Feedback: Serum creatinine level is directly related to muscle metabolism. Because muscle mass is reduced in elderly persons, the creatinine level does not increase as readily with a lower GFR. Drug tolerance and renal perfusion can affect the GFR, but the age-related normal creatinine level can also be present. Calcium intake is unrelated to creatinine levels or GFR.

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1. Chapter 27 In anatomy class, the instructor asks, “Explain how urine is expelled from the bladder during voiding.” The student with the most accurate response would be: A) “The urothelium acts as a barrier to prevent urine from seeping into capillaries.”

B) “The beginning of micturition occurs when neurons send messages down to the pudendal nerve.”

C) “The detrusor muscle contract down on the urine and the ureteral orifices are forced shut. The external sphincter relaxes as urine moves out of the bladder.”

D) “It's really the external sphincter muscle that controls urination. The somatic nervous system innervates the muscles of the external sphincter and the pelvic floor muscles that together control the outflow of urine.”

Ans: C Feedback: During the act of micturition, the detrusor muscle of the bladder fundus and bladder neck contracts down on the urine and the ureteral orifices are forced shut. The bladder neck is widened and shortened, and the external sphincter relaxes as urine moves out of the bladder. Descent of the diaphragm and contraction of the abdominal muscles raise intra-abdominal pressure and aid in the expulsion of urine from the bladder.

2. A newly diagnosed paraplegic client who suffered an automobile accident appears to have control of bladder emptying. The health care provider explains this process to the client/family stating, “This function is allowing the motor component of the neural reflex to assist with bladder emptying and is primarily controlled by the: A) Parasympathetic division of the ANS.” B) Sympathetic division of the ANS.” C) Somatic nervous system.”

D) Hypogastric nervous system.”

Ans: A Feedback: The motor component of the neural reflex to assist with bladder emptying is primarily controlled by the parasympathetic division of the ANS, and the relaxation and storage functions of the bladder are controlled by the sympathetic division. The somatic nervous system innervates the skeletal muscles of the external sphincter and the pelvic floor muscles that together control the outflow of urine. The afferent input from the bladder and urethra is carried to the CNS by fibers that travel with PS, somatic, and sympathetic (hypogastric) nerves.

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3. After reviewing the 24-hour intake and output of a hospital client, the nurse suspects that the client may be experiencing flaccid bladder dysfunction. Which of the following diagnostic methods is most likely to confirm or rule out whether the client is retaining urine?

A) Blood test for creatinine, blood urea nitrogen, and glomerular filtration rate B) Urine test for culture and sensitivity C) Routine urinalysis D) Measurement of postvoid residual (PVR) by ultrasound Ans: D Feedback: Measurement of PVR can be achieved quickly, accurately, and painlessly by the use of ultrasonography. A PVR value of less than 50 mL is considered adequate bladder emptying, and more than 200 mL indicates inadequate bladder emptying. Urine tests and blood tests will not directly indicate whether a client is experiencing bladder fill with insufficiency in emptying.

4. Although urinary obstruction and urinary incontinence have almost opposite effects on urination, they can both result from: A) Bladder structure changes B) Bladder wall atrophy C) Micturition reflex spasms D) Bladder distensibility loss Ans: A Feedback: Disorders of lower urinary tract structure and function include urinary obstruction with retention or stasis of urine and urinary incontinence with involuntary loss of urine. Both types of disorders can have their origin in the structures of the lower urinary tract or in the neural mechanisms that control their function. Urinary incontinence can result from loss of bladder distensibility. Chronic outlet obstruction can cause bladder wall hypertrophy. Incontinence can result from reflex spasms, leading to segmental reflex bladder control instead of micturition center control.

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5. The client has had prolonged urethral outlet obstruction. The nurse knows that physiologically, the client may likely develop small pockets of mucosal tissue, called cellulae, which can ultimately cause: Select all that apply.

A) Infections due to stasis B) Backpressure on the ureters C) Development of hydroureters D) Sphincter dystonia Ans: A, B, C Feedback: With continued outflow obstruction, this smooth surface is replaced with coarsely woven structures (i.e., hypertrophied smooth muscle fibers) called trabeculae. Small pockets of mucosal tissue, called cellulae, commonly develop between the trabecular ridges. These pockets form diverticula when they extend between the actual fibers of the bladder muscle. Because the diverticula have no muscle, they are unable to contract and expel their urine into the bladder, and secondary infections caused by stasis are common. Along with hypertrophy of the bladder wall, there is hypertrophy of the trigone area and the interureteric ridge, which is located between the two ureters. This causes backpressure on the ureters, the development of hydroureters and, eventually, kidney damage. Detrusor–sphincter dyssynergia is uncoordinated activity that causes overdistention. Sphincter dystonia is a cause of incontinence. Interstitial cystitis is a condition of increased sensitivity to bladder pressure, loss of bladder elasticity, and severe urgency unrelated to outlet obstruction.

6. Which of the following events would suggest that an individual's physiologic response to an obstruction has progressed beyond the compensatory stage and is now in the decompensatory stage?

A) The bladder muscle hypertrophies.

B) The detrusor loses its power of contraction.

C) The ability to suppress urination is diminished.

D) The individual experiences urgency.

Ans: B Feedback: The compensatory stage of the response to a bladder obstruction involves hypertrophy of the bladder wall, urgency, and difficulty suppressing the urge to urinate. If these compensatory measures are ineffective, decompensation occurs. The period of detrusor muscle contraction becomes too short to expel the urine completely, and residual urine remains in the bladder. At this point, the symptoms of obstruction—frequency of urination, hesitancy, need to strain to initiate urination, a weak and small stream, and termination of the stream before the bladder is completely emptied—become pronounced.

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7. The body compensates for obstructed urine outflow up to a certain point. Which of the following signs/symptoms lead the nurse to suspect decompensatory changes are occurring? Select all that apply.

A) Reports of renal colic B) Urinary frequency noted C) High residual volume up to 1000 mL D) Postvoid residual volume less than 50 mL E) Must strain to initiate the stream of urine Ans: B, C, E Feedback: Compensatory changes to chronic obstruction include increased urge to urinate (urinary frequency). When compensatory mechanism no longer is effective, signs of decompensation begin to appear. The period of detrusor muscle contraction becomes too short to expel the urine completely, and residual urine remains in the bladder. A PVR value of less than 50 mL is considered adequate bladder emptying, and more than 200 mL indicates inadequate bladder emptying. At this point, the symptoms of obstruction—frequency of urination (during day and night), hesitancy, need to strain to initiate urination, a weak and small stream, and termination of the stream before the bladder is completely emptied—become pronounced. Bladder spasms are a symptom of outlet obstruction and do not increase urine output/decrease obstruction.

8. A 40-year-old female with the diagnosis of multiple sclerosis has been experiencing severe bladder spasms along with less bladder volume. This is likely due to: Select all that apply.

A) Bladder atonia B) Autonomic hyperreflexia C) Uninhibited bladder D) Neurogenic detrusor overactivity Ans: C, D Feedback: Neurogenic detrusor overactivity, or spastic bladder, is usually characterized by reflex bladder spasms and a decrease in bladder volume. The most common causes of neurogenic detrusor overactivity are spinal cord lesions such as spinal cord injury; vascular lesions, tumors, or herniated intervertebral disk; and multiple sclerosis. Bladder atonia is caused by spinal cord injury. Autonomic hyperreflexia is due to spinal cord injuries at the cervical level. Uninhibited bladder can develop after a stroke or during the early stages of multiple sclerosis.

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9. A client fell off a ladder and sustained a spinal cord injury that has resulted in bladder dysfunction. During the period immediately after the spinal injury, spinal shock develops and the bladder displays what type of function?

A) Atonic B) Spasmodic C) Uninhibited D) Hyperactive Ans: A Feedback: Immediately following spinal cord injury, a state of spinal shock develops in which all reflexes, including the micturition reflex, are depressed. During this stage, the bladder becomes atonic and cannot contract. Spasmodic, hyperactive, and uninhibited bladder function occurs after the acute stage of spinal cord injury and during the recovery stage.

10. In men experiencing nonrelaxing external sphincter with associated urine retention, the health care worker should assess for which of the following possible causes?

A) Increased intra-abdominal pressure B) Chronic prostatitis C) Chronic stress response D) Pelvic inflammatory disease Ans: B Feedback: In men, chronic prostatitis contributes to impaired (nonrelaxing) external sphincter with urine retention. The stress response can cause retention of urine as part of the “fight-or-flight” response, unrelated to sphincter dysfunction. Developmental delays are associated with female or male children (not men). If intra-abdominal pressure increases as it does during actions such as coughing, laughing, or sneezing and if this pressure is not equally transmitted to the urethra, then incontinence occurs. PID is primarily a female disorder.

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11. 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.

12. 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.

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13. 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.

14. 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.

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15. 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.

16. A female teenager has experienced three uncomplicated urinary tract infections in the last 3 months. Knowing the anatomical location of the urethra, the nurse should educate this teenager about: A) Proper handwashing to decrease amount of Pseudomonas growing on the hands B) Wiping from front to back to prevent Escherichia coli contamination of the urethra C) Wearing gloves when wiping perineum after defecation to prevent Staphylococcus aureus infection D) Washing hands prior to inserting a tampon to minimize the risk of group B Streptococcus Ans: B Feedback: Most commonly, urinary tract infections (UTIs) are caused by Escherichia coli that enter through the urethra. Escherichia coli are abundant in fecal matter. Other uropathic pathogens include Staphylococcus saprophyticus in uncomplicated UTIs and both non– E. coli gram-negative rods (Proteus mirabilis, Klebsiella pneumoniae, Pseudomonas) and gram-positive cocci (Staphylococcus aureus, group B Streptococcus) in complicated UTIs.

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17. Although the distal portion of the urethra often contains pathogens, the urine formed in the kidney and found in the bladder is sterile because of the: A) Alkaline urine B) Glomerular filtering C) Warm temperature D) Washout phenomenon Ans: D Feedback: Although the distal portion of the urethra often contains pathogens, the urine formed in the kidneys and found in the bladder normally is sterile or free of bacteria. This is because of the washout phenomenon, in which urine from the bladder normally washes bacteria out of the urethra during voiding. Because most urinary tract infection (UTI) bacteria ascend through the urethra, glomerular filtration cannot remove it. Pathogens are less likely to survive in acidic conditions; struvite calculi form secondary to bacterial infections causing alkaline urine. The core body temperature is not high enough to destroy bacterial microorganisms in the urine.

18. Which of the following clients is likely at the greatest risk of developing a urinary tract infection?

A) A pregnant woman who has been experiencing urinary frequency B) A client with a diagnosis of chronic kidney disease who requires regular hemodialysis C) A 79-year-old client with an indwelling catheter for urinary incontinence D) A confused, 81-year-old client who is incontinent of urine Ans: C Feedback: There is an increased risk for UTIs in persons with urinary obstruction and reflux, in people with neurogenic disorders that impair bladder emptying, in women who are sexually active, in postmenopausal women, in men with diseases of the prostate, and in elderly persons. Instrumentations and urinary catheterization are the most common predisposing factors for nosocomial, or hospital-acquired UTIs. Frequency and incontinence may be signs and symptoms of UTIs, but they are not causative of the infections.

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19. A woman has sought care because of recurrent urinary tract infections, which have been increasing in both frequency and severity. The health care worker should explain which of the following physiological factors to the client that is likely contributing to recurrent UTIs? A) Reflux flow of urine that can occur from coughing or sneezing B) Fluctuations in urine pH related to beverage consumption C) Urethral trauma that occurs during sexual intercourse D) Inadequate intake of water Ans: A Feedback: A phenomenon called urethrovesical reflux occurs when urine from the urethra moves into the bladder. In women, urethrovesical reflux can occur during activities such as coughing or squatting, in which an increased intra-abdominal pressure causes the urine to be squeezed into the urethra and then to flow back into the bladder as the pressure decreases. Reflux flow of urine is a significant risk factor for UTIs in general and for recurrent UTIs in particular. Fluctuations in urine pH are not noted to contribute to recurrent UTIs. Urethral trauma and inadequate fluid intake may contribute to the development or prolonging of UTIs, but these risk factors are less significant than the presence of urine reflux.

20. A client who has had recurrent UTIs asks the nurse about the old wise tale of drinking cranberry juice daily. The nurse can respond: A) “There is no research on this topic, so I don't think it will help you.”

B) “Studies on this are based on a person drinking at least 1 gallon of juice/day.”

C) “Research suggests cranberry juice will reduce bacterial adherence to the lining of the urinary tract.”

D) “Beer is probably more effective at killing bacteria than cranberry juice.”

Ans: C Feedback: Cranberry juice or blueberry juice has been suggested as a preventive measure for persons with frequent UTIs. Studies suggest that these juices reduce bacterial adherence to the epithelial lining of the urinary tract.

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21. A pregnant woman who is beginning her third trimester has been diagnosed with a urinary tract infection (UTI). Which of the following factors most likely predisposed this client to the development of a UTI? A) Increased urine alkalinity during pregnancy B) Hypertrophy of the bladder wall C) Dilation of the upper urinary structures D) Spastic peristalsis of the ureters Ans: C Feedback: Normal changes in the functioning of the urinary tract that occur during pregnancy predispose to UTIs. These changes involve the collecting system of the kidneys and include dilation of the renal calyces, pelves, and ureters that begins during the first trimester and becomes most pronounced during the third trimester. Bladder hypertrophy, spastic peristalsis, and increased urine pH are not phenomena that are common accompaniments to pregnancy.

22. Which of the following signs and symptoms in a 2-year-old child should prompt assessment for a urinary tract infection?

A) Unexplained fever and anorexia B) Decreased urine output and irritability C) Production of concentrated urine and recurrent nausea D) Frank hematuria Ans: A Feedback: Although all of the cited symptoms warrant further assessment and follow-up, the presence of fever and anorexia is typical of UTIs in toddlers.

23. A public health nurse is conducting a health promotion class for a group of older adults.

Which of the participants' following statements demonstrates an accurate understanding of the risk factors for bladder cancer?

A) “I suppose I should listen to my doctor and drink more cranberry juice.”

B) “More than ever, I guess it would worthwhile for me to quit smoking.”

C) “I can see that preventing bladder cancer is one more benefit of a healthy diet.”

D) “I think I should be okay because there's no history of bladder cancer in my family that I'm aware of.”

Ans: B Feedback: Smoking is implicated in 30% to 50% of all bladder cancers among males who are current or past smokers. Cranberry juice may be of benefit in the prevention of UTIs, not cancer, and neither poor diet nor family history is as significant as cigarette smoking in the etiology of bladder cancer.

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24. A neighbor is complaining to a friend (who happens to be a nurse) about several changes in their body. Which of the following complaints raises a “red flag” because it could be a sign of epithelial cell bladder cancer?

A) “Seems like I'm holding onto more water these days.”

B) “Every now and then, I have urine leak when I cough.”

C) “Sometimes I get a sharp pain in my side while exercising.”

D) “I noticed my urine is pinkish red, but I'm not having any pain when I pee.”

Ans: D Feedback: The most common sign of bladder cancer is intermittent painless hematuria. Fluid retention, stress incontinence, and pain with exercise are not usual signs of cancer.

25. A bladder cancer client asks the nurse, “What did the doctor mean by intravesicular chemotherapy? Am I going to lose all my hair and have to do for treatments over months and months?” The best response would be: A) “This is when they put the chemotherapy directly into the bladder to kill any cancer cells.”

B) “They will take you to radiology and inject some chemotherapy through your abdomen into your bladder.”

C) “The doctor will place a scope up your urethra, into the bladder, and burn the lining of the bladder with a laser and then inject some tuberculosis bacillus into the lining.”

D) “This is when they use a CyberKnife to cut off any lesions and then inject chemotherapy into the remaining portion of the bladder.”

Ans: A Feedback: Surgical treatment of superficial bladder cancer is often followed by intravesicular chemotherapy or immunotherapy, a procedure in which the therapeutic agent is directly instilled into the bladder. None of the other responses describe this procedure. The chemotherapy drug is not injected through the abdomen into the bladder. BCG is instilled into the bladder to elicit an inflammatory response that can kill the tumor. A CyberKnife is used with the brain, not the bladder.

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1. Chapter 28 A client has been diagnosed with an incompetent pyloric sphincter. This client is experiencing a lot of abdominal pain and nausea. When this client vomits, the nurse should expect what type of secretions will be in the basin?

A) Green, stringy emesis B) Bright red, bloody emesis C) Thick, brownish, foul-smelling emesis D) Clear mucous-looking emesis Ans: C Feedback: The pylorus is located between the body of the stomach and the duodenum. At the end of the pyloric canal, the circular smooth muscle layer thickens to form the pyloric sphincter. This muscle serves as a valve that controls the rate of stomach emptying and prevents the regurgitation of intestinal contents back into the stomach. Therefore, if the pyloric sphincter is incompetent, intestinal content will flow back into the stomach.

2. A client who has had his gallbladder (GB) removed asks the nurse, “Why do I feel sick every time I go through a drive-in fast-food restaurant and order burgers and fries?” The nurse bases the response knowing that: A) The restaurant may have “bad” grease in their fryer.

B) Without a GB, the size of the client's stomach has been decreased.

C) Bile from the GB is needed to breakdown lipids.

D) When the GB is removed, the pancreatic duct is also removed.

Ans: C Feedback: The common bile duct and pancreatic duct empty their juices into the duodenum. Bile, a fluid synthesized by the liver that breaks down lipids, and pancreatic juices, which facilitate digestion of lipids, carbohydrates, and proteins, enter the intestine through these ducts. If the GB is removed, a high-lipid meal may not be broken down and digested normally. Neither the stomach size nor the pancreatic duct is removed during GB surgery.

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3. A client asks the nurse to explain the digestive tract layers because the client is experiencing upper GI problems. When talking about the mucosa layer, the nurse will emphasize that the roles/functions of this layer consist of: Select all that apply.

A) Production of mucus to protect and lubricate the inner lining B) Beginning of the digestive process by secreting enzymes to break food down C) Contracting of smooth muscles to propel food forward D) Supporting the abdominal viscera with its connective tissue Ans: A, B Feedback: The inner layer is the mucosal layer that produces mucus. This mucus protects and lubricates the inner lining of the GI tract lumen. Secretion of digestive enzymes and substances that break food down, absorption of the breakdown products of digestion, and maintenance of a barrier to prevent the entry of noxious substances and pathogenic organisms also occur in the mucosal layer. Contracting of smooth muscles to propel food forward occurs in the muscularis externa layer. Supporting the abdominal viscera with its connective tissue is the role of the serous layer.

4. A client has been told he has abdominal adhesions due to an old appendix infection.

Knowing the structures of the abdominal cavity, the nurse will explain which of the following structures can form bands of fibrous scar tissue to wall off the infection, preventing it from spreading to other parts of the body?

A) Mesentery B) Omentum C) Haustration D) Peritoneum Ans: B Feedback: The greater omentum helps to prevent infection from entering the peritoneal cavity and protects the intestines from cold. It often forms adhesions (i.e., bands of fibrous scar tissue) adjacent to inflamed organs such as the appendix, walling off the infection and thereby preventing its spread. The peritoneum is the largest serous membrane and constitutes the outer wall of the intestine, continuous with the mesentery. Haustration is the segmental mixing movements of the large intestine (colon).

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5. Motility along the length of the GI tract, controlling the function of each segment of the GI tract and integrating signals for absorption of nutrients primarily, is innervated by which portion of the enteric nervous system?

A) Submucosal plexus B) Vasovagal C) Sympathetic D) Preganglionic Ans: A Feedback: The enteric nervous system consists of the intramural neurons (contained in the gastrointestinal tract) of two networks—myenteric and submucosal plexus. The submucosal plexus, which lies between the submucosal and mucosal layers of the wall, is mainly concerned with controlling the function of each segment of the GI tract. It integrates signals received from the mucosal layer into control of motility, intestinal secretions, and absorption of nutrients. The ANS innervates the preganglionic parasympathetic fibers and controls vasovagal reflexes. Sympathetic innervation is mediated by intramural plexus activity.

6. When trying to explain to a newly diagnosed irritable bowel syndrome (IBS) client how the nervous system affects gastrointestinal (GI) disorders, the nurse mentions which of the following in regard to IBS? A) Increase in smooth muscle tone B) Enhancement of sphincter function C) Decrease in gastrointestinal motility D) Increase in enteric nervous system activity Ans: D Feedback: Stimulation of the parasympathetic nervous system causes a general increase in activity of the entire enteric nervous system. Sympathetic stimulation inhibits activity, causing many effects opposite to those of the parasympathetic system, including enhancement of sphincter function, decreased motility, and increased smooth muscle tone.

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7. The client chews an apple and starts the swallowing process. As the food bolus enters the back of the mouth and swallowing is initiated, the nurse knows that the client's motor impulses are being carried out by which of the following cranial nerves? Select all that apply.

A) Trigeminal (V) B) Vagus (X) C) Hypoglossal (XII) D) Abducent (VI) Ans: A, B, C Feedback: The esophageal phase is innervated by the vagus (X) nerve, which initiates the peristaltic waves that will carry the food bolus into the stomach. Gagging is a protective reflex response that can occur during the pharyngeal phase, to prevent food from entering the larynx. Tactile receptors initiate the involuntary part of swallowing during the pharyngeal stage. Hypoglossal (XII) and trigeminal (V) nerves are part of the oral and pharyngeal phases of swallowing. Abducent (VI) is a motor nerve that supplies to the pons and perform function of turning eye laterally.

8. In the stomach, chyme is churned by peristalsis into the antrum, which contracts, reverses the flow, and allows more churning. Because the pylorus is contracted during antral contraction, gastric content empties into the duodenum: A) During bile secretion B) Between contractions C) During opening of the pyloric sphincter D) Under gaseous pressure Ans: B Feedback: Gastric contents can empty into the duodenum between antral contractions that block the pylorus. The pH, fatty acid content, and osmolarity of the chyme stimulate cholecystokinin and gastric emptying. Constriction of the pyloric sphincter prevents the backflow of gastric contents and allows them to flow into the duodenum at a rate commensurate with the ability of the duodenum to accept them.

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9. While assessing a client who is experiencing diarrhea caused by Clostridium difficile, the nurse should anticipate hearing: A) Normal bowel sounds B) Hypoactive bowel sounds C) Absence of bowel sounds D) Hyperactive bowel sounds Ans: D Feedback: Inflammatory changes increase motility, which would lead to hyperactive bowel sounds.

In many instances, it is not certain whether changes in motility occur because of inflammation or are secondary to the effects of toxins or unabsorbed materials.

10. A client who is quadriplegic following a motor vehicle accident adheres to a bowel protocol to promote regular bowel movements and prevent constipation. Which of the following actions performed by the client's caregiver is likely to promote defecation?

A) Digital stimulation of the client's rectum B) Massage of the client's abdomen C) Sitting the client in an upright position D) Administration of large amounts of free water Ans: A Feedback: When the nerve endings in the rectum are stimulated, signals are transmitted first to the sacral cord and then reflexively back to the descending colon, sigmoid colon, rectum, and anus by the pelvic nerves. These impulses greatly increase peristaltic movements as well as relax the internal sphincter, resulting in defecation. Massage, increased fluid intake, and upright positioning are less likely to promote defecation.

11. While planning care for a client with irritable bowel syndrome, knowing the client has an increased amount of secretions with impaired GI absorption, the priority nursing diagnosis would be: A) Fluid volume deficit B) Hypotonic GI motility C) Fatigue D) Metabolic acidosis Ans: A Feedback: Intestinal secretions are mainly water (it contains electrolytes, but the main component is water). Altered secretion or absorption causes fluid volume deficit (dehydration—not hypervolemia), which correlates with hypertonicity (not hypotonicity). Fatigue may be related to loss of volume, but the priority is to restore fluid volume. With lots of secretion loss, the client will likely experience metabolic alkalosis (not acidosis).

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12. When discussing digestion with a group of nursing students, the instructor asks, “Where does the digestion of our food begin?” The most accurate student response would be A) The stomach with its hydrochloric acid production B) The duodenum with common bile duct secretions C) The mouth with ptyalin and amylase breaking down starches D) The jejunum, where peristaltic waves begin Ans: C Feedback: Saliva performs three roles: lubrication, antimicrobial protection, and initiation of starch digestion. Saliva contains ptyalin and amylase, which initiate the digestion of dietary starches. The other portions of the GI tract aid in digestion, but all begins in the mouth.

13. Biopsy results reveal that a client has a deficit amount of parietal (oxyntic) cells in their stomach. The client asks the nurse to explain what this means. The nurse explains that parietal cells secrete HCl and intrinsic factor, which is needed for absorption of: A) Vitamin A B) Vitamin K C) Vitamin B12 D) Vitamin D3 Ans: C Feedback: The oxyntic glands are located on the inside surfaces of the body and fundus of the stomach. They secrete HCl and intrinsic factor, which is needed for vitamin B 12 absorption.

14. Which of the following clients likely faces the greatest risk of a gastrointestinal bleed?

A) A man whose hypertension requires him to take a diuretic, an ACE inhibitor, and a -adrenergic blocker B) A client who is taking a broad-spectrum antibiotic to treat a urinary tract infection C) A client with a history of anxiety who takes benzodiazepines several times daily D) A client who takes aspirin with each meal to control symptoms of osteoarthritis Ans: D Feedback: The gastric mucosa can be easily damaged by drugs such as aspirin, resulting in local ischemia, vascular stasis, hypoxia, and tissue necrosis. Antihypertensives, diuretics, antibiotics, and benzodiazepines do not pose such a significant threat to the integrity of the gastric mucosa.

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15. In addition to mucus, the intestinal mucosa produces two other types of secretions.

Copious amounts of the serous-type fluid are secreted to act as a: A) Vehicle for absorption B) Enzyme that splits sugars C) Protection from acid content D) Parasympathetic stimulation Ans: A Feedback: An isotonic alkaline fluid is secreted by crypts of Lieberkühn in the intestinal mucosal layer at a high rate, to secrete mucus, electrolytes, and water and to act as a vehicle to aid absorption. Surface enzymes split sugars. Parasympathetic stimulation increases secretion of mucus. Brunner glands secrete large amounts of alkaline mucus to protect the duodenum from acid content.

16. Gastrin production, a task that is performed by the stomach, results in which of the following effects?

A) Stimulation of pancreatic enzyme secretions B) Stimulation of HCl secretions by parietal cells C) Conversion of polysaccharides to monosaccharides D) Release of insulin in response to glucose load Ans: B Feedback: The primary function of gastrin is the stimulation of gastric acid secretion. It does not have a direct effect on exocrine or endocrine pancreatic function, and it does not participate actively in the digestion of starches.

17. The stomach is the source of two hormones produced by the gastrointestinal tract: gastrin and ghrelin. Ghrelin is a peptide hormone produced in the mucosal layer that has an important role in regulation of: A) Gastric acid fluid B) Growth hormone C) Biliary bicarbonate D) Pancreatic enzyme Ans: B Feedback: Ghrelin hormone has an important role in regulation of growth hormone secretion and energy balance. Gastric acid secretion is regulated by gastrin (in the stomach) and secretin (in the intestine). Pancreatic enzyme, bicarbonate, and biliary fluid secretion are functions of cholecystokinin in the intestine.

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18. When explaining absorption to a client, the nurse mentions that a number of substances require a specific carrier or transport system. An example the nurse could use relates to the transport of amino acids and glucose, which requires the presence of which of the following for absorption to occur?

A) Potassium B) Phosphate C) Sodium D) Calcium Ans: C Feedback: Absorption is accomplished by active transport and diffusion. A number of substances require a specific carrier or transport system. For example, transport of amino acids and glucose occurs mainly in the presence of sodium. The other electrolytes are not required for this specific process.

19. While explaining digestion and absorption of nutrients to a client, the nurse mentions that the brush border enzymes would facilitate absorption of which of the following foods?

A) Ice cream B) Green, leafy vegetables C) Garlic toast D) Fried catfish Ans: C Feedback: Brush border enzymes aid in the digestion of carbohydrates and proteins. The only food listed that is strictly carbohydrates is the garlic toast.

20. The physiological rationale for hanging normal saline (0.9% NS) or 5% dextrose in water (D5W) to a client who has been experiencing diarrhea includes: A) Facilitating the absorption of osmotically active particles B) Activation of the ATP channels C) Activating the pancreatic enzymes of trypsin and elastase D) Emulsification of fats Ans: A Feedback: Water absorption from the intestine is linked to absorption of osmotically active particles, such as glucose and sodium. It follows that an important consideration in facilitating the transport of water across the intestine (and decreasing diarrhea) after temporary disruption in bowel function is to include sodium and glucose in the fluids that are consumed. None of the other distractors addresses this principle. Activating the pancreatic enzymes of trypsin and elastase is needed for protein digestion and absorption. Emulsification of fats begins in the stomach and continues in the duodenum under the influence of bile from the liver.

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21. The intestinal absorption of glucose and amino acids is facilitated by which of the following transport systems?

A) Bile salt micelles B) Fat emulsification C) Sodium linked D) Brush border enzyme Ans: C Feedback: As with glucose, many amino acids are transported across the mucosal membrane in a sodium-linked transport system (for absorption) that utilizes APT as an energy source.

Fat uses bile salts that form micelles for transport to the intestinal villi. Fat emulsification is a digestive process. Brush border enzymes break down carbohydrates for transport.

22. A client has been diagnosed with cholecystitis (gallbladder inflammation) that has impaired the normal release of bile. Which of the following gastrointestinal consequences is this client likely to experience?

A) Incomplete digestion of starches B) Impaired glucose metabolism C) Inadequate gastric acid production D) Impaired digestion of fats Ans: D Feedback: Bile performs a central role in fat metabolism. Gallbladder disease and the accompanying disruption of normal bile release do not result in impaired digestion of carbohydrates, impaired glucose metabolism, or inadequate gastric acid synthesis.

23. A client's complex and worsening pressure ulcer has necessitated the use of numerous antibiotics over the last several months. Which of the following consequences may result from this client's medication regimen?

A) Impaired mucus production B) Vitamin K deficiency C) Impaired protein metabolism D) Excessive release of pepsin Ans: B Feedback: Vitamin K is synthesized by colonic flora, and long-term antibiotic use can result in vitamin K deficiency. Antibiotic use does not curtail mucus production or protein metabolism, and it does not precipitate excessive release of pepsin.

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24. A child who is experiencing the signs and symptoms of influenza has vomited frequently over the last 24 hours. While discussing vomiting with a group of nursing students, the instructor asks, “What site in the neurologic system is responsible for vomiting?” Which student response is most accurate?

A) Myenteric plexus B) Intramural plexus C) Vagus nerve D) Chemoreceptor trigger zone Ans: D Feedback: The act of vomiting is integrated in the vomiting center, which is located in the dorsal portion of the reticular formation of the medulla near the sensory nuclei of the vagus.

The vomiting center can be activated directly by irritants or indirectly following input from four different sources, one of which is the chemoreceptor trigger zone (which is activated by chemical agents such as drugs and toxins).

25. When caring for a cancer client experiencing chemotherapy-induced nausea and vomiting, which of the following drugs work to delay this nausea and vomiting by acting on the CNS to block the activation of the NK-1 receptors? Select all that apply.

A) Serotonin (5-hydroxytryamine) antagonists B) Neurokinin-1 receptor antagonists C) Promethazine, a neuroleptic medication D) Compazine, a dopamine (D2) receptor antagonist Ans: A, B Feedback: The recently developed Neurokinin-1 (NK-1) receptor antagonists are used for the treatment of acute and delayed chemotherapy-induced nausea and vomiting. These drugs act centrally to block the activation of the NK-1 receptors in the vomiting center.

Serotonin (5-hydroxytryamine) antagonists are involved in the nausea and emesis associated with cancer chemotherapy and radiation. Promethazine is a neuroleptic medication. Compazine, a dopamine (D2) receptor antagonist, depresses vomiting caused by stimulation of the chemoreceptor trigger zone.

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1. Chapter 29 A teenager who has a history of achalasia will likely complain of which of the following clinical manifestations?

A) Excessive heartburn following a high-fat meal of French fries B) Feeling like there is food stuck in the back of the throat C) Projectile vomiting across the room unrelated to meals D) Vomiting large amounts of bright red emesis Ans: B Feedback: Achalasia produces functional obstruction of the esophagus so that food has difficulty passing into the stomach, and the esophagus above the lower esophageal sphincter becomes distended. Symptoms following high-fat intake is usually associated with gallbladder disease. Projectile vomiting is usually related to increased intracranial pressure. Vomiting blood can be associated with esophagitis, erosion of the esophagus, bleeding esophageal varices, or esophageal cancer.

2. A client has had severe heart burn associated with persistent gastroesophageal reflux for many years. Which of the following statements made by the client leads the nurse to suspect the client is having a complication related to his reflux? The client is having: A) Difficulty in swallowing with feelings that food is “stuck” in the throat B) Burning sensation a half-hour after a meal C) Substernal chest pain that radiates to the shoulder and arm D) “Hoarseness” unrelieved by coughing or taking a drink of water Ans: A Feedback: Complications can result from persistent reflux, which produces a cycle of mucosal damage that causes hyperemia, edema, and erosion of the luminal surface. Strictures are caused by a combination of scar tissue, spasm, and edema, which narrow the esophagus.

The most frequent symptom of gastroesophageal reflux is heartburn. Other symptoms include belching, wheezing, chronic cough, hoarseness, and epigastric or retrosternal area chest pain, radiating to the throat, shoulder, or back. Because of its location, the pain may be confused with angina.

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3. Which of the following signs and symptoms most clearly suggests the need for endoscopy to rule out esophageal cancer?

A) Heartburn after an individual consumes high-fat meals B) Dysphagia in an individual with no history of neurologic disease C) A new onset of gastroesophageal reflux in a previously healthy individual D) Recurrent episodes of gastritis that do not respond to changes in diet Ans: B Feedback: Dysphagia is by far the most frequent complaint of persons with esophageal cancer. It is apparent first with ingestion of bulky food, later with soft food, and finally with liquids.

Heartburn, reflux, and gastritis are not health problems that are closely associated with the development of esophageal cancer.

4. Acute gastritis refers to a transient inflammation of the gastric mucosa that is most commonly associated with: A) Diarrhea B) Food allergies C) Gastric reflux D) Alcohol intake Ans: D Feedback: Acute gastritis refers to a transient inflammation of the gastric mucosa that is most commonly associated with local irritants such as bacterial endotoxins, alcohol, or aspirin. Gastritis associated with excessive alcohol consumption often causes transient gastric distress, which may lead to vomiting, bleeding, and hematemesis. Allergic response to ingested substances may cause acute itching, rash, vomiting, or diarrhea.

Gastric reflux causes esophageal inflammation rather than gastritis.

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5. A client has visited the health care provider following several days of nausea/vomiting and abdominal pain. The provider thinks the client may have Helicobacter pylori (H. pylori) infection. As part of the education provided, the client should be informed that which of the following complications can occur if this infection is not eradicated? Select all that apply.

A) GI bleeding due to peptic ulcer formation B) Failure to thrive due to malabsorption C) Pyloric stenosis due to inability to empty the stomach D) Gastric cancer due to metaplasia changes in the cells Ans: A, D Feedback: Most cases of peptic ulcer are caused by H. pylori, which are a small, curved, gram-negative rods that can colonize the mucus-secreting epithelial cells of the stomach; these bacteria secrete urease, which enables them to produce ammonia to buffer the acidity of their immediate environment. H. pylori is nonerosive and produces enzymes and toxins that have the capacity to interfere with mucosal protection against gastric acid, produce intense inflammation, and elicit an immune response. Chronic infection with H. pylori can lead to gastric atrophy and peptic ulcer and is associated with increased risk of gastric adenocarcinoma and low-grade B-cell gastric lymphoma.

The characteristic pain is relieved by food or antacids. Ischemia is a cause of stress ulcers, which is manifested by painless upper gastrointestinal tract bleeding.

6. A 60-year-old male client has presented to his primary care provider to follow up with his ongoing treatment for peptic ulcer disease. What is the most likely goal of this client's pharmacologic treatment?

A) Inhibiting gastric acid production B) Promoting hypertrophy of the gastric mucosa C) Increasing the rate of gastric emptying D) Increasing muscle tone of the cardiac sphincter Ans: A Feedback: Current therapies for peptic ulcer disease are aimed at neutralization of gastric acid, inhibition of gastric acid (H2 antagonists and proton pump inhibitors), and promotion of mucosal protection. Growth of the mucosa itself, strengthening the gastrointestinal (GI) sphincters, and changing the rate of stomach emptying are not goals of the usual pharmacologic treatments for peptic ulcers.

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7. A client is diagnosed with Zollinger-Ellison syndrome. Which of the following clinical manifestations confirm this diagnosis? Select all that apply.

A) Burning, gnawing pain when the stomach is empty B) Pain located near the midline close to the xiphoid process C) Excessive belching and burping following meals D) Continuous vomiting lasting many days at a time Ans: A, B Feedback: Zollinger-Ellison syndrome is a rare condition caused by gastrin-secreting tumors that are most commonly found in the small intestine or pancreas. Gastric acid secretions reach levels that ulceration becomes inevitable. Excessive belching and burping following meals are associated with GERD. Continuous vomiting lasting many days at a time may be associated with a neurological event or may be drug related (e.g., chemotherapy).

8. Which of the following diagnostic methods are utilized when gastric cancer is suspected? Select all that apply.

A) Barium swallow study B) Endoscopic exam with biopsy C) Echocardiography D) Papanicolaou smear of gastric secretions Ans: A, B, D Feedback: Diagnosis of gastric cancer is accomplished by a variety of techniques, including barium x-ray studies, endoscopic studies with biopsy, and cytologic studies (Pap smear) of gastric secretions. Echocardiography is used primarily for suspected or known heart diseases.

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9. The physician thinks a teenager is having clinical manifestations of irritable bowel syndrome. Which of the following complaints would support this diagnosis? Select all that apply.

A) Pain is relieved by defecation.

B) Pain is most severe at night.

C) Pain is worse after and between meals.

D) Pain is described as “cramping” in the lower abdomen.

E) Belching makes the pains go away.

Ans: A, D Feedback: A hallmark of irritable bowel syndrome is abdominal pain that is relieved by defecation and associated with a change in consistency or frequency of stools. Irritable bowel disease is characterized by persistent or recurrent symptoms of abdominal pain, altered bowel function, and varying complaints of flatulence, bloating, nausea and anorexia, constipation or diarrhea, and anxiety or depression. Abdominal pain usually is intermittent, is described as cramping in the lower abdomen, and does not usually occur at night or interfere with sleep. Inflammatory bowel disease is characterized by blood in stool. Peptic ulceration pain occurs when the stomach is empty.

10. While assessing a client diagnosed with inflammatory bowel diseases, the nurse should assess for systemic manifestations that may include: Select all that apply.

A) Autoimmune anemia B) Rheumatoid arthritis C) Thrombocytopenia D) Lactose intolerance E) Mouth ulcerations Ans: A, D Feedback: Inflammatory bowel diseases produce inflammation of the bowel, with a lack of confirming evidence of a proven causative agent, have a pattern of familial occurrence, and can be accompanied by systemic manifestations. A number of systemic manifestations have been identified: osteoarthritis affecting the spine, sacroiliac joints, large joints of the arms and legs; inflammatory conditions of the eye; skin lesions, especially erythema nodosum; stomatitis; and autoimmune anemia, hypercoagulability of blood (rather than thrombocytopenia), and sclerosing cholangitis. With irritable (rather than inflammatory) bowel syndrome, a history of lactose intolerance should be considered because intolerance to lactose and other sugars may be a precipitating factor in some persons.

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11. A college student goes to the campus health office complaining of diarrhea, lower right abdominal pain, and weight loss. Suspecting Crohn disease, the nurse will assess for which complication associated with this diagnosis?

A) Urine that has the look and smell of feces B) Inability to control diarrhea C) Tender right upper quadrant pain upon deep palpation D) Necrotic abscesses from twisting of the bowel Ans: A Feedback: Crohn disease is a recurrent, granulomatous type of inflammatory response with formation of multiple sharply demarcated, granulomatous lesions that are surrounded by normal-appearing mucosal tissue. There usually is a relative sparing of the smooth muscle layers of the bowel, with marked submucosal layer inflammatory and fibrotic changes. Complications of Crohn disease include fistula formation, abdominal abscess formation, and intestinal obstruction. Fistulas are tube-like passages that form connections between different sites in the gastrointestinal tract. They also may develop between other sites, including the bladder, vagina, urethra, and skin (hence, the urine will smell like feces). Characteristics of ulcerative colitis (rather than Crohn disease) are crypts of Lieberkühn lesions in the base of the mucosal layer, formation of pinpoint mucosal hemorrhages, and development of crypt abscesses that become necrotic.

12. The ulcerative colitis client should be assessed by the health care provider for which of the following clinical manifestations? Select all that apply.

A) Persistent diarrhea B) Steatorrhea C) Stool containing blood (hematochezia) D) External hemorrhoids E) Prolapsed colon Ans: A, C Feedback: Unlike Crohn disease, which can affect various sites in the gastrointestinal tract, ulcerative colitis is confined to the rectum and colon. Ulcerative colitis typically presents as a relapsing disorder marked by attacks of diarrhea. The diarrhea may persist for days, weeks, or months and then subside, only to recur after an asymptomatic interval of several months to years or even decades. Because ulcerative colitis affects the mucosal layer of the bowel, the stools typically contain blood and mucus.

Nutritional deficiencies are common in Crohn disease because of diarrhea, steatorrhea (fatty stools), and other malabsorption problems. Crohn disease causes granulomatous changes, often referred to as skip lesions because they are interspersed between what appear to be normal segments of the bowel. External hemorrhoids and prolapsed colon are not associated with ulcerative colitis.

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13. Which of the following individuals most likely faces the greatest risk of developing Clostridium difficile colitis?

A) A 55-year-old man who takes proton pump inhibitors for the treatment of peptic ulcers B) A 79-year-old hospitalized client who is being treated with broad-spectrum antibiotics C) A premature neonate who has developed hyperbilirubinemia and is receiving phototherapy D) A 30-year-old client who has a history of Crohn disease and has been admitted to a hospital to treat a recent flare-up Ans: B Feedback: C. difficile colitis is associated with antibiotic therapy; C. difficile is noninvasive, and development of C. difficile colitis requires disruption of normal intestinal flora. Peptic ulcers, hyperbilirubinemia, and Crohn disease are not common risk factors for the development of C. difficile colitis.

14. The nurse caring for a client with diverticulitis should assess for which of the following clinical manifestations?

A) Frequent rectal bleeding B) Increased abdominal distention C) Large-volume diarrhea D) Lower left quadrant pain Ans: D Feedback: Diverticulitis is a complication of diverticulosis in which there is inflammation and gross or microscopic perforation of the diverticulum with possible abscess formation and without bleeding. One of the most common complaints of diverticulitis is pain in the lower left quadrant, accompanied by nausea and vomiting. Appendicitis has an abrupt onset of general pain referred to the epigastric or periumbilical area. The large-volume form of diarrhea usually is a painless, watery type without blood or pus in the stools. Acute abdominal distention is associated with acute bowel obstruction or peritonitis.

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15. A 66-year-old woman has been diagnosed with diverticular disease based on her recent complaints and the results of a computed tomography (CT) scan. Which of the client's following statements demonstrates an accurate understanding of this diagnosis?

A) “From now on, I'm going to stick to an organic diet and start taking more supplements.”

B) “I think this might have happened because I've used enemas and laxatives too much.”

C) “I've always struggled with heartburn and indigestion, and I guess I shouldn't have ignored those warning signs.”

D) “I suppose I should try to eat a bit more fiber in my diet.”

Ans: D Feedback: Increased fiber is important in both the prevention and treatment of diverticular disease.

Overuse of laxatives is not linked to diverticular disease, and heartburn and indigestion are not specific signs of the problem. An organic diet and the use of dietary supplements are not key treatments.

16. An ultrasound has confirmed appendicitis as the cause of a 20-year-old man's sudden abdominal pain. Which of the following etiologic processes is implicated in the development of appendicitis?

A) Obstruction of the intestinal lumen B) Elimination of normal intestinal flora C) Sloughing of the intestinal mucosa D) Increased osmolality of intestinal contents Ans: A Feedback: Appendicitis is thought to be related to intraluminal obstruction with a fecalith or to twisting. Osmotic and bacterial changes are not thought to induce appendicitis, and the intestinal mucosa does not slough off either before or during episodes of appendicitis.

17. Which of the following characteristics differentiates inflammatory diarrhea from the noninflammatory type?

A) Larger volume of diarrhea B) Electrolyte imbalances C) Absence of blood in the stool D) Infection of intestinal cells Ans: D Feedback: Inflammatory diarrhea may be caused by invasion of intestinal cells, whereas noninflammatory diarrhea normally results from the disruption of the normal absorption or secretory process. The volume of diarrhea is typically smaller and bloody. Electrolyte imbalances may accompany either type.

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18. An elderly client is complaining about chronic constipation. When evaluating the client's medication regimen, the nurse will note that which of the following medications may contribute to his constipation? Select all that apply.

A) Calcium channel blockers for his hypertension B) Antacids for his heartburn C) Diuretics for his heart failure D) Propylthiouracil for his hyperthyroidism Ans: A, B, C Feedback: Drugs such as narcotics, anticholinergic agents, calcium channel blockers, diuretics, calcium (antacids and supplements), iron supplements, and aluminum antacids tend to cause constipation. Propylthiouracil is indicated for hyperthyroidism. Hypothyroidism can be associated with constipation.

19. Which of the following signs/symptoms would lead the nurse to suspect the post-op client has developed a mechanical bowel obstruction? Select all that apply.

A) Sluggish to absent bowel sounds B) Increase in abdominal distention C) Nausea and vomiting D) Rectal bleeding E) Continuous abdominal pain Ans: A, B, C, E Feedback: Major inciting causes of mechanical bowel obstruction include external hernia (i.e., inguinal, femoral, or umbilical) and postoperative adhesions. The major symptoms of acute intestinal obstruction are pain, absolute constipation, abdominal distention, and vomiting. With mechanical obstruction, the pain is severe and colicky, in contrast with the continuous pain and silent abdomen of paralytic ileus. Paralytic (adynamic) obstruction accompanies inflammatory conditions of the abdomen, occurs early in the course of peritonitis, and can result from chemical irritation caused by bile, bacterial toxins, electrolyte imbalances as in hypokalemia, and vascular insufficiency. The major effects (rather than causes) of both types of intestinal obstruction are abdominal distention and loss of fluids and electrolytes. The most common direct causes of peritonitis include ruptured appendix.

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20. Which of the following clients should the nurse observe most closely for the signs and symptoms of paralytic ileus?

A) A client who is first day postoperative following gallbladder surgery B) A client whose acute diarrhea has necessitated the use of antidiarrheal medications C) An obese client who refuses to ambulate because he complains of shortness of breath D) A client with a long-standing diagnosis of irritable bowel syndrome Ans: A Feedback: Paralytic ileus is a significant complication of abdominal surgery. The problem is not associated with the use of antidiarrheal medications, obesity, or irritable bowel syndrome.

21. As a protective measure to keep abdominal inflammation and infection localized, the peritoneum: A) Constricts bowel contents B) Secretes fibrous exudate C) Increases intestinal motility D) Causes abdominal vasoconstriction Ans: B Feedback: The peritoneum produces an inflammatory response as a means of controlling infection.

It tends, for example, to exude a thick, sticky, and fibrinous substance that adheres to other structures, such as the mesentery and omentum, as a means of sealing off the perforation and localizing the process. Localization is enhanced by sympathetic stimulation that limits/decreases intestinal motility. The peritoneum is connective tissue without the ability to constrict. The vasoconstriction can decrease dissemination of the bacteria in the blood but also causes ischemic bowel damage that may be irreversible.

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22. A teenager has been diagnosed with failure to thrive. The health care providers suspect a malabsorption syndrome. In addition to having diarrhea and bloating, the client more than likely has what hallmark manifestation of malabsorption?

A) Feeling there is incomplete emptying of the bowel B) Abdominal distention C) Esophageal reflux with heartburn D) Fatty, yellow-gray, foul-smelling stools Ans: D Feedback: General symptoms of malabsorption syndrome include diarrhea, flatulence, bloating, cramping, and weight loss. A hallmark of malabsorption is steatorrhea, characterized by fatty, yellow-gray, and foul-smelling stools. Feeling there is incomplete emptying of the bowel is one of the signs/symptoms of colon cancer. Abdominal distention occurs with many GI diseases and is not specific to malabsorption syndrome. Esophageal reflux with heartburn is usually associated with GERD.

23. Which of the following meals is most likely to exacerbate an individual's celiac disease?

A) Spaghetti with meatballs and garlic bread B) Stir-fried chicken and vegetables with rice C) Oatmeal with milk, brown sugar, and walnuts D) Barbecued steak and a baked potato with sour cream Ans: A Feedback: Celiac disease is treated by the removal of wheat, barley, and rye from the diet, all of which contain gluten. Both spaghetti and garlic bread are wheat based and would exacerbate celiac disease. The other noted meals do not contain these grains.

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24. When educating residents of a senior citizen living facility, the nurse should review which of the following information about colorectal cancer? Select all that apply.

A) Aspirin and NSAIDs are implicated in the etiology of colorectal cancer.

B) Seek out medication attention for any blood in the stool.

C) Most cases are quite advanced before symptoms become apparent.

D) Survival rates for colorectal cancer are less than 20% but are increasing.

E) Yearly colonoscopy is recommended for early detection after age 40.

Ans: B, C Feedback: Clinical manifestations of colorectal cancer are often not apparent until later stages.

Almost all cancers of the colon and rectum bleed intermittently, although the amount of blood is small and usually does not apparent in the stools. It therefore is feasible to screen for colorectal cancers using commercially prepared tests for occult blood in the stool. Aspirin and NSAIDs may protect against colorectal cancer; it does not have an infectious etiology. Five-year survival rates are close to 90% to 100% if the cancer is found in the early (stage I) stages. It is recommended that persons at average risk for colonic adenomatous polyps or cancer should undergo colonoscopy every 10 years or alternative screening tests at periodically prescribed intervals beginning at age 50.

25. Following the analysis of a recent barium enema and colonoscopy with biopsy, a client has been diagnosed with colorectal cancer. Which of the following treatment modalities will be the mainstay of this client's treatment?

A) Chemotherapy B) Radiation therapy C) Pharmacologic therapies D) Surgery Ans: D Feedback: The only recognized treatment for cancer of the colon and rectum is surgical removal.

Postoperative radiation therapy may be used and has in some cases demonstrated increased 5-year survival rates. Postoperative adjuvant chemotherapy may be used.

Radiation therapy and chemotherapy are used as palliative treatment methods as well.

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1. Chapter 30 The role Kupffer cells play in removing harmful substances or cells from the portal blood as it moves through the venous sinusoids is known as: A) Filters B) Channels C) Phagocytes D) Cytotoxic cells Ans: C Feedback: The venous sinusoids are channels lined with two types of cells: the typical endothelial cells and Kupffer cells. Kupffer cells are reticuloendothelial cells that are capable of removing, engulfing, and phagocytizing old and defective blood cells, bacteria, and other foreign material from the portal blood as it flows through the sinusoid. This phagocytic action removes the enteric bacilli and other harmful substances that have filtered into the blood from the intestine. Kupffer cells do not have cytotoxic capabilities.

2. A liver failure client asks, “How does the liver process ammonia in healthy individuals?” The health care provider explains that ammonia is toxic to tissues, especially neurons, so this ammonia is removed from the blood by the liver, which: A) Converts it into bilirubin, which is then excreted intestinally B) Processes ammonia into nitrogen and hydrogen ions for excretion C) Processes it into urea, releasing it into the circulation D) Combines it with oxygen to create ammonium oxide Ans: C Feedback: The ammonia that is released during the deamination process is rapidly removed from the blood by the liver and converted to urea, which is then released into circulation for removal by the kidneys.

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3. A newborn is admitted to the hospital with a high bilirubin level of 13 mg/dL. The assessment data related to this lab value includes: Select all that apply.

A) Yellowish discoloration of the skin B) Colicky, intermittent pain associated with formula feeding C) Xanthomas D) Yellowing of the sclera of the eye E) Dark-colored urine Ans: A, D, E Feedback: Jaundice (i.e., icterus) results from an abnormally high accumulation of bilirubin in the blood, as a result of which there is a yellowish discoloration to the skin and deep tissues.

Because normal skin has a yellow cast, the early signs of jaundice often are difficult to detect, especially in persons with dark skin. Bilirubin has a special affinity for elastic tissue. The sclera of the eye, which contains a high proportion of elastic fibers, usually is one of the first structures in which jaundice can be detected. Because intrahepatic jaundice usually interferes with all phases of bilirubin metabolism, both conjugated and unconjugated bilirubin are elevated, the urine often is dark because of bilirubin in the urine. Skin xanthomas (focal accumulations of cholesterol) may occur with cholestasis, the result of hyperlipidemia and impaired excretion of cholesterol. Intrahepatic cholestasis, rather than hyperbilirubinemia, causes primary biliary cirrhosis.

4. A client's long-standing diagnosis of congenital hemolytic anemia often manifests itself with jaundice. What type of jaundice does this client most likely experience?

A) Prehepatic B) Intrahepatic C) Posthepatic D) Infectious Ans: A Feedback: The major cause of prehepatic jaundice is excessive hemolysis of red blood cells.

Hemolytic jaundice occurs when red blood cells are destroyed at a rate in excess of the liver's ability to remove the bilirubin from the blood. Intrahepatic jaundice involves dysfunction of the liver itself, whereas posthepatic causes usually involve obstruction.

The classification of jaundice does not include an infectious type.

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5. A client has been diagnosed with cholestasis and is experiencing pruritus. The nurse caring for this client should be educating the client about reduced bile flow that will interfere with intestinal absorption of which of the following vitamins? Select all that apply.

A) Vitamin A B) Vitamin B C) Vitamin C D) Vitamin D E) Vitamin K Ans: A, D, E Feedback: Pruritus is the most common presenting symptom in persons with cholestasis, probably related to an elevation in plasma bile acids. Other manifestations of reduced bile flow relate to intestinal absorption, including nutritional deficiencies of the fat-soluble vitamins A, D, E, and K.

6. A decrease in the serum level of which of the following substances is suggestive of liver injury?

A) -Glutamyltransferase (GGT) B) Albumin C) Alanine aminotransferase (ALT) D) Alkaline phosphatase Ans: B Feedback: Liver injury results in decreased production and reduced serum levels of albumin.

Levels of the enzymes GGT, alkaline phosphatase, and ALT tend to increase when function is compromised.

7. A client presents to the emergency department with some vague symptoms. After history and physical exam, the physician is suspecting the client may have viral hepatitis. Which of the following clinical manifestations leads the nurse to suspect the client is in the prodromal period of viral hepatitis?

A) Slight jaundice in the sclera of the eyes B) Liver tenderness on palpation C) Onset of severe itching with skin breakdown D) Muscle aches and pain along with fatigue Ans: D Feedback: The prodromal period may vary from abrupt to insidious, with general malaise, myalgia, arthralgias, easy fatigability, and severe anorexia out of proportion to the degree of illness. The icterus phase usually follows the prodromal phase within 5 to 10 days. The icterus phase can have the onset of jaundice, followed by severe pruritus and liver tenderness.

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8. Antibody testing has confirmed that a man is positive for hepatitis A virus (HAV).

Which of the client's statements suggests that he understands his new diagnosis?

A) “I guess I'm an example of why you should always use condoms.”

B) “I'm embarrassed that I'll be a carrier of hepatitis from now on.”

C) “I'm still trying to deal with the fact that this will forever change my life.”

D) “I don't know why I didn't bother to get vaccinated against this.”

Ans: D Feedback: A vaccine is available for HAV. The disease is normally self-limiting and does not result in carrier status. Transmission is usually by the fecal–oral route, rather than sexual transmission.

9. A client with hepatitis B asks the nurse, “How did I get this hepatitis?” The nurse responds that the mode of transmission is predominantly by: Select all that apply.

A) Intravenous drug use B) Fecal–oral route C) Unprotected sexual intercourse D) Sharing oral secretions by kissing E) Inhalation of airborne droplets Ans: A, C Feedback: Intravenous drug use and unprotected sexual intercourse are the main routes of transmission in low-prevalence areas as such as the United States. The fecal–oral route of transmission occurs in hepatitis A. HIV can be transmitted through oral secretions.

10. Clients with chronic autoimmune hepatitis may display which of the following clinical manifestations upon physical exam? Select all that apply.

A) Enlarged liver B) Jaundice C) Bacterial meningitis D) Nuchal rigidity E) Edematous joints Ans: A, B Feedback: Clinical manifestations of the disorder cover a spectrum that extends from no apparent symptoms to the signs of liver failure. Physical exam may reveal no abnormalities but may also reveal hepatomegaly, splenomegaly, jaundice, and signs of chronic liver disease. Bacterial meningitis and nuchal rigidity are not manifestations of this disorder.

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11. A 16-year-old girl has been admitted to the emergency department after ingesting 20 g of acetaminophen (Tylenol) in a suicide attempt. The care team would recognize that this client faces a severe risk of acute fulminant hepatitis, with elevated ammonia levels that can result in: Select all that apply.

A) Flapping tremor (asterixis) B) Confusion C) Convulsions D) Elevated creatinine levels E) Photosensitivity Ans: A, B, C Feedback: Among the manifestations of the direct, predictable liver injury that accompanies overdoses of acetaminophen is acute fulminant hepatitis. A very early sign of hepatic encephalopathy is a flapping tremor called asterixis. It also results in CNS signs/symptoms of confusion, coma, and convulsions. Elevated creatinine levels are not usually associated with acute fulminant hepatitis.

12. A client is suspected of having the onset of alcoholic liver disease. The nurse should be assessing for which of the following manifestations related to the necrosis of liver cells?

A) Tremors of the hands B) Rapid onset of jaundice C) Long muscle group atrophy D) Development of multiple skin nodules Ans: B Feedback: Alcoholic hepatitis is the intermediate stage between fatty changes and cirrhosis and is characterized by inflammation and necrosis of liver cells. The condition is always serious and sometimes fatal. The cardinal sign of alcoholic hepatitis is rapid onset of jaundice. Hand tremors are not specific to alcoholic hepatitis. Long muscle group atrophy can occur but is not the primary sign. Development of nodules is not caused by alcoholic hepatitis.

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13. A client is admitted with late manifestations of cirrhosis. Which of the following clinical manifestations confirm this diagnosis? Select all that apply.

A) Hepatomegaly felt on deep palpation B) Diffuse liver fibrosis with large, palpable lumps C) GI bleeding related to esophageal varices D) Acute renal failure with electrolyte imbalances E) Splenomegaly with bleeding tendencies Ans: A, C, E Feedback: The manifestations of cirrhosis are variable, ranging from asymptomatic hepatomegaly to hepatic failure. Often there are no symptoms until the disease is far advanced. The late manifestations of cirrhosis are related to portal hypertension and liver failure.

Splenomegaly, ascites, and portosystemic shunts (i.e., esophageal varices, gastric varices, and caput medusae) result from portal hypertension. Other complications include bleeding due to decreased clotting factors and thrombocytopenia due to splenomegaly. Hepatorenal syndrome refers to a functional renal failure seen during the terminal stages of liver failure with ascites. The end stage of chronic liver disease is characterized by diffuse liver fibrosis that replaces normally functioning liver tissue and forms constrictive bands that disrupt flow in the vascular channels and biliary duct systems.

14. Both prehepatic and posthepatic causes of portal hypertension include the formation of: A) Fibrous nodules B) Venous thrombosis C) Collateral circulation D) Portosystemic shunts Ans: B Feedback: Portal hypertension can be caused by a variety of conditions that increase resistance to hepatic blood flow. Prehepatic causes of portal hypertension include portal vein thrombosis; posthepatic obstruction is caused by conditions such as hepatic vein thrombosis and venoocclusive disease. Fibrous tissue bands and fibrous nodules that increase the resistance to portal blood flow are intrahepatic causes of portal hypertension. With the gradual obstruction of venous blood flow in the liver, portal vein pressure increases, resulting in the development of collateral channels between the portal and systemic veins. The increased pressure also leads to the formation of portopulmonary shunts that cause blood to bypass the pulmonary capillaries, thus interfering with blood oxygenation and producing cyanosis.

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15. A client presents to the emergency department vomiting large amounts of bright red blood. The client has a history of alcohol abuse, and the physician suspects esophageal varices. The drug that is used to reduce splanchnic and hepatic blood flow and portal pressures is: A) Propranolol, a –adrenergic blocking agent B) Lisinopril, an ACE inhibitor C) Ocetrotide, a long-acting synthetic analog of somatostatin D) Famotidine, a histamine-2 blocker to decrease stomach acid Ans: C Feedback: Several methods are used to control acute hemorrhage, including pharmacologic therapy, balloon tamponade, and emergent endoscopic therapy. Pharmacologic methods include administration of ocetrotide, a long-acting synthetic analog of somatostatin.

Beta blockers are commonly used to lower portal venous pressure, thereby preventing the initial hemorrhage. ACE inhibitors do not control acute hemorrhage.

16. 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.

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17. 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.

18. 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.

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19. 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.

20. 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.

21. The client has right upper quadrant pain caused by acute choledocholithiasis. The health care provider suspects the common bile duct is obstructed, based on which of the flowing lab values?

A) Albumin 2.0 g/dL (low) B) Amylase 150 unites/L (high) C) Bilirubin 15 mg/dL (high) D) Serum calcium level 7 mg/dL (low) Ans: C Feedback: Choledocholithiasis, stones in the common duct, usually originate in the gallbladder but can form spontaneously in the common duct. Bilirubinuria and an elevated serum bilirubin are present if the common duct is obstructed. With acute cholecystitis, approximately 75% of clients have vomiting. Ascites is common with late-stage liver failure rather than duct obstructions. Bleeding is associated with liver failure due to deficiency of clotting factors and acute pancreatitis due to activated enzymes, causing fat necrosis and hemorrhage from the necrotic vessels.

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22. When explaining acute pancreatitis to a newly diagnosed client, the nurse will emphasize the pathogenesis begins with an inflammatory process whereby: A) Activated pancreatic enzymes escape into surrounding tissues, causing autodigestion of pancreatic tissue.

B) The pancreas is irreversibly damaged and will not recover to normal functioning (chronic).

C) The pancreas will hypertrophy (enlarge) to the point of causing bowel obstruction.

D) Stones will develop in the common bile duct, resulting in acute jaundice.

Ans: A Feedback: Acute pancreatitis is associated with the escape of activated pancreatic enzymes into the pancreas and surrounding tissues. These enzymes cause fat necrosis, or autodigestion, of the pancreas. Alcohol is known to be a potent stimulator of pancreatic secretions, and it also is known to cause partial obstruction of the sphincter of the pancreatic duct, rather than bowel obstruction. The pancreas is irreversibly damaged and will not recover to normal functioning results from chronic pancreatitis. Acute pancreatitis also is associated with viral infections. The pancreas will hypertrophy (enlarge) to the point of causing bowel obstruction occurring with cancer of the pancreas. Presence of stones in the common bile duct with jaundice is primarily a result of gallstones.

23. Given the fact that acute pancreatitis can result in severe, life-threatening complications, the nurse should be assessing the client for which of the following complications?

A) Cerebral hemorrhage B) Acute tubular necrosis C) Bilateral pneumothorax D) Complete heart block Ans: B Feedback: Complications of acute pancreatitis include the systemic inflammatory response, acute respiratory distress syndrome, acute tubular necrosis, and organ failure. Cerebral hemorrhage, bilateral pneumothorax, and complete heart block are not associated with the complications of acute pancreatitis.

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24. Which of the following individuals most likely faces the highest risk of developing chronic pancreatitis?

A) A woman who has six to eight alcoholic beverages each evening B) A man who has become profoundly ill during a tropical vacation C) A woman who takes two Tylenol tablets five to six times a day D) An obese man who has a high-fat diet and has a sedentary lifestyle Ans: A Feedback: By far, the most common cause of chronic pancreatitis is long-term alcohol abuse. The other cited factors are not noted to contribute significantly to the pathogenesis of chronic hepatitis.

25. The nurse who is providing care for a client with pancreatic cancer should prioritize which of the following assessments?

A) Assessment for ascites and close monitoring of fluid balance B) Respiratory assessment and monitoring of arterial blood gases C) Vigilant monitoring of blood glucose levels D) Assessment for deep vein thrombosis Ans: D Feedback: Migratory thrombophlebitis (deep vein thrombosis) is a common sequela of pancreatic cancer. This likely supersedes the importance of respiratory assessment and blood glucose and fluid balance monitoring.

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1. Chapter 31 When comparing the endocrine and nervous system functions, the nurse knows that the endocrine system: Select all that apply.

A) Sends signals to neurons over a short distance to muscles B) Responds to neurotransmitter molecules within milliseconds C) Releases hormones into the blood that is transported throughout the body D) Glands are widely scattered throughout the body E) Takes longer to respond to innervations but has prolonged actions when they arrive Ans: C, D, E Feedback: The endocrine system uses chemical messengers called hormones as a means of controlling the flow of information between the different tissues and organs of the body.

It does not act alone, however, but interacts with the nervous system to coordinate and integrate the activity of body cells. Hormones regulate and integrate body functions.

Hormones act on specific target cells, but they cause a variety of effects on tissues.

Hormones do not transport other substances; hormones are transported and present in body fluids at all times. The endocrine system uses hormones released into the blood and transported throughout the body to influence the activity of body tissues. Tissue and organ responses to endocrine hormones tend to take much longer than the response to neurotransmitters, but once initiated, they tend to be much more prolonged than those induced by the nervous system. The glands of the endocrine system are widely scattered throughout the body.

2. Paracrine action involves which of the following characteristics?

A) Action on a distant target cell B) Autoregulation C) Act locally on cells other than those that produce the hormone D) Action on nearby target cells Ans: C Feedback: When hormones act locally on cells other than those that produced the hormone, the action is called paracrine. Paracrine action is not synonymous with autoregulation, and action on the same cells that produced the hormone is autocrine action.

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3. While teaching a science class, the instructor mentions that both autocrine and paracrine hormonal actions occur without entering the blood stream. The instructor then asks the students, “What cells do paracrine actions affect?” The student with the correct answer is: A) Self B) Local C) Stored D) Target Ans: B Feedback: Paracrine actions are hormonal interactions with local cells other than those that produce the hormone; autocrine actions are with self-cells (cells from which they were produced). Both autocrine and paracrine hormonal actions affect target cells. Neither paracrine nor autocrine actions affect cell storage.

4. The release of insulin from the pancreatic beta cells can inhibit its further release from the same cells. This is an example of which type of hormone action?

A) Retinoid B) Autocrine C) Juxtaposed D) Arachidonic Ans: B Feedback: Hormones can exert autocrine action on the cells from which they were produced.

Retinoids are compounds with hormone-like actions. Juxtacrine action involves a chemical messenger imbedded in a plasma membrane that interacts with a specific receptor on a juxtaposed cell. Arachidonic acid is a precursor for eicosanoid compounds (similar to retinoids).

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5. Hormones are usually divided into categories according to their structure. The release of epinephrine would be classified as: A) Proteins B) Steroids C) Amines and amino acids D) Peptides and polypeptides Ans: C Feedback: Hormones are divided into three categories according to their structures: amines and amino acids; polypeptides, proteins, and glycoproteins; and steroids. The amine and amino acid hormones include norepinephrine and epinephrine, which are derived from a single amino acid (i.e., tyrosine). The peptide, polypeptide, protein, and glycoprotein hormones can be as small as thyrotropin-releasing hormone (TRH), which contains three amino acids, and as large, and as large and complex as growth hormone (GH) and follicle-stimulating hormone (FSH). Steroid hormones, such as the glucocorticoids, are derivatives of cholesterol.

6. A hormone has been synthesized in the rough endoplasmic reticulum of an endocrine cell after which it has moved into the Golgi complex, been packaged in a vesicle, and been released into circulation. From the following list, which hormone is synthesized and released in this manner?

A) Insulin B) Cortisol C) Testosterone D) Estrogen Ans: A Feedback: Insulin is a peptide hormone; as such, its synthesis and release are vesicle mediated.

Glucocorticoids (such as cortisol), androgens (such as testosterone), and estrogens are synthesized by non–vesicle-mediated pathways.

7. Which of the following hormones are synthesized by non–vesicle-mediated pathways?

Select all that apply.

A) Epinephrine B) Estrogen C) Insulin D) Aldosterone Ans: B, D Feedback: Glucocorticoids, androgens, estrogens, and mineralocorticoids (aldosterone is an example of a mineralocorticoid) are all hormones synthesized by non–vesicle-mediated pathways. Epinephrine and insulin are synthesized by vesicle-mediated pathways.

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8. When trying to explain hypothyroidism to a newly diagnosed client, the nurse stresses the fact that the thyroid hormone is transported in blood by specific: A) Proteins B) Target cells C) Cholesterol molecules D) Prohormones Ans: A Feedback: Some hormones, such as steroids and thyroid hormone, are bound to protein carriers for transportation to the target cell destination. The extent of carrier binding influences the rate at which hormones leave the blood and enter the cells. Cholesterol is a precursor for steroid hormone. Prohormones have an extra amino acid and are converted to hormones in the Golgi complex.

9. As part of maintaining homeostasis, hormones secreted by endocrine cells are inactivated continuously to: A) Free receptor sites B) Stimulate production C) Prevent accumulation D) Absorb metabolic waste Ans: C Feedback: Continuous inactivation of secreted hormones is necessary to prevent accumulation that could disrupt the feedback mechanism. Increased secretion stimulates production of more receptor sites. Metabolic waste absorption is not a function of the endocrine system.

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10. While discussing the elimination of hormones from the body to prevent overaccumulation, which of the following hormones are eliminated in bile? Select all that apply.

A) Catecholamines B) Unbound adrenal hormones C) Gonadal steroid hormones D) Thyroid hormones E) Peptide hormones Ans: B, C, D Feedback: Steroid hormones are bound to protein carriers for transport and are inactive in the bound state. Unbound adrenal and gonadal steroid hormones are conjugated in the liver, which renders them inactive, and then excreted in the bile or urine. Thyroid hormones also are transported by carrier molecules. The free hormone is rendered inactive by the removal of amino acids in the tissues, and the hormone is conjugated in the liver and eliminated in the bile. The catecholamine production is measured by some of their metabolites. In general, peptide hormones also have a short life span in the circulation.

Their major mechanism of degradation is through binding to cell surface receptors, with subsequent uptake and degradation by peptide-splitting enzymes in the cell membrane or inside the cell.

11. When explaining factors that influence the number of receptors present on target cells, the instructor will likely mention: Select all that apply.

A) The role antibodies may have on receptor proteins.

B) A decreased hormone level may produce increased receptor numbers.

C) A sustained excess hormone level brings about a decrease in receptor numbers.

D) How any given hormone can change its affinity to supply a need to all cells.

E) It may take days to weeks before a hormone can react to target cells.

Ans: A, B, C Feedback: Target cell response varies with the number and affinity of the relevant receptors. The number of hormone receptors on a cell may be altered for any of several reasons.

Antibodies may destroy or block the receptor proteins. Increased or decreased hormone levels often induce changes in the activity of the genes that regulate receptor synthesis.

For example, decreased hormone levels often produce an increase in receptor numbers by means of a process called up-regulation; this increases the sensitivity of the body to existing hormone levels. Likewise, sustained levels of excess hormone often bring about a decrease in receptor numbers by down-regulation, producing a decrease in hormone sensitivity.

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12. Cyclic adenosine monophosphate (cAMP) performs which of the following roles in the functioning of the endocrine system?

A) Mediating hormone synthesis by non–vesicle-mediated pathways B) Acting as a high-affinity receptor on the surface of target cells C) Inactivating hormones to prevent excess accumulation D) Acting as a second messenger to mediate hormone action on target cells Ans: D Feedback: cAMP is one of the most common second messengers, whose role is to generate an intracellular signal in response to cell surface receptor activation by a hormone. cAMP does not mediate hormone synthesis, act as a receptor itself, or inactivate hormones.

13. Thyroid and steroid hormones, which exert their effect on target cells by way of nuclear receptors, have which of the following characteristics?

A) The selective use of a second messenger B) The ability to cross the cell membrane of target cells C) The ability to regulate surface receptor affinity D) Both lipid solubility and water solubility Ans: B Feedback: Hormones that utilize nuclear receptors enter the target cell (i.e., cross the cell membrane) and bind to receptors in the cell nucleus that are gene regulatory proteins.

These hormones do not selectively utilize second messengers, and they do not interact with surface receptors. They are not both lipid and water soluble.

14. A diabetic client is controlled on Avandia (rosiglitazone), a thiazolidinedione medication that acts at the level of nuclear peroxisome proliferator-activated receptors (PPARs) to promote: A) Glucose uptake B) Stimulation of the beta cells in the pancreas C) Increase in basal metabolic rate D) Weight loss by shrinking fat cells Ans: A Feedback: The thiazolidinedione medications, which are used in the treatment of type 2 diabetes mellitus, act at the level of nuclear PPAR- receptors to promote glucose uptake and utilization by adipose tissue cells. These drugs do not increase release of insulin from the pancreas, increase BMR, or promote weight loss.

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15. When describing to a newly diagnosed diabetic client how insulin is regulated, the nurse will draw upon her knowledge of which hormonal regulation mechanism?

A) Basal metabolic rate B) The hypothalamic–pituitary–target cell system C) The cytokine–interleukin regulatory mechanism D) The angiotensin I to angiotensin II to aldosterone system Ans: B Feedback: The hypophysis (pituitary plus hypothalamus) and hypothalamus stimulatory hormones regulate the release and synthesis of anterior pituitary hormones. The levels of hormones such as insulin and antidiuretic hormone (ADH) are regulated by feedback mechanisms that monitor substances such as glucose (insulin) and water (ADH) in the body. The levels of many of the hormones are regulated by feedback mechanisms that involve the hypothalamic–pituitary–target cell system.

16. Which of the following statements best describes the relationship between the hypothalamus and the posterior pituitary in the normal functioning of the endocrine system?

A) Posterior pituitary hormones are constituted from components of both the hypothalamus and the pituitary gland itself.

B) The posterior pituitary gland regulates the release of hypothalamic hormones.

C) Posterior pituitary hormones are produced in the hypothalamus but released from the pituitary gland.

D) The hypothalamus regulates the production and release of posterior pituitary hormones by the pituitary gland.

Ans: C Feedback: The posterior pituitary hormones, ADH and oxytocin, are synthesized in the cell bodies of neurons in the hypothalamus that have axons that travel to the posterior pituitary, where they are released when needed. The two glands do not contribute components that are subsequently combined.

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17. When discussing luteinizing hormone and follicle-stimulating hormone with students, the instructor will emphasize that these hormones are under the control of: A) Thyroid gland B) Anterior pituitary gland C) Posterior adrenal cortex D) Pancreas Ans: B Feedback: The pituitary gland has been called the master gland because its hormones control the functions of many target glands and cells. The anterior pituitary gland or adenohypophysis contains five cell types: (1) thyrotrophs, which produce thyrotropin, also called TSH; (2) corticotrophs, which produce corticotropin, also called ACTH; (3) gonadotrophs, which produce the gonadotropins, LH, and FSH; (4) somatotrophs, which produce GH; and (5) lactotrophs, which produce prolactin.

18. A nursing student who has a history of brain tumors that resulted in partial removal of her pituitary gland years ago is asking her OB/GYN doctor about her ability to breast-feed her infant. This is based on which physiological function of the pituitary gland that facilitates breast milk production?

A) Growth hormone (GH) B) Oxytocin C) Corticotropin-releasing hormone (CRH) D) Lactotrophs Ans: D Feedback: The anterior pituitary gland or adenohypophysis contains five cell types: (1) thyrotrophs, which produce thyrotropin, also called TSH; (2) corticotrophs, which produce corticotropin, also called ACTH; (3) gonadotrophs, which produce the gonadotropins, LH, and FSH; (4) somatotrophs, which produce GH; and (5) lactotrophs, which produce prolactin that is involved with breast growth and milk production.

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19. When sensors detect a change in a hormone level, the hormonal response is regulated by which of the following mechanisms that will return the level to within normal range.

A) Metabolic B) Feedback C) Production D) Action potential Ans: B Feedback: Feedback (negative and sometimes positive) mechanisms respond to levels that are too high or too low. The level of many of the hormones in the body is regulated by negative feedback mechanisms. The function of this type of system is similar to that of the thermostat in a heating system. For example, when the sensors detect a decrease in blood levels, they initiate changes that cause an increase in hormone production.

Metabolic responses and increased/decreased production occur as a consequence of hormone level fluctuations, not as a regulating mechanism. Action potential is not a regulating mechanism for this function.

20. Which of the following physiologic processes best exemplifies a positive feedback mechanism?

A) The increase in prolactin secretion that occurs with more frequent breast-feeding B) The regulation of blood glucose levels by insulin C) The release of parathyroid hormone in response to decreased serum calcium levels D) The release of antidiuretic hormone when sodium levels are higher than normal Ans: A Feedback: A positive feedback mechanism occurs when one hormonal or physiologic factor stimulates further hormonal release, creating a cascade that will increase until corrected.

Correction of alterations in homeostasis is normally achieved using negative feedback mechanisms, such as those accomplished by insulin, parathyroid hormone, and ADH.

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21. Which of the following statements about immunoradiometric assay (IRMA) testing for measuring plasma hormone levels is most accurate?

A) This bioassay test uses an intact animal or a portion of tissue from an animal to calculate specificity and sensitivity.

B) This testing procedure uses antibody-coated plates to produce colored reaction.

C) A 24-hour urine test will be required along with blood tests to calculate specific results.

D) These tests are very specific since they utilize two antibodies instead of one.

Ans: D Feedback: Immunoradiometric assay (IRMA) testing is very specific since they utilize two antibodies instead of one. These two antibodies are directed against two different parts of the molecule, and therefore IRMA assays are more specific. Hormones circulating in the plasma were first detected by bioassay test, which used an intact animal or a portion of tissue from an animal to calculate specificity and sensitivity. ELISA testing procedure utilizes antibody-coated plates to produce colored reaction. The IRMA is a blood test, not a urine test.

22. When hypofunction of an endocrine organ is suspected, which hormone test can be administered to measure and assess target gland response?

A) Stimulation B) 24-hour urine C) Agglutination D) Antibody binding Ans: A Feedback: Stimulating hormone can be given to identify (determine hypofunction) if the target gland is able to increase hormone response to increased stimulation. Agglutination with enzymes is a way of measuring hormone antigen levels. The 24-hour urine sample measures hormone metabolite excretion. Radioactive hormone–antibody binding levels are a method of measuring plasma levels.

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23. In major athletic competition, athletes are required to submit to liquid chromatography testing looking for: A) Blood doping to increase RBC levels B) Low serum sodium levels indicating dehydration C) Use of opioids to minimize pain during competition D) Use of performance-enhancing agents to increase the chances of winning Ans: D Feedback: For some steroid or peptide hormones, mass spectrometry is becoming increasingly useful and can be combined with other analytical techniques, such as liquid chromatography. These approaches provide definitive identification of the relevant hormone or compound according to its chemical or physical characteristics (e.g., unequivocal detection of performance-enhancing agents in sports).

24. A client has received an injection containing thyrotropin-releasing hormone (TRH) and is now being assessed for levels of thyroid-stimulating hormone (TSH). This client has undergone which of the following diagnostic tests?

A) Suppression testing B) Radioimmunoassay (RIA) C) Autoantibody testing D) Stimulation testing Ans: D Feedback: Introduction of TRH tests the pituitary gland's ability to produce TSH, and is an example of a stimulation test. Suppression testing examines a gland's response to a stimulus that would normally result in decreased hormone production. RIA and autoantibody testing are examples of direct and indirect measurement of serum levels of a hormone.

25. A client with many nonspecific complaints has been ordered a positron emission tomography (PET) scanning for evaluation of: A) The pancreas response to an insulin injection B) Tumors located on the endocrine glands C) Bone density D) Radioactivity of the thyroid gland Ans: B Feedback: Positron emission tomography (PET) scanning is being used more widely for evaluation of endocrine tumors. PET scans do not calculate the pancreas response to insulin. A DEXA is used for diagnosis and monitoring of osteoporosis (bone density). Isotopic imaging includes radioactive scanning of the thyroid (using radioiodine) and parathyroids.

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1. Chapter 32 Which of the following individuals is experiencing the effects of a primary endocrine disorder? A client: A) With adrenal cortical insufficiency due to pituitary hyposecretion of ACTH B) Who has hypothyroidism as a result of low TSH production C) Whose dysfunctional hypothalamus has resulted in endocrine imbalances D) Who has low calcium levels because of the loss of his parathyroid gland Ans: D Feedback: The loss of a gland, and the subsequent absence of the hormone that it normally produces, results in a primary endocrine disorder. The lack of a stimulating hormone such as ACTH or TSH results in a secondary disorder, whereas hypothalamic dysfunction causes tertiary endocrine disorders.

2. A woman who is exhibiting clinical manifestations of a pituitary adenoma will likely complain of: Select all that apply.

A) Cessation of menses B) Unusual milk secretion unrelated to pregnancy C) Enlargement of the abdomen D) Pelvic pain E) Infertility Ans: A, B, E Feedback: The signs and symptoms of pituitary adenomas include endocrine abnormalities related specifically to functional hormone-secreting adenomas and to the local mass effects from the expanding tumor. Lactotrophic adenomas are the most frequent type of hyperfunctioning pituitary adenoma. Hyperprolactinemia inhibits the pulsatile secretion of LH, which is essential for normal ovulation in women. Thus, manifestations of hyperprolactinemia are easily recognized to include amenorrhea (lack of menses), galactorrhea (spontaneous milk secretion unrelated to pregnancy), and infertility.

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3. Loss of pituitary function can result in deficiencies/loss of which of the following hormones' secretions? Select all that apply.

A) Growth hormone B) Luteinizing hormone C) Follicle stimulating hormone D) Corticotropin-releasing hormone E) Prolactin Ans: A, B, C, E Feedback: Anterior pituitary hormone loss is usually gradual, especially with progressive loss of pituitary reserve due to tumors or previous pituitary radiation therapy (which may take 10 to 20 years to produce hypopituitarism). The loss of pituitary function tends to follow a classic course beginning with the loss of GH, LH, and FSH secretion followed by deficiencies in TSH, then ACTH, and finally prolactin.

4. Which of the following physiologic processes is a direct effect of the release of growth hormone by the anterior pituitary?

A) Development of cartilage and bone B) Production of insulin-like growth factors (IGFs) by the liver C) Increase in overall metabolic rate and cardiovascular function D) Positive feedback of the hypothalamic–pituitary–thyroid feedback system Ans: B Feedback: GH cannot directly produce bone growth; instead, it acts indirectly by causing the liver to produce IGFs. It affects neither metabolic rate nor the function of the hypothalamic– pituitary–thyroid feedback system.

5. Which of the following individuals displays the precursors to acromegaly?

A) An adult with an excess of growth hormone due to an adenoma B) A girl who has been diagnosed with precocious puberty C) An adult who has a diagnosis of Cushing syndrome D) A client who has recently developed primary adrenal carcinoma Ans: A Feedback: When growth hormone (GH) excess occurs in adulthood or after the epiphyses of the long bones have fused, it causes a condition called acromegaly, which represents an exaggerated growth of the ends of the extremities.

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6. A client with excessive production of growth hormone level will likely exhibit which clinical manifestations? Select all that apply.

A) Short stature with obesity B) Large hands and feet due to increased production of GH C) Excess thirst and urination due to decreased glucose uptake D) Difficulty chewing food E) Tendency to develop asthma Ans: B, C, D Feedback: Growth hormone causes increased release of free fatty acids from adipose tissue, leading to increased concentration of free fatty acids in body fluids. In addition, GH exerts multiple effects on carbohydrate metabolism, including decreased glucose uptake by tissues such as skeletal muscle and adipose tissue, increased glucose production by the liver, and increased insulin secretion. Each of these changes results in GH-induced insulin resistance. Impaired glucose tolerance occurs in as many as 50% to 70% of persons with acromegaly; overt diabetes mellitus subsequently can result. The predominant effect of prolonged growth hormone (GH) excess is to increase glucose levels despite an insulin increase. Persons with classic GH deficiency have normal intelligence, short stature, and obesity with immature facial features. Exceptionally tall children (i.e., genetic tall stature and constitutional tall stature) can be treated with sex hormones—estrogens in girls and testosterone in boys—to effect early epiphyseal closure and stop bone growth.

7. A client has just undergone a diagnostic cardiac angiogram. As part of their ordered labs, the physician has ordered a thyroid panel. The physiological principle behind ordering this lab tests includes which of the following correlations? Hyperthyroidism can cause: Select all that apply.

A) Rise in oxygen consumption B) Sharp decrease in heart rate and blood pressure C) Increase in cardiac output D) Vasoconstriction of all arteries Ans: A, C Feedback: Cardiovascular and respiratory functions are strongly affected by thyroid function. With an increase in metabolism, there is a rise in oxygen consumption and production of metabolic end products, with an accompanying increase in vasodilation. Blood volume, cardiac output, and ventilation all are increased as a means of maintaining blood flow and oxygen delivery to body tissues. Heart rate and cardiac contractility are enhanced as a means of maintaining the needed cardiac output, whereas there is little change in blood pressure because the increase in vasodilation tends to offset the increase in cardiac output.

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8. Which of the following residents of a long-term facility is exhibiting clinical manifestations of hypothyroidism?

A) An 80-year-old woman who has uncharacteristically lost her appetite and often complains of feeling cold B) A 90-year-old woman with a history of atrial fibrillation whose arrhythmia has recently become more severe C) An 88-year-old man with a history of Alzheimer disease who has become increasingly agitated and is wandering around the facility more frequently D) A 91-year-old man with a chronic venous ulcer and a sacral ulcer who has developed sepsis Ans: A Feedback: Loss of appetite and cold intolerance are characteristic symptoms of hypothyroidism.

Arrhythmias, agitation, and infections are not typically associated with hypofunction of the thyroid gland.

9. One of the first signs that indicates an infant may have congenital hypothyroidism is: A) No passage of meconium within the first 72 hours after birth B) Palpable mass in the neck region C) Prolonged period of physiologic jaundice D) Full, bounding fontanels Ans: C Feedback: With congenital lack of the thyroid gland, the infant usually appears normal and functions normally at birth because of hormones supplied in utero by the mother.

Prolongation of physiologic jaundice, caused by delayed maturation of the hepatic system for conjugating bilirubin, may be the first sign. There may be respiratory difficulties and a hoarse cry, feeding difficulties, and an enlarged abdomen. This condition will not interfere with meconium passage, elevated ICP resulting in full, tight fontanels, or having a palpable mass in the neck.

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10. Which of the following clients are at risk for developing hypothyroidism? Select all that apply.

A) A client who is prescribed amiodarone for frequent dysrhythmias B) A client who has bulging eyeballs being treated with -adrenergic blockers C) A client who has precancerous thyroid lesions who underwent ablation with radiation D) A female experiencing an autoimmune disorder called thyroiditis E) A bipolar client prescribed lithium carbonate Ans: A, C, D, E Feedback: The most common cause of hypothyroidism is Hashimoto thyroiditis, an autoimmune disorder in which the thyroid gland may be totally destroyed by an immunologic process. It is the major cause of goiter and hypothyroidism in children and adults.

Hypothyroidism may result from thyroidectomy (i.e., surgical removal) or ablation of the gland with radiation. Certain goitrogenic agents, such as lithium, and the antithyroid drugs propylthiouracil and methimazole in continuous dosage can block hormone synthesis and produce hypothyroidism with goiter. Large amounts of iodine (i.e., ingestion of kelp tablets or iodide-containing cough syrups, or administration of iodide-containing radiographic contrast media or the cardiac drug amiodarone, which contains 75 mg of iodine per 200-mg tablet) also can block thyroid hormone production and cause goiter, particularly in persons with autoimmune thyroid disease. Myxedema is associated with severe hypothyroidism and is characterized by a nonpitting mucus-type edema caused by the accumulation of hydrophobic extracellular matrix substances in the connective tissues of a number of body tissues. Although the myxedema is most obvious in the face and other superficial parts, it also affects many of the body organs and is responsible for many of the manifestations of the hypothyroid state.

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11. A student nurse is taking a test on the endocrine system. From the following list of clinical manifestations, she needs to select the ones she would see in hypothyroidism.

Which answers should she select? Select all that apply.

A) Weight gain despite loss of appetite B) Nervousness with fine muscle tremors C) Coarse brittle hair D) Heat intolerance E) Puffy face with swollen eyelids Ans: A, C, E Feedback: The hypometabolic state associated with hypothyroidism is characterized by a gradual onset of weakness and fatigue, a tendency to gain weight despite a loss of appetite, and cold intolerance. As the condition progresses, the skin becomes dry and rough and the hair becomes coarse and brittle. Reduced conversion of carotene to vitamin A and increased blood levels of carotene may give the skin a yellowish color. The face becomes puffy with edematous eyelids, and there is thinning of the outer third of the eyebrows. Nervousness with fine muscle tremors and heat intolerance are signs of hyperthyroidism.

12. A client has developed the facial appearance that is characteristic of myxedema, along with an enlarged tongue, bradycardia, and voice changes. Which of the following treatment modalities is most likely to benefit this client?

A) Synthetic preparations of T3 or T4 B) -Adrenergic blocking drugs C) Corticosteroid replacement therapy D) Oral or parenteral cortisol replacement Ans: A Feedback: Myxedema and the client's other signs are associated with hypothyroidism, which necessitates thyroid hormone replacement. -Adrenergic blocking drugs and antithyroid drugs are indicated in the treatment of hyperthyroidism, whereas treatments relevant to adrenal cortical function are not relevant to hypothyroidism.

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13. Which of the following clinical manifestations lead the health care worker to suspect the client is at the end-stage expression of hypothyroidism? A client: Select all that apply.

A) Who takes analgesics for chronic pain that goes into a coma B) Brought to the emergency department with hypothermia who presents with low serum sodium levels C) In the emergency department presenting with tachycardia and palpitations D) Whose family took him to the health care provider complaining of shortness of breath and heat intolerance E) Who has abnormal retraction of eyelids and infrequent blinking Ans: A, B Feedback: Myxedematous coma is a life-threatening, end-stage expression of hypothyroidism. It is characterized by coma, hypothermia, cardiovascular collapse, hypoventilation, and severe metabolic disorders including hyponatremia, hypoglycemia, and lactic acidosis.

With the hypermetabolic state of hyperthyroidism, there are frequent complaints of nervousness, irritability, and fatigability. Weight loss is common despite a large appetite. Other manifestations include tachycardia, palpitations, shortness of breath, excessive sweating, muscle cramps, and heat intolerance.

14. The most common cause of thyrotoxicosis is Graves disease. When assessing this client, the nurse should put priority on which of the following signs/symptoms?

A) Complaints of muscle fatigue B) Facial myxedema with puffy eyelids C) Ophthalmopathy D) Pulse rate of 64 beats/minute Ans: C Feedback: Graves disease is characterized by a triad of hyperthyroidism, goiter, ophthalmopathy (exophthalmos), or less commonly, dermopathy (pretibial edema due to accumulation of fluid and glycosaminoglycans). Even in persons without exophthalmos (i.e., bulging of the eyeballs seen in ophthalmopathy), there is an abnormal retraction of the eyelids and infrequent blinking such that they appear to be staring. Although the myxedema of hypothyroidism is most obvious in the face and other superficial parts, it also affects many of the body organs. Common to all types of thyrotoxicosis, rather than unique to Graves disease, cholesterol blood levels are decreased; muscle proteins are broken down and used as fuel, which accounts for the muscle fatigue that occurs with all types of hyperthyroidism.

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15. A 33-year-old client has been admitted to the hospital for the treatment of Graves disease. Which of the following assessments should the client's care team prioritize?

A) Assessment of the client's level of consciousness and neurologic status B) Assessment of the client's peripheral vascular system for thromboembolism C) Assessment of the client's vision and oculomotor function D) Cardiac monitoring and assessment of peripheral perfusion Ans: C Feedback: Ophthalmopathy occurs in a large proportion (up to one third) of clients with Graves disease and may result in permanent vision damage. This supersedes the importance of cardiac, neurologic, and peripheral vascular assessments, although these assessments are relevant to the broader effects of hyperthyroidism that the client may likely experience.

16. Which of the following clinical manifestations following thyroidectomy would alert the nurse that the client is going into a life-threatening thyroid storm? Select all that apply.

A) Temperature of 104.2°F B) Telemetry showing heart rate of 184 C) Unable to close eyelids completely together D) Extremely agitated E) Bruising on knees and feet Ans: A, B, D Feedback: Thyroid storm, or crisis, is an extreme and life-threatening form of thyrotoxicosis, rarely seen today. When it does occur, it is seen most often in undiagnosed cases or in person with hyperthyroidism that has not been adequately treated. It often is precipitated by stress such as an infection, diabetic ketoacidosis, physical or emotional trauma, or manipulation of a hyperactive thyroid gland during thyroidectomy. It is manifested by a very high fever, extreme cardiovascular effects (tachycardia, HF, angina), and severe CNS effects (agitation, restlessness, and delirium).

17. When educating a client with possible glucocorticoid dysfunction, the nurse will explain that the CRH controls the release of ACTH. The best time to perform the blood test to measure peak ACTH levels would be: A) 06:00 to 08:00 AM B) 10:00 to 12:00 AM C) 04:00 to 6:00 PM D) 09:00 to 11:00 PM Ans: A Feedback: Levels of cortisol increase as ACTH levels rise and decrease as ACTH levels fall. There is considerable diurnal variation in ACTH levels, which reach their peak in the early morning (around 6 to 8 AM) and decline as the day progresses.

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18. The immune suppressive and anti-inflammatory effects of cortisol cause: A) Moderate insulin resistance B) Increased capillary permeability C) Increased cell-mediated immunity D) Inhibition of prostaglandin synthesis Ans: D Feedback: Large quantities of cortisol are required for an effective anti-inflammatory action. The increased cortisol blocks inflammation at an early stage by decreasing capillary permeability and stabilizing the lysosomal membranes so that inflammatory mediators are not released. Cortisol suppresses the immune response by reducing humoral and cell-mediated immunity. Cortisol also inhibits prostaglandin synthesis, which may account in large part for its anti-inflammatory actions. Cortisol stimulates glucose production by the liver; as glucose production by the liver rises and peripheral glucose use falls, a moderate resistance to insulin and hyperglycemia develop.

19. A client who has been taking 80 mg of prednisone, a glucocorticoid, each day has been warned by his primary care provider to carefully follow a plan for the gradual reduction of the dose rather than stopping the drug suddenly. What is the rationale for this directive?

A) Sudden changes in glucocorticoid dosing may reverse the therapeutic effects of the drug.

B) Stopping the drug suddenly may “shock” the HPA axis into overactivity.

C) Sudden cessation of a glucocorticoid can result in adrenal gland necrosis.

D) Stopping the drug suddenly may cause acute adrenal insufficiency.

Ans: D Feedback: Chronic suppression of the HPA system by the use of steroids causes atrophy of the adrenal gland, and the abrupt withdrawal of drugs can cause acute adrenal insufficiency.

Activity of the HPA system is consequently insufficient. The efficacy of the drug is not the primary concern, and necrosis of the gland itself does not occur.

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20. Primary adrenal insufficiency is manifested by: A) Truncal obesity and 3+ pitting edema in lower legs B) Potassium level of 2.8 mEq/L and weight gain of 3 pounds overnight C) Serum sodium level of 120 mmol/L (low) and blood glucose level of 48 mg/dL (low) D) Hypopigmentation over neck and BP greater than 150/90 Ans: C Feedback: Primary adrenal insufficiency is adrenal cortical hormone deficiency with elevated adrenocorticotropic hormone (ACTH) levels caused by a lack of feedback inhibition.

Manifestations are related primarily to mineralocorticoid deficiency, causing increased urinary losses of sodium, chloride, and water, along with decreased excretion of potassium. The result is hyponatremia, loss of extracellular fluid, decreased cardiac output, and hyperkalemia. Because of a lack of glucocorticoid, the person with Addison disease has poor tolerance to stress. This deficiency causes hypoglycemia, lethargy, weakness, fever, and gastrointestinal symptoms such as anorexia, nausea, vomiting, and weight loss. Hypopigmentation results from elevated ACTH levels.

21. 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.

22. 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.

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23. 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.

24. 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.

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25. Which of the following clinical manifestations would support the medical diagnosis of Cushing syndrome? Select all that apply.

A) Excessive facial hair growth B) Muscle hypertrophy C) Blood glucose level in 200 mg/dL range D) “Buffalo hump” on back E) Blood pressure reading less than 90/70 Ans: A, C, D 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.”

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1. Chapter 33 A hospital client with a diagnosis of type 1 diabetes has been administered a scheduled dose of regular insulin. Which of the following effects will result from the action of insulin?

A) Promotion of fat breakdown B) Promotion of glucose uptake by target cells C) Promotion of gluconeogenesis D) Initiation of glycogenolysis Ans: B Feedback: The actions of insulin are threefold: (1) it promotes glucose uptake by target cells and provides for glucose storage as glycogen; (2) it prevents fat and glycogen breakdown; and (3) it inhibits gluconeogenesis and increases protein synthesis. Glucagon, not insulin, promotes glycogenolysis.

2. A client with long-standing type 2 diabetes is surprised at his high blood sugar readings while recovering from an emergency surgery. Which of the following factors may have contributed to the client's inordinately elevated blood glucose levels?

A) The tissue trauma of surgery resulted in gluconeogenesis.

B) Illness inhibited the release and uptake of glucagon.

C) The stress of the event caused the release of cortisol.

D) Sleep disruption in the hospital precipitated the dawn effect.

Ans: C Feedback: Elevation of glucocorticoid levels, such as during stressful events, can lead to hyperglycemia. Tissue trauma does not cause gluconeogenesis, and illness does not inhibit the action of glucagon. The dawn phenomenon is not a likely cause of the client's disruption in blood sugar levels.

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3. Which of the following clients would be considered to be exhibiting manifestations of “prediabetes”?

A) A middle-aged overweight adult with a fasting plasma glucose level of 122 with follow-up OGTT of 189 mg/dL. B) A school-aged child who had a blood glucose level of 115 following lunch.

C) A retired female registered nurse with a fasting plasma glucose level of 92 mg/dL. D) An elderly client who got “light-headed” when he skipped his lunch. Blood glucose level was 60 mg/dL at this time.

Ans: A Feedback: Persons with IFG (impaired fasting plasma glucose [IFG] defined by an elevated FPG of 100 to 125 mg/dL) and/or IGT (impaired glucose tolerance [IGT] plasma glucose levels of 140 to 199 mg/dL with an OGTT) are often referred to as having prediabetes, meaning they are at relatively high risk for the future development of diabetes as well as cardiovascular disease.

4. A young child develops type 1A diabetes. The parents ask, “They tell us this is genetic.

Does that mean our other children will get diabetes?” The best response by the health care provider would be: A) “Probably not since genetically your other children have a different cellular makeup, they just might not become diabetic.”

B) “If you put all your children on a low-carbohydrate diet, maybe they won't get diabetes.”

C) “We don't know what causes diabetes, so we will just have to wait and see.”

D) “This autoimmune disorder causes destruction of the beta cells, placing your children at high risk of developing diabetes.”

Ans: D Feedback: Type 1 diabetes is subdivided into two types: type 1A, immune-mediated diabetes, and type 1B, idiopathic diabetes. Type 1A diabetes is characterized by autoimmune destruction of beta cells. The other choices are not absolutely correct. The fact that type 1 diabetes is thought to result from an interaction between genetic and environmental factors led to research into methods directed at prevention and early control of the disease. These methods include the identification of genetically susceptible persons and early intervention in newly diagnosed persons with type 1 diabetes.

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5. While trying to explain the physiology behind type 2 diabetes to a group of nursing students, the instructor will mention which of the following accurate information?

A) The destruction of beta cells and absolute lack of insulin in people with type 2 diabetes means that they are particularly prone to the development of diabetic complication.

B) Because of the loss of insulin response, all people with type 2 diabetes require exogenous insulin replacement to control blood glucose levels.

C) In skeletal muscle, insulin resistance prompts decreased uptake of glucose.

Following meals (postprandial), glucose levels are higher due to diminished efficiency of glucose clearance.

D) They have increased predisposition to other autoimmune disorders such as Graves disease, rheumatoid arthritis, and Addison disease.

Ans: C Feedback: The metabolic abnormalities that lead to type 2 diabetes include (1) peripheral insulin resistance, (2) deranged secretion of insulin by the pancreatic beta cells, and (3) increased glucose production by the liver. In skeletal muscle, insulin resistance prompts decreased uptake of glucose. Although muscle glucose uptake is slightly increased after a meal, the efficiency with which it is taken up is decreased, resulting in an increase in blood glucose levels following a meal. The other distractors relate to type 1 diabetes.

6. The results of a 44-year-old obese man's recent diagnostic workup have culminated in a new diagnosis of type 2 diabetes. Which of the following pathophysiologic processes underlies the client's new diagnosis?

A) Beta cell exhaustion due to long-standing insulin resistance B) Destruction of beta cells that is not attributable to autoimmunity C) T-lymphocyte–mediated hypersensitivity reactions D) Actions of insulin autoantibodies (IAAs) and islet cell autoantibodies (ICAs) Ans: A Feedback: Exhaustion of the beta cells arising from insulin resistance is characteristic of type 2 diabetes. Beta cell destruction in the absence of an autoimmune reaction is associated with type 1b diabetes, while autoimmune processes contribute to type 1a diabetes.

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7. A client with type 2 diabetes has routine lab work, which reveals elevated free fatty acids (FFA). The client asks, “Why is this significant?” The most accurate response would be: Select all that apply.

A) This may increase the amount of triglyceride (a form of fat) stored in your liver or around your heart.

B) Your pancreas is affected by increased fat (lipotoxicity), which causes beta cell dysfunction, leading to the need for insulin.

C) Excess fat in the liver causes a decrease in hepatic glucose production leading to severe hypoglycemia.

D) Nonalcoholic fatty liver disease may lead to needing a liver transplant.

E) Excess fatty acids may interfere with the way your body responds to an infection.

Ans: A, B Feedback: Visceral obesity is accompanied by an increase in postprandial FFA concentrations and subsequent triglyceride storage, including in sites that do not normally store fat such as the liver, skeletal muscle, heart, and pancreatic beta cells. A consequence to this may a direct cause of pancreatic beta cell dysfunction (lipotoxicity). The accumulation of FFAs and triglycerides reduces hepatic insulin sensitivity, leading to increased hepatic glucose production and hyperglycemia. In the liver, the uptake of FFAs from the portal blood can lead to hepatic triglyceride accumulation and nonalcoholic fatty liver disease.

8. Which of the following assessment findings of a male client constitutes a criterion for a diagnosis of metabolic syndrome? The client: A) States that he does less than 30 minutes of strenuous physical activity each week B) Has a resting heart rate between 85 and 95 beats/minute C) Has blood pressure that is consistently in the range of 150/92 mm Hg D) Has a fasting triglyceride level of 100 mg/dL Ans: C Feedback: Diagnostic criteria for metabolic syndrome include blood pressure of greater than 130/85 mm Hg. A triglyceride level below 150 mg/dL is within normal range. Sedentary lifestyle, high resting heart rate, and a family history of type 2 diabetes are associated with other health problems, including diabetes, but these are not diagnostic criteria for metabolic syndrome.

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9. Which of the following pregnant women likely faces the greatest risk of developing gestational diabetes? A client who: A) Was diagnosed with placenta previa early in her pregnancy B) Is gravida five (in her fifth pregnancy) C) Has BP of 130/85 mm Hg and pulse rate of 90 beats/minute D) Is morbidly obese defined as greater than 100 pounds over ideal weight Ans: D Feedback: Obesity is among the risk factors for gestational diabetes mellitus (GDM). Obstetric complications, multiple pregnancies, high triglycerides, and hypertension are not specific risk factors for GDM.

10. A client's primary care provider has ordered an oral glucose tolerance test (OGTT) as a screening measure for diabetes. Which of the following instructions should the client be given?

A) “The lab tech will give you a sugar solution and then measure your blood sugar levels at specified intervals.”

B) “You'll have to refrain from eating after midnight and then go to the lab to have your blood taken first thing in the morning.”

C) “They'll take a blood sample and see how much sugar is attached to your red blood cells.”

D) “You can go to the lab at any time; just tell the technician when you last ate before they draw a blood sample.”

Ans: A Feedback: The OGTT measures the plasma glucose response to 75 g of concentrated glucose solution at selected intervals, usually 1 and 2 hours. A fasting blood glucose test requires 8 hours without food, and A1C measures glucose binding to hemoglobin. A casual blood glucose test is administered without regard for time or last meal.

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11. A diabetic client presents to a clinic for routine visit. Blood work reveals a HbA 1C of 11.0% (high)? Which response by the patient may account for this abnormal lab result?

A) “I've had more periods of hypoglycemia than usual over the past few months.”

B) “I've been doing great. I haven't needed much insulin coverage before meals.”

C) “To tell you the truth, my blood glucose levels have been pretty normal for me.”

D) “My meter broke so I have not been checking my blood glucose levels for a while.”

Ans: D Feedback: Glycosylated hemoglobin is hemoglobin into which glucose has been irreversibly incorporated. Because glucose entry into the red blood cell is not insulin dependent, the rate at which glucose becomes attached to the hemoglobin molecule depends on blood glucose; the level is an index of blood glucose levels over the previous 6 to 12 weeks. If the diabetic client is not monitoring his or her blood glucose, he or she could be having more periods of hyperglycemia and just is not aware of the need for insulin coverage.

12. A client with type 1 diabetes has started a new exercise routine. Knowing there may be some increase risks associated with exercise, the health care provider should encourage the client to: A) Watch for too rapid weight loss B) Monitor for respiratory disorders C) Be careful that you're not experiencing a rebound hyperglycemia D) Carry a snack with carbs to prevent profound hypoglycemia Ans: D Feedback: People with diabetes are usually aware that delayed hypoglycemia can occur after exercise. Although muscle uptake of glucose increases significantly, the ability to maintain blood glucose levels is hampered by failure to suppress the absorption of injected insulin and activate the counterregulatory mechanisms that maintain blood glucose (to cause a hyperglycemia response). Even after exercise ceases, insulin's lowering effect on blood glucose levels continues, resulting in profound symptomatic hypoglycemia. Rapid weight loss accompanies the polyuria and dehydration of hyperglycemia rather than hypoglycemia. Respiratory disorders are associated with preexisting pulmonary or vascular problems exacerbated by the period of exercise.

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13. A newly diagnosed type 2 diabetic client has been prescribed metformin. When explaining the actions of this medication, the nurse should include which statement?

This medication: A) Inhibits hepatic glucose production and increases the sensitivity of peripheral tissues to the actions of insulin B) Blocks the action of intestinal brush border enzymes that break down complex carbohydrates C) Increases insulin sensitivity in the insulin-responsive tissues—liver, skeletal muscle, and fat—allowing the tissues to respond to endogenous insulin more efficiently D) Acts like a hormone released into the circulation by the gastrointestinal tract after a meal, especially one high in carbohydrates, which amplify the glucose-induced release of insulin Ans: A Feedback: Metformin, the only currently available biguanide, inhibits hepatic glucose production and increases the sensitivity of peripheral tissues to the actions of insulin. Secondary benefits of metformin therapy include weight loss and improved lipid profiles. This medication does not stimulate insulin secretion; therefore, it does not produce hypoglycemia. Distractor B relates to -glucosidase inhibitors; distractor C relates to thiazolidinediones; and distractor D relates to incretin-based agents.

14. Which of the following insulin administration regimens is most likely to result in stable blood glucose levels for a client with a diagnosis of type 1 diabetes?

A) One large dose of long-acting insulin each day before breakfast B) Intermediate-acting insulin at 8:00 AM and 8:00 PM with rapid-acting insulin before each meal C) Six to eight small doses of rapid-acting insulin each day, with capillary monitoring before each D) Long-acting insulin twice daily (breakfast and bedtime), with intermediate-acting insulin in the afternoon Ans: B Feedback: With multiple daily injections (MDIs), the basal insulin requirements are met by an intermediate- or long-acting insulin administered once or twice daily. Boluses of rapidor short-acting insulin are used before meals. Serial injections of short- or rapid-acting insulin are not typically used.

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15. A client with a history of diabetes presents to the emergency department following several days of polyuria and polydipsia with nausea/vomiting. On admission, the client labs show a blood glucose level of 480 mg/dL and bicarbonate level of 7.8 mEq/dL. The nurse suspects the client has diabetic ketoacidosis (DKA). The priority intervention should include: A) Limit fluid intake to only 250 mL/4 hours.

B) Begin a loading dose of IV regular insulin followed by a continuous insulin infusion.

C) Give at least 50 units of regular insulin IV stat and recheck blood glucose in 2 hours.

D) Push a stat dose of bicarbonate followed by a double-dose (loading) of metformin.

Ans: B Feedback: The goals in treating DKA are to improve circulatory volume and tissue perfusion, decrease blood glucose, and correct the acidosis and electrolyte imbalances. These objectives usually are accomplished through the administration of insulin and intravenous fluid and electrolyte replacement solutions. An initial loading dose of short-acting (i.e., regular) or rapid-acting insulin often is given intravenously, followed by continuous low-dose short-acting insulin infusion. Frequent laboratory tests are used to monitor blood glucose. The fluids need to be replaced, not withheld. Too rapid a drop in blood glucose may cause hypoglycemia that can occur with a large dose of regular insulin. The client may require bicarbonate, but glucose levels are lowered with insulin in this emergency situation, not by oral medication.

16. A client is admitted in the ICU with diagnosis of hyperglycemic hyperosmolar state (HHS). The nurse caring for the client knows that the client's elevated serum osmolality has pulled water out of this brain cells based on which of the following assessment findings? Select all that apply.

A) Weakness one side of the body B) After the sole of the foot has been firmly stroked, the toes flex and flare out C) Increase in urine output in proportion to the increase in blood glucose D) Unable to respond verbally to questions E) Uncontrollable twitching of a muscle group Ans: A, B, D, E Feedback: HHS is characterized by hyperglycemia (blood glucose >600 mg/dL); hyperosmolarity (plasma osmolarity >310 mOsm/L); and dehydration, the absence of ketoacidosis, and depression of the sensorium. The most prominent manifestations are weakness, dehydration, polyuria, neurologic signs and symptoms, and excessive thirst. The neurologic signs include hemiparesis (weakness on one side of the body), Babinski reflex (the sole of the foot has been firmly stroked, the toes flex and flare out), aphasia (unable to respond verbally to questions), muscle fasciculations (uncontrollable twitching of a muscle group), hyperthermia, hemianopia, nystagmus, visual hallucinations, seizures, and coma.

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17. While working on the med-surg floor, the nurse has a client who is experiencing an insulin reaction. The client is conscious and can follow directions. The most appropriate intervention would be: A) Call the physician and wait for him or her to respond to give you orders of what he or she prefers you do for this client.

B) Immediately administer 15 g of glucose (preferably via oral route if the client is alert enough to swallow) and wait for 15 minutes. Then repeat this if necessary.

C) Start pushing 50% glucose solution slowly and do not stop pushing until the client's repeat blood glucose level is above 100 mg/dL. D) Skip the oral glucose tablets and go directly to giving intramuscular glucagon.

Repeat the glucagon in 15 minutes if the blood glucose level is not within a normal range.

Ans: B Feedback: The most effective treatment of an insulin reaction is the immediate administration of 15 g of glucose in a concentrated carbohydrate source. According to the so-called rule of 15, this 15 g of glucose can be repeated every 15 minutes for up to three doses.

Alternative methods for increasing blood glucose may be required when the person having the reaction is unconscious or unable to swallow. Glucagon may be given intramuscularly or subcutaneously. Glucagon acts by hepatic glycogenolysis to raise blood glucose. In situations of severe or life-threatening hypoglycemia, administer glucose (20 to 50 mL of a 50% solution) intravenously.

18. A hospital client has been complaining of increasing fatigue for several hours, and his nurse has entered his room to find him unarousable. The nurse immediately checked the client's blood glucose level (and reverified with a second blood glucose meter), which is 22 mg/dL (1.2 mmol/L). The nurse should prepare to administer which of the following?

A) A snack that combines simple sugars, protein, and complex carbohydrates B) A 50% glucose solution intravenously C) Infusion of rapid-acting insulin D) An oral solution containing glucagon and simple sugars Ans: B Feedback: The client's presentation and low blood sugars indicate the need for aggressive treatment such as glucose (20 to 50 mL of a 50% solution) intravenously. The unconscious client cannot take anything by mouth, and glucagon can never be administered orally. Insulin would be potentially fatal.

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19. A client tells his health care provider that his body is changing. It used to be normal for his blood glucose to be higher during the latter part of the morning. However, now his fasting blood glucose level is elevated in the early AM (07:00). The health care provider recognizes the client may be experiencing: A) Possible stress-related hypoglycemia B) Somogyi effect C) Hyperglycemic hyperosmolar state (HHS) D) Dawn phenomenon Ans: D Feedback: A change in the normal circadian rhythm for glucose tolerance, which usually is higher during the later part of the morning, is altered in people with diabetes, with abnormal nighttime growth hormone secretion as a possible factor. The dawn phenomenon is characterized by increased levels of fasting blood glucose or insulin requirements, or both, between 5 AM and 9 AM without preceding hypoglycemia. The Somogyi effect describes a cycle of insulin-induced posthypoglycemic episodes. The cycle begins when the increase in blood glucose and insulin resistance is treated with larger insulin doses.

The insulin-induced hypoglycemia produces a compensatory increase in blood levels of catecholamines, glucagon, cortisol, and growth hormone, leading to increased blood glucose with some insulin resistance.

20. A diabetic client presents to the clinic. He is concerned his lower legs are “feeling funny.” Which of the following assessment findings lead the health care provider to suspect the client may have developed somatic neuropathy? Select all that apply.

A) Both legs appear to be the same as far as numbness is involved.

B) Bilateral cool ankles and feet.

C) Right foot has a diminished perception of vibration; left foot is normal.

D) With eyes closed, the client cannot identify where the HCP is touching his feet.

E) One leg has a reddened area in the calf and has a positive Homan sign.

Ans: A, B, D Feedback: A distal symmetric polyneuropathy, in which loss of function typically occurs in a stocking–glove pattern, is the most common form of peripheral neuropathy. Somatic sensory involvement usually occurs first, often is bilateral and symmetric, and is associated with diminished perception of vibration, pain, and temperature, particularly in the lower extremities. The loss of feeling, touch, and position sense increases the risk of falling. A reddened area on calf with +Homan sign is diagnostic for a blood clot.

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21. A diabetic client was visiting the endocrinologist for annual checkup. The client's blood work reveals an increased level of which lab result that reveals early signs of diabetic nephropathy?

A) Microalbuminuria B) Oliguria C) Hypokalemia D) Hyperlipidemia Ans: A Feedback: One of the first manifestations of diabetic nephropathy is increased urinary albumin excretion (i.e., microalbuminuria). Risk factors, rather than renal manifestations, include glycosylated hemoglobin levels greater than 8.1%, genetic and familial predisposition, hypertension, poor glycemic control, smoking, and hyperlipidemia. Usually, serum potassium levels are elevated (hyperkalemia) in diabetic nephropathy. The presence of ketones in the urine is a sign of ketoacidosis and severe hyperglycemia rather than nephropathy.

22. A diabetic client's most recent blood work indicated a decreased glomerular filtration rate and urine testing revealed + microalbuminuria. Which priority self-care measures should the client's care team prescribe for this client?

A) Use of over-the-counter herbal products for natural diuretic properties B) Increased fluid intake to at least 2000 mL/day C) Decreased oral sugar intake to less than 5 tsp/day D) Diet, exercise, and prescriptions to lower blood pressure below 140/80 mm Hg Ans: D Feedback: Both systolic hypertension and diastolic hypertension accelerate the progression of diabetic nephropathy. Even moderate lowering of blood pressure can decrease the risk of chronic kidney disease. Diuretics may exacerbate diabetes, and neither increased fluid intake nor decreased sugar intake will necessarily mitigate the potential for further kidney damage.

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23. Diabetic retinopathy, the leading cause of acquired blindness in the United States, is characterized by retinal: A) Glaucoma B) Hemorrhages C) Dehydration D) Infections Ans: B Feedback: Although people with diabetes are at increased risk for the development of cataracts and anterior chamber glaucoma, retinopathy is the most common pattern of eye disease.

Diabetic retinopathy is characterized by abnormal retinal vascular permeability, microaneurysm formation, neovascularization and associated hemorrhage, scarring, and retinal detachment. In conjunction with the retinopathy, the inflammatory response causes macular edema rather than loss of vitreous fluid (dehydration). Intraocular infection is an uncommon, yet potential, complication of retinal surgery.

24. Which of the following comorbidities represent the greatest risk for the development of foot ulcers in a diabetic client? Select all that apply.

A) Bilateral distal loss of pain sensation B) Previous incidents of diabetic ketoacidosis with blood glucose levels of 400 mg/dL C) Diabetic renal problems with severely decreased GFR D) Motor neuropathy related to improperly fitted shoes E) Smoking history averaging 2 packs/day Ans: A, D, E Feedback: Distal symmetric neuropathy is a major risk factor for foot ulcers due to the fact that people with sensory neuropathies have impaired pain sensation. Motor neuropathy with weakness of the intrinsic muscles of the foot may result in foot deformities, which lead to focal areas of high pressure. When the abnormal focus of pressure is coupled with loss of sensation, a foot ulcer can occur. Smoking should be avoided because it causes vasoconstriction and contributes to vascular disease. This risk factor supersedes that posed by nephropathy or DKA, although each problem suggests that the client's diabetes is inadequately controlled.

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25. Impaired and delayed healing in a person with diabetes is caused by long-term complications that include: A) Ketoacidosis B) Somogyi effect C) Fluid imbalances D) Chronic neuropathies Ans: D Feedback: Suboptimal response to infection in a person with diabetes is caused by the presence of chronic complications, such as vascular disease and neuropathies, poorly controlled hyperglycemia, and altered immune cell and neutrophil function. Sensory deficits may cause a person with diabetes to ignore minor trauma and infection, and vascular disease may impair circulation and delivery of blood cells and other substances needed to produce an adequate inflammatory response and effect healing. Somogyi effect is an acute complication of diabetes, causing hypoglycemia. Ketoacidosis is an acute complication of hyperglycemia when liver ketone production exceeds cell use.

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1. Chapter 34 Which of the following physiologic principles would be considered a function of the somatic nervous system?

A) The act of typing a report using a computer keyboard B) Withdrawing the hand after touching a hot surface C) The patellar reflex "knee jerk" activated by tapping the patellar tendon abdominal viscera D) The beginning of depolarization in the cardiac conduction of impulses Ans: A Feedback: The somatic nervous system provides sensory and motor innervation for all parts of the central nervous system (CNS) and peripheral nervous system (PNS) except viscera, smooth muscle, and glands. The autonomic nervous system (ANS) provides efferent motor innervation to smooth muscle, the conducting system of the heart, and glands.

2. Following a car accident that has resulted in partial amputation of the lower limbs, the client's body has implemented a compensatory mechanism releasing antidiuretic hormone (ADH) into the blood stream, causing retention of water and vasoconstriction of blood vessels. This is accomplished as a result of: A) Rapid axonal transport of ADH from the hypothalamus into the posterior pituitary B) Extension of Nissl bodies and free ribosomes carrying ADH into the dendrites C) Dendrites conducting information and ADH toward the cell body D) Afferent, or sensory, neurons of the PNS transmitting information to the CNS Ans: A Feedback: Antidiuretic hormone (ADH) and oxytocin, which are synthesized by neurons in the hypothalamus, are carried by rapid axonal transport to the posterior pituitary, where the hormones are released into the bloodstream. ADH increases peripheral vascular resistance (vasoconstriction) and thus increases arterial blood pressure. This becomes an important compensatory mechanism for restoring blood pressure in hypovolemic shock such as that which occurs during hemorrhage. The proteins and other materials used by the axon are synthesized in the cell body and then flow down the axon through its cytoplasm. The Nissl bodies and free ribosomes extend into the dendrites, but not into the axon. The dendrites (i.e., “treelike”) are multiple, branched extensions of the nerve cell body; they conduct information toward the cell body and are the main source of information for the neuron. The dendrites and cell body are studded with synaptic terminals that communicate with axons and dendrites of other neurons.

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3. A 60-year-old woman has been recently diagnosed with multiple sclerosis, a disease in which the oligodendrocytes of the client's central nervous system (CNS) are progressively destroyed. Which physiologic process within the neurologic system is most likely to be affected by this disease process?

A) Oxygen metabolism B) Neurotransmitter synthesis C) Nerve conduction D) Production of cerebrospinal fluid Ans: C Feedback: The oligodendrocytes form the myelin in the central nervous system (CNS). As with peripheral myelinated fibers, the covering of axons in the CNS increases the velocity of nerve conduction. Oxygen metabolism and synthesis of CSF and neurotransmitters are not directly affected.

4. Following a stroke, injury to nerve cells within the central nervous system needs to be repaired. The health care provider knows that which of the following processes explains how this occurs?

A) Astrocytes fill up the space to form a glial scar, repairing the area and replacing the CNS cells that cannot regenerate.

B) The microglia are responsible for cleaning up debris after cerebral infection, or cell death.

C) Ependymal cells are responsible for phagocytosis.

D) Oligodendrocytes are responsible for integrative metabolism.

Ans: A Feedback: Astrocytes are the largest and most numerous of neuroglia and are particularly prominent in the gray matter of the CNS. They form a network within the CNS and communicate with neurons to support and modulate their activities. Astrocytes are also the principal cells responsible for repair and scar formation in the brain. The microglia is a small phagocytic cell that is available for cleaning up debris after cellular infection or cell death. The ependymal cell forms the lining of the neural tube cavity, the ventricular system. The oligodendrocytes form the myelin in the CNS. Instead of forming a myelin covering for a single axon, these cells reach out with several processes, each wrapping around and forming a multilayered myelin segment around several different axons.

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5. A client has been brought to the emergency department following an overdose of insulin that resulted in unconsciousness. When explaining the rationale for this to the family, the nurse will emphasize that neurons: A) Store glycogen within the brain cavity B) Must rely on glucose from the blood to meet their energy needs C) Require many amino acids in order to produce enough energy to function properly D) Can cause the liver to convert triglycerides into energy if needed quickly Ans: B Feedback: Nervous tissue has a high rate of metabolism. Glucose is the major fuel source for the nervous system. Unlike muscle cells, neurons have no glycogen stores and must rely on glucose from the blood or the glycogen stores of supporting glial cells to meet their energy needs. Persons receiving insulin for diabetes may experience signs of neural dysfunction and unconsciousness when blood glucose drops because of insulin excess.

Neither amino acid production nor liver conversion of triglycerides will produce the quick energy that the brain requires to function properly.

6. What happens during the depolarization phase of nerve cells?

A) It is an undisturbed period of the action potential during which the nerve is not transmitting impulses.

B) The cell membrane decreases its permeability to sodium.

C) The neurons are stimulated to fire.

D) A rapid change in polarity to one that is positive on the inside and the membrane becomes open to sodium.

Ans: D Feedback: Depolarization is characterized by a rapid change in polarity of the resting membrane potential, which was negative on the inside and positive on the outside, to one that is positive on the inside and negative on the outside. During the depolarization phase, the membrane suddenly becomes permeable to sodium ions. The rapid inflow of sodium ions produces local electric currents that travel through the adjacent cell membrane, causing the sodium channels in this part of the membrane to open. The resting membrane potential is the undisturbed period of the action potential during which the nerve is not transmitting impulses. A threshold potential represents the membrane potential at which neurons or other excitable tissues are stimulated to fire.

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7. A neuron has been hyperpolarized. How will this affect the excitability of the neuron?

A) The neuron will have a membrane potential farther from the threshold.

B) The neuron will be more difficult to repolarize after firing.

C) The membrane potential of the neuron will be closer to the threshold.

D) The neuron's excitability will be significantly increased.

Ans: A Feedback: Hyperpolarization brings the membrane potential farther from the threshold and has an inhibitory effect, decreasing the likelihood that an action potential will be generated.

Hypopolarization increases the excitability of the postsynaptic neuron by bringing the membrane potential closer to the threshold potential so that a smaller subsequent stimulus is needed to cause the neuron to fire. Neither situation has a direct bearing on the process of repolarization after the neuron fires.

8. Since catecholamines can be degraded by enzymes, the medication category usually prescribed to treat a Parkinson disease client, thereby controlling this interaction, is: A) Dopamine B) -Adrenergic blocker C) Epinephrine D) Monoamine oxidase (MAO) inhibitor Ans: D Feedback: Catecholamines also can be degraded by enzymes, such as catechol-O-methyltransferase (COMT) in the synaptic space or monoamine oxidase (MAO) in the nerve terminals.

COMT inhibitors and MAO inhibitors are used in the treatments of various conditions, such as Parkinson disease, major depression, and anxiety. The other medications listed do not perform this function.

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9. Drugs like diazepam (Valium), a benzodiazepine, exert their action on ion channels.

These drugs do not open the GABA-operated ion channel, but they: A) Modulate the release from axon terminals B) Modulate the peripheral sympathetic nerves and can have both a transmitter and modulator function C) Change the effect that GABA has when it binds to the channel at the same time as the drug D) Play a necessary role in the long-term survival of presynaptic neurons Ans: C Feedback: Amino acids, such as glutamine, glycine, and GABA, serve as neurotransmitters at most CNS synapses. GABA mediates most synaptic inhibition in the CNS. Drugs such as the benzodiazepines (e.g., the tranquilizer diazepam) and the barbiturates exert their action by binding to their own distinct receptor on a GABA-operated ion channel. The drugs by themselves do not open the channel, but they change the effect that GABA has when it binds to the channel at the same time as the drug. Another class of messenger molecules, known as neuromodulators, also may be released from axon terminals. In contrast to neurotransmitters, neuromodulators do not directly activate ion channel receptors but bring about long-term changes that subtly enhance or depress the action of the receptors. Neuromodulators, such as dopamine, serotonin, acetylcholine, histamine, and others, may act at either presynaptic or postsynaptic sites.

10. Neurotrophic factors contribute to the maintenance of homeostasis by promoting the growth and survival of neurons. Which of the following clients may be experiencing an alteration in neurotrophin levels? Select all that apply.

A) A 92-year-old who fell and fractured the hip getting out of a shower B) A 55-year-old who is exhibiting clinical manifestations of early-onset Alzheimer disease C) A 38-year-old recently diagnosed with multiple sclerosis following initial complaint of vision loss as he was driving to work D) A 44-year-old with a family history of Huntington disease who is exhibiting jerky, uncontrollable movements Ans: B, D Feedback: Neurotrophic or nerve growth factors are required to maintain the long-term survival of the postsynaptic cell and are secreted by axon terminals independent of action potentials. Alterations in neurotrophin levels have been implicated in neurodegenerative disorders such as Alzheimer disease and Huntington disease, as well as psychiatric disorders such as depression and substance abuse.

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11. The pathophysiologic effects of spina bifida are due to: A) Malformation of the brain and spinal column causing spinal fluid to pool at the base of the spine B) Failure of one or more neural arches to close within the vertebral column of the neural tube C) Cystic lesions growing into the dorsal root ganglia D) Hypertrophy of the primary vesicles, which eventually causes the excess fluid to bulge in weakened structures Ans: B Feedback: The major morphogenic defects of the spinal cord and brain are due to the abnormal formation or closure of the neural tube and surrounding tissues, problems that often result in spina bifida. The health problem is not due to the malformation of the mesoderm, lesions in the dorsal root ganglia, or hypertrophy of the primary vesicles.

12. Which of the following messages is most likely to be carried by general somatic afferent (GSA) neurons?

A) The sensation of cold when touching ice B) The message to move a finger and thumb C) The message to move the larynx during speech D) Information about the position of a joint Ans: A Feedback: General somatic afferent (GSA) neurons innervate the skin and other somatic structures, responding to stimuli such as those that produce pressure or pain. Initiation of motion is the control of efferent neurons, whereas information about the position of a joint is undercarried by the special somatic afferent (SSA) fibers.

13. Which of the following processes is most likely to occur as a result of a spinal reflex?

A) Peristalsis of the small and large bowel B) Control of oculomotor function in changing light levels C) Pain sensation from a potentially damaging knee movement D) Withdrawal of a hand from a hot stove element Ans: D Feedback: A reflex is a highly predictable relationship between a stimulus and an elicited motor response. The withdrawal reflex is stimulated by a painful (nociceptive) stimulus and quickly moves the body part away from the offending stimulus, usually by flexing a limb part. Peristalsis, oculomotor function, and pain are not mediated by spinal reflexes.

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14. Which area of the brain is responsible for respiration?

A) Brain stem B) Midbrain C) Diencephalon D) Frontal lobe Ans: A Feedback: The respiratory center is located in the brain stem.

15. Which cranial nerves that have their origin in the pons assist with the manipulation of the jaw during chewing and speech? Select all that apply.

A) Cranial nerve I B) Cranial nerve III C) Cranial nerve VI D) Cranial nerve VII E) Cranial nerve VIII Ans: C, D, E Feedback: In the pons, the reticular formation is large and contains the circuitry for manipulating the jaw during chewing and speech. Cranial nerves VIII, VII, and VI have their origin in the pons. Axons of the olfactory nerve, or cranial nerve I, terminate in the most primitive portion of the cerebrum—the olfactory bulb, where initial processing of olfactory information occurs. The outflow from the midbrain passes through the oculomotor nerve (cranial nerve III) to supply the pupillary sphincter muscle of each eye and the ciliary muscles that control lens thickness for accommodation.

16. A client with a diagnosis of epilepsy has required surgical removal of part of her prefrontal cortex. Which of the following effects should her family and care team anticipate?

A) Lapses in balance and coordination B) Deficits in regulation of the endocrine system C) Sensory losses D) Changes in behavior and judgment Ans: D Feedback: The prefrontal cortex is thought to be involved in anticipation and prediction of consequences of behavior. It does not contribute directly to balance, sensation, or endocrine function.

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17. The perception of “where” a stimulus is in space and in relation to body parts is a function of the: A) Occipital lobe B) Parietal lobe C) Hypothalamus D) Prefrontal cortex Ans: B Feedback: In the parietal lobe, just behind the primary sensory cortex is the somatosensory association cortex (areas 5 and 7), which is connected with the thalamic nuclei, and with the primary sensory cortex is the region necessary for perceiving the meaningfulness of integrated sensory information from various sensory systems, especially the perception of “where” the stimulus is in space and in relation to body parts. Maintenance of blood gas concentration, water balance, food consumption, and major aspects of endocrine and autonomic nervous system control requires hypothalamic function. The prefrontal cortex is involved in anticipation and prediction of consequences of behavior. Integrity of the association cortex of the occipital lobe is required for gnostic visual function, by which the meaningfulness of visual experience occurs.

18. When providing discharge teaching related to some newly prescribed medications, the client who received a head injury on the left temporal lobe area will need for the health care provider to: A) Print materials using extra large font sizes, so the client will be able to see the instructions B) Bring one of the pills into the room during teaching, so the client can recognize the color and shape C) Sit on the right side and speak slowly and clearly during the education D) Draw the shades on the window to minimize glare from bright lights Ans: C Feedback: The temporal lobe lies below the lateral sulcus and merges with the parietal and occipital lobes. The primary auditory cortex is important in discrimination of sounds entering opposite ears. The auditory association area (area 22) functions in the recognition of certain sound patterns and their meaning. Therefore, the injury is on the left side, so the health care provider should sit on the right side so they can speak directly into the right ear. The occipital lobe contains the primary visual cortex (area 17), stimulation of which causes the experience of bright lights called phosphenes in the visual field.

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19. The region of the brain involved in emotional experience and control of emotional behavior is the: A) Limbic system B) Occipital lobe C) Parietal lobe D) Cerebral hemisphere Ans: A Feedback: The limbic region of the brain is involved in emotional experience and in the control of emotion-related behavior. Stimulation of specific areas in this system can lead to feelings of dread, high anxiety, or exquisite pleasure. It also can result in violent behaviors, including attack, defense, or explosive and emotional speech. The occipital lobe plays an important role in the meaningfulness of visual experience, including experiences of color, motion, depth perception, pattern, form, and location in space. The parietal lobe is necessary for perceiving the meaningfulness of integrated sensory information from various sensory systems, especially the perception of “where” the stimulus is in space and in relation to body parts. Axons of the olfactory nerve, or cranial nerve I, terminate in the most primitive portion of the cerebrum—the olfactory bulb, where initial processing of olfactory information occurs.

20. College students were given various amounts of alcohol within a specified timeframe and then asked to drive an obstacle course. The rationale for poor performance in driving as the amount of alcohol intake increased includes, “The blood–brain barrier: A) Allows more bilirubin to cross the barrier producing brain damage.”

B) Allows alcohol, a very lipid-soluble molecule to rapidly enter the brain.”

C) Excludes water-based compounds from crossing the brain with the exception of alcohol.”

D) Interacts negatively with the potassium–sodium pump, allowing alcohol to freely flow into the capillaries of the brain.”

Ans: B Feedback: The blood–brain barrier prevents many drugs from entering the brain. Most highly water-soluble compounds are excluded from the brain, especially molecules with high ionic charge, such as many of the catecholamines. In contrast, many lipid-soluble molecules cross the lipid layers of the blood–brain barrier with ease. Alcohol, nicotine, and heroin are very lipid soluble and rapidly enter the brain.

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21. In contrast to the sympathetic nervous system, the functions of the parasympathetic nervous system include: A) Sweating B) Anabolism C) Pupil dilation D) Vasoconstriction Ans: B Feedback: In contrast to the sympathetic nervous system, the functions of the parasympathetic nervous system are concerned with conservation of energy, resource replenishment and storage (i.e., anabolism), and maintenance of organ function during periods of minimal activity. The parasympathetic nervous system contracts the pupil, protecting the retina from excessive light during periods when visual function is not vital to survival.

Sweating and regulation of arteriolar blood vessel diameter are controlled by a single division of the autonomic nervous system (ANS), in this case the sympathetic nervous system.

22. While walking down the street, a cat jumps out of an alley into the pathway of an adult.

They note that his heart is “racing.” This response is primarily due to: A) Reflex circuitry produced by the ANS reflexes B) Parasympathetic effects on the vagus nerve C) Secretions of sympathetic neurotransmitters produced in the adrenal medulla D) The cell body of the first motor neuron that lies in the brain stem Ans: A Feedback: The organization of many life-support reflexes occurs in the reticular formation of the medulla and pons. These areas of reflex circuitry, often called centers, produce complex combinations of autonomic and somatic efferent functions required for the cough, sneeze, swallow, and vomit reflexes, as well as for the more purely autonomic control of the cardiovascular system. One of the striking features of ANS function is the rapidity and intensity with which it can change visceral function. Within 3 to 5 seconds, it can increase heart rate to approximately twice its resting level. The vagus nerve provides parasympathetic innervation for the heart, trachea, lungs, esophagus, etc. The adrenal medulla, which is part of the sympathetic nervous system, contains postganglionic sympathetic neurons that secrete sympathetic neurotransmitters directly into the bloodstream. The cell body of the first motor neuron, called the preganglionic neuron, lies in the brain stem or the spinal cord.

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23. While explaining the role of skeletal muscle relaxants, such as succinylcholine, used during anesthesia, the faculty mentions that these effects are caused by blocking: A) Nicotinic acetylcholine receptors, muscle-type receptor (NM) B) Norepinephrine C) Muscarinic acetylcholine receptors D) N2, neuronal-type receptor, a type of nicotinic acetylcholine receptor Ans: A Feedback: Some skeletal muscle relaxants, such as succinylcholine, can be used to induce muscle relaxation and short-term paralysis in anesthesia by blocking NM receptors at the neuromuscular junction. The drug atropine is a competitive antagonist for the muscarinic acetylcholine receptor that prevents the action of acetylcholine at excitatory and inhibitory muscarinic receptor sites. Norepinephrine is released at most sympathetic nerve endings.

24. Which of the following catecholamines may have a vasodilator effect on the renal blood vessels and be prescribed for clients in shock who are experiencing renal insufficiency manifestations?

A) Enkephalin B) Norepinephrine C) Dopamine D) Acetylcholine Ans: C Feedback: The catecholamines, which include norepinephrine, epinephrine, and dopamine, are synthesized in the sympathetic nervous system and are the neurotransmitters for most postganglionic sympathetic neurons. Dopamine, which is an intermediate compound in the synthesis of norepinephrine, also acts as a neurotransmitter. It is the principal inhibitory transmitter of interconnecting neurons in the sympathetic ganglia. It also has vasodilator effects on renal, splanchnic, and coronary blood vessels when given intravenously and is sometimes used in the treatment of shock. Endorphins and enkephalins are involved in pain sensation and perception. Acetylcholine is the transmitter for all preganglionic neurons, for postganglionic parasympathetic neurons, and for selected postganglionic sympathetic neurons.

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25. A client's primary care provider has prescribed a -adrenergic receptor blocker. Which of the following therapeutic effects do the client and care provider likely seek?

A) Reduction in heart rate and blood pressure B) Slowing of gastrointestinal motility C) Increase in mental acuity D) Decreased production of gastric acid Ans: A Feedback: 1-Adrenergic receptors are located primarily in the heart, the blood vessels of skeletal muscle, and the bronchioles. As such, drugs that block these receptors can bring about a reduction in heart rate, stroke volume, and blood pressure.

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1. Chapter 35 The somatosensory system consists of three types of sensory neurons. The special somatic type of afferent sensory neurons has receptors that sense: A) Muscle position B) Visceral fullness C) Temperature D) Painful touch Ans: A Feedback: The somatosensory system is designed to provide the central nervous system (CNS) with information about the body. Sensory neurons can be divided into three types that vary in distribution and the type of sensation detected: general somatic, special somatic, and general visceral afferent neurons. General somatic afferent neurons have branches with widespread distribution throughout the body and with many distinct types of receptors that result in sensations such as pain, touch, and temperature. Special somatic afferent neurons have receptors located primarily in muscles, tendons, and joints. These receptors sense position and movement of the body. General visceral afferent neurons have receptors on various visceral structures and sense fullness and discomfort.

2. A woman has cut her finger while dicing onions in the kitchen, causing her to drop her knife in pain. Which of the following components of this pain signal was transmitted by a third-order neuron? The neurons: A) Between the woman's finger and her spinal cord B) Between the thalamus and the cortex C) Between the CNS and the thalamus D) Of the efferent pathway that causes muscle contraction Ans: B Feedback: First-order neurons transmit sensory information from the periphery to the CNS. Second-order neurons communicate with various reflex networks and sensory pathways in the spinal cord and travel directly to the thalamus. Third-order neurons relay information from the thalamus to the cerebral cortex. This typology does not apply to motor neurons.

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3. While playing outside in the snow, a young child complained of painful fingertips since he would not keep his gloves on. In the emergency department, the nurse knows this painful sensation is a result of which transmission of proprioceptive somatosensory information?

A) Reflexive networks B) Type C dorsal root ganglion neurons C) Anterolateral pathway D) Myelinated type B trigeminal sensory neurons Ans: B Feedback: All somatosensory information from the limbs and trunk shares a common class of sensory neurons called dorsal root ganglion neurons. The unmyelinated type C fibers have the smallest diameter and the slowest rate of conduction. They convey warm–hot sensation and mechanical and chemical as well as heat- and cold-induced pain sensation. Somatosensory information from the face and cranial structures, however, is transmitted by trigeminal sensory neurons, which function in the same manner as the dorsal root ganglion neurons. The second-order neurons communicate with various reflex networks and sensory pathways in the spinal cord and contain the ascending pathways that travel to the thalamus. In contrast to the dorsal column–medial lemniscal pathway, the anterolateral pathway transmits sensory signals such as pain, thermal sensations, crude touch, and pressure that do not require highly discrete localization of the signal source or fine discrimination of intensity.

4. A client who has had a spinal injury now has sensory changes on the distal forearm and fourth and fifth fingers. The nurse can predict that this client has experienced an injury to the: Select all that apply.

A) Cervical (C) 7 B) Cervical (C) 8 C) Thoracic (T) 1 dorsal root D) Thoracic (T) 2 dorsal root Ans: B, C Feedback: Dermatome maps are helpful in interpreting the level and extent of sensory deficits that are the result of segmental nerve and spinal cord damage. For example, on the basis of the dermatomal map, we can predict that sensory changes limited to the distal forearm and fourth and fifth fingers are the result of injury to the cervical (C) 8 and thoracic (T) 1 dorsal roots.

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5. While explaining the somatosensory cortex to a group of nursing students, the instructor asks, “What is involved in the final processing of somatosensory information?” The correct response includes: Select all that apply.

A) Full localization B) Autonomic nervous system C) Discrimination of intensity D) Interpretation of somatosensory stimuli E) Pacinian corpuscle receptors Ans: A, C, D Feedback: The full localization, discrimination of the intensity, and interpretation of the meaning of the stimuli require processing by the somatosensory cortex. The anterolateral pathway gives off numerous branches that travel to the reticular formation of the brain stem; the branches provide the basis for increased wakefulness or awareness after strong somatosensory stimulation and for the generalized startle reaction that occurs with sudden and intense stimuli. They also stimulate the autonomic nervous system. Ruffini end organs are found in the skin and deeper structures and detect tissue vibration, heavy and continuous touch, and pressure. Stretch-sensitive receptors in the skin (i.e., Ruffini endings, Pacinian corpuscles, and Merkel cells) also signal postural information.

6. Stretch-sensitive receptors in the skin (Ruffini end organs, Pacinian corpuscles, and Merkel cells) help signal postural information and are processed through the: A) Third-order neurons B) Dorsal column–medial lemniscus pathway C) Anterolateral pathway D) Posterior column of the spinal cord Ans: B Feedback: There are two submodalities of proprioception: the stationary or static component (limb position sense) and the dynamic aspects of position sense (kinesthesia). Both of these depend on constant transmission of information to the CNS regarding the degree of angulation of all joints and the rate of change in angulation. In addition, stretch-sensitive receptors in the skin (Ruffini end organs, pacinian corpuscles, and Merkel cells) also signal postural information. Signals from these receptors are processed through the dorsal column–medial lemniscus pathway. In addition, stretch-sensitive receptors in the skin (Ruffini end organs, pacinian corpuscles, and Merkel cells) also signal postural information. Third-order neurons forward information from the thalamus to the somatosensory cortex. The anterolateral pathway crosses within the first few segments of entering the spinal cord and consists of bilateral, multisynaptic, slow-conducting tracts that transmit information such as pain, thermal sensations, crude touch, and pressure. Lesions affecting the posterior column of the spinal cord impair position sense.

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7. What pain theory proposes that pain receptors share pathways with other sensory modalities and that different activity patterns of the same neurons can be used to signal painful or nonpainful stimuli?

A) Pattern B) Specificity C) Gate control D) Neuromatrix Ans: A Feedback: A group of pain theories known as the pattern theory proposes that receptors share pathways with other sensory modalities, and different activity patterns of the same neurons can be used to signal painful or nonpainful stimuli. The specificity theory regards pain as a separate sensory modality evoked by the activity of specific receptors that transmit information to forebrain pain centers, where pain is experienced. Gate control theory postulated the presence of neural gating mechanisms at the segmental spinal cord level to account for interactions between pain and other sensory modalities.

The neuromatrix theory proposes that the brain contains a widely distributed neural network.

8. Nociceptors are sensory receptors that are activated by: A) Cortisol B) Noxious stimuli C) Pressure and touch D) Sudden movements Ans: B Feedback: Nociceptors, or pain receptors, are sensory receptors that are activated by noxious insults to peripheral tissues and respond to several forms of painful stimulation, including mechanical, thermal, and chemical. Nociceptive stimuli are objectively defined as stimuli of such intensity that they cause or are close to causing tissue damage.

Hormones do not activate nociceptors. Pressure, touch, and startle are not considered painful stimuli unless sufficiently extreme to elicit the reflexive withdrawal response.

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9. When a person is stung on the index finger by a bee, the thalamus interprets the pain as: A) Somewhere on the hand B) A spot on the index finger C) Attributable to a bee stung D) Similar to a previous bee sting Ans: A Feedback: The basic sensation of hurtfulness, or pain, occurs at the level of the thalamus. In the neospinothalamic system, interconnections between the lateral thalamus and the somatosensory cortex are necessary to add precision and discrimination to the pain sensation. In addition, association areas of the parietal cortex are essential to the learned meaningfulness of the pain experience. For example, if a person is stung on the index finger by a bee and only the thalamus is functional, the person reports pain somewhere on the hand. With the primary sensory cortex functional, the person can localize the pain to the precise area on the index finger. With the association cortex functional, the person can interpret the buzzing and sight of the bee that preceded the pain as being related to the bee sting.

10. Opioid receptors are highly concentrated in which region of the CNS and produce pain relief through the release of endogenous opioids?

A) The enkephalins B) Primary afferent neurons C) Thalamus D) Periaqueductal gray (PAG) region Ans: D Feedback: A major advance in understanding pain was the discovery of neuroanatomic pathways that arise in the midbrain and brain stem, descend to the spinal cord, and modulate ascending pain impulses. One such pathway begins in an area of the midbrain called the periaqueductal gray (PAG) region. Opioid receptors are highly concentrated in this region of the CNS and produce analgesia (pain relief) through the release of endogenous opioids. Three families of opioid peptides have been identified—the enkephalins, endorphins, and dynorphins. Although they appear to function as neurotransmitters, their full significance in pain control and other physiologic functions is not completely understood. There is evidence that opioid receptors and endogenously synthesized opioid peptides are found on the peripheral processes of primary afferent neurons and in many regions of the CNS.

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11. 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.

12. 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?”

B) “Can you financially afford your medicine?”

C) “What kind of stressors are you experiencing?”

D) “Do you consider yourself a good driver?”

E) “Are you having trouble sleeping?”

Ans: B, C, E Feedback: Unlike acute pain that serves as a warning system, persistent 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.

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13. 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.

14. 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.

15. 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.

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16. An otherwise healthy client has been referred to a pain clinic because she claims to experience exquisite pain from the friction of her clothes on her torso. This client is likely to be diagnosed with which of the following health problems?

A) Visceral pain B) Hypoalgesia C) Allodynia D) Primary hyperalgesia Ans: C Feedback: Allodynia is pain that follows a nonnoxious stimulus to apparently normal skin. Visceral pain is a deep, nonspecific pain that results from disruption of organs or deep tissues.

Hypoalgesia is an abnormal decrease in pain sensitivity, whereas primary hyperalgesia describes pain sensitivity that occurs directly in damaged tissues.

17. Which of the following clients may be experiencing the effects of neuropathic pain?

A) A girl whose playground accident resulted in an arm fracture B) A man with pain secondary to his poorly controlled diabetes C) An elderly woman with a stage III pressure ulcer D) A man whose pain is caused by gastric cancer Ans: B Feedback: Conditions that can lead to pain by causing damage to peripheral nerves in a wide area include diabetes mellitus, alcohol use, hypothyroidism, rash, and trauma. Fractures, wounds, and cancer pain do not typically have an etiology that is rooted in the neurologic system.

18. A client with trigeminal neuralgia usually complains of excruciating pain. Which of the following activities may trigger an acute pain attack? Select all that may apply.

A) Brushing the teeth with lukewarm water B) Working in the office that has an air duct located directly overhead C) One's significant other lightly stroking their face D) Applying lipstick E) Walking outside on a windy day Ans: B, C, E Feedback: Trigeminal neuralgia is manifested by facial tics or spasms and characterized by paroxysmal attacks of stabbing pain that usually are limited to the unilateral sensory distribution of one or more branches of the trigeminal cranial nerve (CN V). Although intermittent, the pain often is excruciating and may be triggered by light touch, movement, drafts (like an air duct overhead), and eating. Brushing ones teeth and applying lipstick should not increase the pain.

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19. Complex regional pain syndrome is characterized by: A) Repetitious dermatome pain attacks B) Trigeminal neuralgia with facial tics C) Severe limb pain after amputation D) Disproportionate pain with mobility Ans: D Feedback: Complex regional pain syndrome is a rare disorder of the extremities characterized by autonomic and vasomotor instability. Most persons with the disorder have had an identifiable inciting or irritating injury, which may be trivial, such as a minor joint sprain, or severe, such as trauma involving a major nerve or nerves. The IASP lists the diagnostic criteria of CRPS I as the presence of an initiating traumatic event, continuing pain, allodynia (perception of pain from a nonpainful stimulus), or hyperalgesia disproportionate to the inciting event with evidence at some time of edema, changes in skin blood flow, or abnormal sensorimotor activity in the area of pain. The hallmark is pain and mobility problems more severe than the injury warrants. Neuralgia is characterized by severe, brief, often repetitiously occurring attacks of lightning-like pain that occurs along the distribution of a spinal or cranial nerve. Trigeminal neuralgia is manifested by facial tics or grimaces. Phantom limb pain, a neurologic pain, can occur after amputation of a limb or part of a limb.

20. Following an automobile accident that resulted in a traumatic amputation of the right lower leg, the client complains of feeling tingling, heaviness, and shooting pain in the amputated limb. The health care providers treat phantom limb pain by which of the following interventions? Select all that apply.

A) TENS of the large myelinated afferents innervating the area B) Hypnosis C) Relaxation techniques D) Warm, moist compresses E) Use of mirrors to visualize the limb is no longer there Ans: A, B, C Feedback: Treatment of phantom limb pain has been accomplished by the use of sympathetic blocks, TENS of the large myelinated afferents innervating the area, hypnosis, and relaxation training. There is no extremity to place the warm compresses on.

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21. Which of the following characteristics differentiates a migraine with aura from a migraine without aura?

A) Gastrointestinal involvement in the hours leading up to the headache B) A decrease in mood and affect prior to the headache C) Lack of response to nonpharmacologic treatments D) Visual symptoms that precede the headache Ans: D Feedback: An aura is visual (flickering lights, spots, or loss of vision), sensory (feeling of pins and needles, or numbness), and/or speech disturbance that precedes a migraine.

Nonpharmacologic treatments may be used with varying success in both types of migraine, and nausea and vomiting may precede or accompany each. Changes in mood and affect are not central to an aura.

22. While talking about their migraine headaches, two women have found that they have some common triggers for their migraines, which may include: Select all that apply.

A) Nonpharmacologic treatments like yoga B) Piercings of their nose and cheeks C) At the time of their menstrual cycle D) When drinking white wine E) Consuming chocolate Ans: C, E Feedback: Although the pathophysiology of migraines is not well understood, it is thought that hormone levels, particularly estrogen levels, may underlie their increased prevalence in women. Fluctuations in hormone levels, particularly in estrogen levels, are thought to play a role in the pattern of migraine attacks. For many women, migraine headaches coincide with their menstrual periods. The greater predominance of migraine headaches in women is thought to be related to the aggravating effect of estrogen on the migraine mechanism. Dietary substances, such as monosodium glutamate, aged cheese, and chocolate, also may precipitate migraine headaches. Yoga, piercings, and drinking white wine are not known to be triggers for migraines.

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23. A 44-year-old woman has sought care for the treatment of headaches that have been increasing in severity and frequency and has been subsequently diagnosed with migraines. Which of the following teaching points should her care provider emphasize?

A) “Weight loss and exercise are very important components of your treatment.”

B) “Stopping all of your current medications, even temporarily, should provide some relief.”

C) “It would be helpful for you to take control of your diet, sleep schedule, and stress levels.”

D) “Your headaches are likely a result of a nerve disorder and, unfortunately, cannot be treated successfully.”

Ans: C Feedback: Migraines may be precipitated by certain foods as well as stress and lack of sleep.

Obesity and sedentary lifestyle are not thought to be risk factors. Migraines are not believed to result from a nerve disorder, and treatment is often difficult, but positive. It would be inappropriate and ineffective to recommend the cessation of all the client's drugs.

24. Which of the following principles should underlie the pain control strategy in the care of a child with a diagnosis of cancer?

A) Opioids should be avoided in order to prevent liver and kidney insult.

B) Dosing and timing should aim for a steady serum level of the prescribed drug.

C) Doses of analgesia should be given only when the client's pain becomes severe.

D) Drugs from numerous classifications should be used to maximize pain control.

Ans: B Feedback: Pain control can be maximized and side effects minimized by timing the administration of analgesia so that a steady blood level is achieved and, as much as possible, pain is prevented. Opioids can be safely used in children, and analgesia should not be withheld until pain is severe. Using drugs from numerous classifications will not necessarily increase pain control.

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25. Pain assessment is likely to be most challenging when providing care for which of the following older adult clients?

A) A 90-year-old client who takes multiple medications for cardiac and respiratory conditions B) A 77-year-old man who has sustained burns on the lower part of his body C) An 82-year-old woman who has been diagnosed with diabetes and an anxiety disorder D) An 87-year-old man with vascular dementia and other health problems like heart failure Ans: D Feedback: Pain in the elderly has been associated with impaired appetite, increased sleep disturbances, and in some cases a decrease in cognitive functions. Anxiety, polypharmacy, and the presence of acute pain are factors that may also influence the assessment process, but these are more likely to have a bearing on pain treatment and management than on pain assessment.

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1. Chapter 36 More complex patterns of movements, such as throwing a ball or picking up a fork, are controlled by which portion of the frontal lobe?

A) Premotor cortex B) Primary motor cortex C) Reflexive circuitry D) Supplementary motor cortex Ans: A Feedback: Nerve signals generated by the premotor cortex produce much more complex “patterns” of movement; the movement pattern to accomplish a particular objective, such as throwing a ball or picking up a fork, is programmed by the prefrontal association cortex and associated thalamic nuclei. The primary motor cortex is concerned with the purpose and planning of the motor movement and controls specific muscle movement sequences.

The lowest level of the hierarchy occurs at the spinal cord, which contains the basic reflex circuitry needed to coordinate the function of the motor units involved in the planned movement. The supplementary motor cortex, which contains representations of all parts of the body, is involved in the performance of complex, skillful movements that require coordination of both sides of the body.

2. Disorders of the pyramidal tracts, such as a stroke, are characterized by: A) Paralysis B) Hypotonia C) Muscle rigidity D) Involuntary movements Ans: A Feedback: Disorders of the pyramidal tracts (e.g., stroke) are characterized by spasticity and paralysis, whereas those affecting the extrapyramidal tracts (e.g., Parkinson disease) by involuntary movements, muscle rigidity, and immobility without paralysis. Hypotonia is a condition of less than normal muscle tone, hypertonia or spasticity is a condition of excessive tone, and paralysis refers to a loss of muscle movement. Upper motor neuron (UMN) lesions produce spastic paralysis and lower motor neuron (LMN) lesions flaccid paralysis.

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3. A clinician is assessing the muscle tone of a client who has been diagnosed with a lower motor neuron (LMN) lesion. Which of the following assessment findings is congruent with the client's diagnosis?

A) Hypotonia B) Spasticity C) Tetany D) Rigidity Ans: A Feedback: Typically, UMN lesions produce increased tone (e.g., spasticity, tetany, and rigidity), whereas LMN lesions produce decreased tone (hypotonia).

4. An elderly client has been brought to his primary care provider by his wife, who is concerned about his recent decrease in coordination. Upon assessment, his primary care provider notes that the client's gait is wide-based, unsteady, and lacking in fluidity, although his muscle tone appears normal. This client requires further assessment for which of the following health problems?

A) Muscle atrophy B) Cerebellar disorders C) Impaired spinal reflexes D) Lower motor neuron lesions Ans: B Feedback: An ataxic gait is characteristic of cerebellar and/or vestibular disorders. An LMN lesion typically results in decreased muscle tone. Impaired spinal reflexes would not normally manifest as ataxia, and muscle atrophy would cause weakness and decreased muscle tone.

5. Knowing that she is a carrier for Duchene muscular dystrophy (DMD), a pregnant woman arranged for prenatal genetic testing, during which her child was diagnosed with DMD. As her son develops, the woman should watch for which of the following early signs that the disease is progressing?

A) Impaired sensory perception and frequent wounds B) Spasticity and hypertonic reflexes C) Muscle atrophy with decreased coordination D) Frequent falls and increased muscle size Ans: D Feedback: Pseudohypertrophy, falls, and muscle weakness are characteristic signs during the early course of DMD. Spasticity and muscle atrophy do not occur and sensory function is not affected.

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6. A client with laryngeal dystonia has gotten to the point that people on the telephone cannot understand her. She has heard about getting Botox injections into her vocal cords. The nurse will teach about the actions of Botox. Which is the most accurate description? This drug: A) Will slow the decline in muscle strength and function B) Produces paralysis of the larynx muscles by blocking acetylcholine release C) Prevents the depolarizing effect of the neurotransmitters D) Inhibits the peripheral metabolism of dopamine Ans: B Feedback: Pharmacologic preparations of the botulinum toxin (botulinum type A toxin [Botox] and botulinum type B toxin [Myobloc]) produce paralysis by blocking acetylcholine release.

Glucocorticoids are the only medication currently available to slow the decline in muscle strength and function in DMD. Curare acts on the postjunctional membrane of the motor endplate to prevent the depolarizing effect of the neurotransmitter.

Neuromuscular transmission is blocked by curare-type drugs during many types of surgical procedures to facilitate relaxation of involved musculature. Levodopa, a dopamine agonist used in Parkinson disease, is administered with carbidopa, which inhibits its peripheral metabolism, allowing therapeutic concentrations of the drug to enter the brain without disabling adverse effects.

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7. A client presents to a health clinic complaining of several vague symptoms. As the history/physical continues, the health care provider clearly thinks the client may have myasthenia gravis. Which statements by the client would correlate with this diagnosis?

Select all that apply.

A) “Sometimes I have double vision.”

B) “I have more energy in the morning but get worse as the day goes by.”

C) “Sometimes I have numbness/tingling on my face.”

D) “I had what felt like an electric shock race down the back of my leg when I bend my neck.”

E) “I feel like I don't have enough energy to chew my food sometimes.”

Ans: A, B, E Feedback: Now recognized as an autoimmune disease, myasthenia gravis is caused by an antibody-mediated destruction of acetylcholine receptors in the neuromuscular junction.

This results in both muscle weakness and fatigability with sustained effort. Most commonly affected are the eye and periorbital muscles, with ptosis (drooping of eyelids) or diplopia (double vision) due to weakness of the extraocular muscles as an initial symptom. The disease may progress from ocular muscle weakness to generalized weakness. Chewing and swallowing may be difficult. In most persons, symptoms are least evident when arising in the morning, but grow worse with effort and as the day proceeds. Multiple sclerosis clients have paresthesias exhibited as numbness, tingling, burning sensations, or pressure on the face or involved extremities. The Lhermitte sign is an electric shock–like tingling down the back and onto the legs that is produced by flexion of the neck.

8. A client with a diagnosis of myasthenia gravis has required a mastectomy for the treatment of breast cancer. The surgery has been deemed a success, but the client has gone into a myasthenic crisis on postoperative day 1. Which of the following measures should the care team prioritize in this client's immediate care?

A) Positioning the client to minimize hypertonia and muscle rigidity B) Seizure precautions with padded side rails and bed in lowest height C) Respiratory support and protection of the client's airway D) Monitoring the client for painful dyskinesias Ans: C Feedback: Myasthenic crisis occurs when muscle weakness becomes severe enough to compromise ventilation to the extent that ventilatory support and airway protection are needed.

Seizures, dyskinesias, hypertonia, and muscle rigidity are not associated with myasthenia gravis in general or myasthenic crisis in particular.

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9. Which of the following peripheral nerve injuries will likely result in cellular death with little chance of regeneration?

A) Nerve fibers destroyed close to the neuronal cell body B) Crushing injury where the nerve is traumatized but not severed C) Cutting injury where slow-regeneration axonal branches are located D) Incomplete amputation where tubular implants are used to fill in the gaps of nerves Ans: A Feedback: The successful regeneration of a nerve fiber in the PNS depends on many factors. If a nerve fiber is destroyed relatively close to the neuronal cell body, the chances are that the nerve cell will die; if it does, it will not be replaced. If a crushing type of injury has occurred, partial or often full recovery of function occurs. Cutting-type trauma to a nerve is an entirely different matter. A number of scar-inhibiting agents have been used in an effort to reduce this hazard, but have met with only moderate success. Various types of tubular implants have been used to fill longer gaps in the endoneurial tube but again only with moderate success.

10. A client works as a data entry worker for a large company. The client goes to employee health with pain in the wrist/hand. The nurse suspects that it is carpal tunnel syndrome based on which of the following assessment findings? Select all that apply.

A) Describes numbness/tingling in the thumb and first digit B) States his forearm feels funny (paresthesia) C) Loss of tendon reflexes on the affected extremity D) Precision grip weakness in the affected hand E) Pain interferes with sleeping Ans: A, D, E Feedback: Carpal tunnel syndrome is a mononeuropathy with compression of the median nerve as it travels with the flexor tendons through a canal made by the carpal bones and transverse carpal ligament. The condition can be caused by a variety of conditions that produce a reduction in the capacity of the carpal tunnel or an increase in the volume of the tunnel contents. Carpal tunnel syndrome is characterized by hand and wrist pain, hand or finger paresthesia, and numbness of the thumb and first two and one half digits of the hand; atrophy of abductor pollicis muscle; pain interferes with sleep; and weakness in precision grip. Guillain-Barré syndrome is characterized by rapidly progressive limb weakness and loss of tendon reflexes.

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11. Following his annual influenza vaccination, a client begins to feel achy, like he has developed the flu. An hour later, the client is rushed to the emergency department.

Diagnosis of Guillain-Barré syndrome was made based on which of the following assessment findings? Select all that apply.

A) Rapid deterioration of respiratory status B) Lack of any physical pain C) Flaccid paralysis of limbs D) BP 90/62 E) Pale, cool, dry skin Ans: A, C, D Feedback: Guillain-Barré syndrome usually is a medical emergency. There may be a rapid development of ventilatory failure and autonomic disturbances that threaten circulatory function. The disorder is characterized by progressive ascending muscle weakness of the limbs, producing a symmetric flaccid paralysis. Paralysis may progress to involve the respiratory muscles. Autonomic nervous system involvement that causes postural hypotension, arrhythmias, facial flushing, abnormalities of sweating, and urinary retention is common. Pain is another common feature of Guillain-Barré syndrome.

12. A client who experienced a traumatic head injury from a severe blow to the back of his head now lives with numerous function deficits, including an inability to maintain steady posture while he is in a standing position, although he is steadier when walking.

Which of the following disorders most likely resulted from his injury?

A) Cerebellar dystaxia B) Cerebellar tremor C) A lower motor neuron lesion D) A vestibulocerebellar disorder Ans: D Feedback: Damage to the part of the cerebellum associated with the vestibular system leads to difficulty in maintaining or to inability to maintain a steady posture of the trunk, which normally requires constant readjusting movements. Tremors are repetitive movements, while dystaxia is a characterized by uneven movement. An LMN lesion typically manifests as hypotonia.

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13. Unlike disorders of the motor cortex and corticospinal (pyramidal) tract, lesions of the basal ganglia disrupt movement: A) Without causing paralysis B) Posture and muscle tone C) And cortical responses D) Of upper motor neurons Ans: A Feedback: Disorders of the basal ganglia comprise a complex group of motor disturbances characterized by tremor and other involuntary movements, changes in posture and muscle tone, and poverty and slowness of movement. They include tremors and tics, spasticity, hypokinetic disorders, and hyperkinetic disorders. Unlike disorders of the motor cortex and corticospinal (pyramidal) tract, lesions of the basal ganglia disrupt movement but do not cause paralysis. Disorders of the upper motor neuron pyramidal tracts are characterized by spasticity and paralysis.

14. A family brings their father to his primary care physician for a checkup. Since their last visit, they note their dad has developed a tremor in his hands and feet. He also rolls his fingers like he has a marble in his hand. The primary physician suspects the onset of Parkinson disease when he notes which of the following abnormalities in the client's gait?

A) Slow to start walking and has difficulty when asked to “stop” suddenly B) Difficulty putting weight on soles of feet and tends to walk on tiptoes C) Hyperactive leg motions like he just can't stand still D) Takes large, exaggerated strides and swings arms/hands wildly Ans: A Feedback: The cardinal symptoms of Parkinson disease (PD) are tremor, rigidity (hypertonicity), and bradykinesia or slowness of movement. Bradykinesia is characterized by slowness in initiating and performing movements and difficulty in sudden, unexpected stopping of voluntary movements. Persons with the disease have difficulty initiating walking and difficulty turning. While walking, they may freeze in place and feel as if their feet are glued to the floor, especially when moving through a doorway or preparing to turn.

When they walk, they lean forward to maintain their center of gravity and take small, shuffling steps without swinging their arms.

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15. A client's recent diagnosis of Parkinson disease has prompted his care provider to promptly begin pharmacologic therapy. The drugs that are selected will likely influence the client's levels of: A) Dopamine B) Acetylcholine C) Serotonin D) Adenosine Ans: A Feedback: Although some antiparkinsonian drugs act by reducing the excessive influence of excitatory cholinergic neurons, most act by improving the function of the dopaminergic system. Serotonin and adenosine are not known to participate directly in the pathophysiology of Parkinson disease.

16. A client is devastated to receive a diagnosis of amyotrophic lateral sclerosis (ALS). The symptomatology of this disease is a result of its effects on upper and lower motor neurons. The health care provider caring for this client will focus on which priority intervention for this client?

A) Ability to turn from side to side, thereby preventing skin breakdown B) Ability to empty bladder completely, thereby preventing autonomic dysreflexia C) Respiratory ventilation assessment and prevention of aspiration pneumonia D) Assessment of lower extremities to prevent deep vein thrombosis Ans: C Feedback: Amyotrophic lateral sclerosis is a mixed upper motor neuron (UMN) and lower motor neuron (LMN) disorder. In the more advanced stages of ALS, muscles of the palate, pharynx, tongue, neck, and shoulders become involved, causing impairment of chewing, swallowing (dysphagia), and speech. Dysphagia with recurrent aspiration and weakness of the respiratory muscles produces the most significant acute complications of the disease. Airway/breathing is always the priority over bladder emptying; skin breakdown, and assessing for DVT.

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17. During physiology class, the instructor asks students to explain the pathology behind development of multiple sclerosis. Which student gave the most accurate description?

A) The demyelination and subsequent degeneration of nerve fibers and decreased oligodendrocytes, which interfere with nerve conduction B) Muscle necrosis with resultant increase in fat/connective tissue replacing the muscle fibers C) Atherosclerotic destruction of circulation to the brain resulting in lactic acid buildup that affects nerve transmission D) Autoimmune disease where antibody loss of acetylcholine receptors at the neuromuscular junction causes decrease motor response Ans: A Feedback: Multiple sclerosis (MS) is an immune-mediated disorder that occurs in genetically susceptible individuals. The pathophysiology of MS involves demyelination and subsequent degeneration of nerve fibers in the central nervous system (CNS), marked by prominent lymphocytic invasion in the lesion. The infiltrate in nerve fiber (rather than vascular) sclerotic plaques contains CD8+ and CD4+ T cells as well as macrophages, which are thought to induce oligodendrocyte injury. With muscular dystrophy, the muscle undergoes necrosis, and fat and connective tissue replace the muscle fibers, which increases muscle size and results in muscle weakness. Now recognized as an autoimmune disease, myasthenia gravis is caused by an antibody-mediated loss of acetylcholine receptors in the neuromuscular junction.

18. The family of a multiple sclerosis client asks, “What psychological manifestations may we expect to see in our mother?” The health care provider informs them to expect which of the following? Select all that apply.

A) Depression B) Hallucinations C) Delirium D) Inattentiveness E) Forgetfulness Ans: A, D, E Feedback: Psychological manifestations, such as mood swings, may represent an emotional reaction to the nature of the disease or, more likely, involvement of the white matter of the cerebral cortex. Depression, euphoria, inattentiveness, apathy, forgetfulness, and loss of memory may occur. Hallucinations and delirium are not usually associated as a manifestation of MS.

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19. Among the treatments for multiple sclerosis (MS), which medication will reduce the exacerbation of relapsing–remitting MS? A) Long-term corticosteroid administration B) Mitoxantrone, an antineoplastic agent C) Interferon-, a cytokine injection D) Baclofen, a muscle relaxer Ans: C Feedback: Disease-modifying agents include interferon-b and glatiramer acetate. These agents have shown some benefit in reducing exacerbations in persons with relapsing–remitting MS. Interferon- is a cytokine that acts as an immune enhancer. Corticosteroids are the mainstay of treatment for acute attacks of MS. These agents are thought to reduce the inflammation, improve nerve conduction, and have important immunologic effects.

Long-term administration does not, however, appear to alter the course of the disease and can have harmful side effects. Mitoxantrone, an anticancer drug, is recommended for persons with worsening forms of the disease. Baclofen is a muscle relaxer for helping with symptom relief.

20. A sudden traumatic complete transection of the spinal cord results in what type of injury below the site?

A) Flaccid paralysis B) Vasoconstriction C) Deep visceral pain D) 3+ tendon reflexes Ans: A Feedback: Sudden complete transection of the spinal cord results in complete loss of motor, sensory, reflex, and autonomic function below the level of injury. This immediate response to spinal cord injury, spinal cord shock, is characterized by flaccid paralysis with loss of tendon reflexes below the level of injury, absence of somatic and visceral sensations below the level of injury, and loss of bowel and bladder function. Loss of systemic sympathetic vasomotor tone may result in vasodilation, increased venous capacity, and hypotension. These manifestations occur regardless of whether the level of the lesion eventually will produce spastic or flaccid paralysis. In persons in whom the loss of reflexes persists, hypotension and bradycardia may become critical but manageable problems. In general, the higher the level of injury, the greater is the effect.

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21. The client has a traumatic complete spinal cord transection at the C5 level. Based on this injury, the health care worker can expect the client to have control of which body function/part?

A) Bladder B) Finger flexion C) Diaphragm D) Trunk muscle Ans: C Feedback: The functional levels of cervical injury are related to C5, C6, C7, or C8 innervation. All motor and sensory function is absent below the level of cord transection. At the C5 level, deltoid and biceps function is spared, allowing full head, neck, and diaphragm control with good shoulder strength and full elbow flexion. At the C8 level, finger flexion is added. Thoracic cord injuries (T1 to T12) allow full upper extremity control with limited to full control of intercostal and trunk muscles and balance. Sacral (S1 to S5) innervation allows for full leg, foot, and ankle control and innervation of perineal musculature for bowel, bladder, and sexual function.

22. A client with a spinal cord injury at T8 would likely retain normal motor and somatosensory function of her: A) Arms B) Bowels C) Bladder D) Perineal musculature Ans: A Feedback: A spinal cord injury at T8 would likely allow the client to retain normal function of the upper extremities, while innervations governing the function of the bowels, bladder, and perineum would be severed.

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23. The nurse is caring for a spinal cord injury client. Assessment reveals shallow breath sounds with a very weak cough effort. The nurse correlates this with which level of injury on the spinal column?

A) C2 B) C5 C) T1 D) T10 Ans: B Feedback: Although a C3-to-C5 injury allows partial or full diaphragmatic function, ventilation is diminished because of the loss of intercostal muscle function, resulting in shallow breaths and a weak cough. Cord injuries involving C1 to C3 result in a lack of respiratory effort, and affected clients require assisted ventilation. The intercostal muscles, which function in elevating the rib cage and are needed for coughing and deep breathing, are innervated by spinal segments T1 through T7. The major muscles of expiration are the abdominal muscles, which receive their innervation from levels T6 to T12.

24. A recently injured (3 months ago) client with a spinal cord injury at T4 to T5 is experiencing a complication. He looks extremely ill. The nurse recognizes this as autonomic dysreflexia (autonomic hyperreflexia). His BP is 210/108; skin very pale; gooseflesh noted on arms. The priority nursing intervention would be to: A) Check the mouth/throat for pustules and redness B) Check the jugular vein for distention C) Assess calves of legs for redness, warmth, or edema D) Scan his bladder to make sure it is empty Ans: D Feedback: Autonomic hyperreflexia, an acute episode of exaggerated sympathetic reflex responses that occur in persons with injuries at T6 and above, in which central nervous system (CNS) control of spinal reflexes is lost, does not occur until spinal shock has resolved and autonomic reflexes return. Autonomic dysreflexia is characterized by vasospasm, hypertension ranging from mild to severe, skin pallor, and gooseflesh associated with the piloerector response. In many cases, the dysreflexic response results from a full bladder. There is no indication the client has right-sided heart failure (jugular vein distention); has a DVT (calf redness, warmth, or edema); or has strep throat (pustules and red throat/tonsils).

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25. While teaching a class of nursing students about spinal cord injury, the instructor mentions that male SCI clients will be able to have a sexual response if their injury is at which level on the spinal column?

A) T12 B) S1 C) L2 D) S4 Ans: D Feedback: Sexual function, like bladder and bowel control, is mediated by the S2 to S4 segments of the spinal cord. The S2 to S4 cord segments have been identified as the sexual touch reflex center. The T11 to L2 cord segments have been identified as the mental–stimulus, or psychogenic, sexual response area, where autonomic nerve pathways in communication with the forebrain leave the cord and innervate the genitalia. In T10 or higher injuries, reflex sexual response to genital touch may occur freely. However, a sexual response to mental stimuli (T11 to L2) does not occur because of the spinal lesion blocking the communication pathway. In an injury at T12 or below, the sexual reflex center may be damaged, and there may be no response to touch.

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1. Chapter 37 When trying to explain the difference between vasogenic versus cytotoxic cerebral edema, the physiology instructor mentions that cytotoxic edema displays which of the following functions in the brain? Select all that apply.

A) Impaired blood–brain barrier that allows water/proteins to leave vessels and go into the interstitial space B) Mainly allows edema to form in the white mater of the brain C) May cause herniation by displacing a cerebral hemisphere D) Causes ischemia to build up lactic acid due to anaerobic metabolism E) Allows cells to increase volume to the point of rupture, damaging neighboring cells Ans: D, E Feedback: Cytotoxic edema involves an increase in intracellular fluid. Ischemia results in the inadequate removal of anaerobic metabolic end products such as lactic acid, producing extracellular acidosis. If blood flow is reduced to low levels for extended periods or to extremely low levels for a few minutes, cellular edema can cause the cell membrane to rupture, allowing the escape of intracellular contents into the surrounding extracellular fluid. This leads to damage of neighboring cells. Vasogenic edema occurs with conditions that impair the function of the blood–brain barrier and allow transfer of water and proteins from the vascular into the interstitial space. It occurs primarily in the white matter of the brain, possibly because the white matter is more compliant than the gray matter. Vasogenic edema can result in displacement of a cerebral hemisphere and various types of brain herniation.

2. The intracranial volume that is most capable of compensating for increasing intracranial pressure is the: A) Brain cell tissue B) Intravascular blood C) Surface sulci fluid D) Cerebrospinal fluid Ans: D Feedback: Initial increases in intracranial pressure (ICP) are largely buffered by a translocation of cerebrospinal fluid (CSF) to the spinal subarachnoid space and increased reabsorption of CSF. Of the intracranial volumes, the tissue volume is least capable of undergoing change. Surface sulcus fluid is negligible and not a factor in increased ICP. The compensatory ability of the intravascular blood compartment is also limited by the small amount of blood that is in the cerebral circulation. As the volume-buffering capacity of this compartment becomes exhausted, venous pressure increases and cerebral blood volume and ICP rise.

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3. A late indicator of increased intracranial pressure is: A) Tachycardia B) Right-sided heart failure C) Narrow pulse pressure D) High mean arterial pressure Ans: D Feedback: The cerebral perfusion pressure (CPP), which represents the difference between the mean arterial blood pressure (MABP) and the ICP (CPP = MABP – ICP), is the pressure perfusing the brain. CPP (normally 70 to 100 mm Hg) is determined by the pressure gradient between the internal carotid artery and the subarachnoid veins. The MABP and ICP are monitored frequently in persons with brain conditions that increase ICP and impair brain perfusion. When the pressure in the cranial cavity approaches or exceeds the MABP, tissue perfusion becomes inadequate, cellular hypoxia results, and neuronal death may occur. Elevated MABP, wide pulse pressure and reflex, and slowing of the heart rate are important but late indicators of increased ICP. Heart failure, not a part of the reflex, occurs with compression or herniation of the brain stem.

4. A traumatic brain injury client has developed extreme cerebral edema. The nurse is monitoring the client closely for signs of brain herniation. Which clinical manifestations would correlate to upward herniation of the midbrain from the infratentorial compartment? Select all that apply.

A) Deep coma B) Rhythmic movement of arms and legs C) Respiratory rate of 8 with intermittent sighs D) Intracranial bleeding from nose and ears E) Bilateral small, fixed pupils Ans: A, C, E Feedback: Infratentorial herniation results from increased pressure in the infratentorial compartment. Herniation may occur superiorly (upward) through the tentorial incisura or inferiorly (downward) through the foramen magnum. The most prominent signs of upward herniation include immediate onset of deep coma; small equal, fixed pupils; and abnormal respirations (slow rate with intermittent sighs or ataxia) and other vital signs.

Downward displacement of the midbrain through the tentorial notch or of the cerebellar tonsils through the foramen magnum can interfere with medullary functioning and cause cardiac or respiratory arrest. Tissue infarction and intracranial bleeding are causes of cerebral edema, rather than an outcome of herniation. Rhythmic movement of arms and legs could be caused by many things and is not specific to infratentorial herniation.

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5. A client's recent computed tomography (CT) scan has revealed the presence of hydrocephalus. Which of the following treatment measures is most likely to resolve this health problem?

A) Aggressive diuresis B) Placement of a shunt C) Administration of hypertonic intravenous solution D) Lumbar puncture Ans: B Feedback: Hydrocephalus represents a progressive enlargement of the ventricular system due to an abnormal increase in cerebrospinal fluid (CSF) volume. This increase in CSF volume can be resolved by the placement of a shunt to drain the offending fluid volume.

Diuresis, hypertonic solution administration, and lumbar puncture are not usual treatment modalities.

6. A teenager has been in a car accident and experienced acceleration–deceleration head injury. Initially, the client was stable but then started to develop neurological signs/symptoms. The nurse caring for this client should be assessing for which type of possible complication?

A) Brain contusions and hematomas B) TIAs and cerebrovascular infarction C) Momentary unconsciousness D) Status epilepticus Ans: A Feedback: Contusions (focal brain injury) cause permanent damage to brain tissue. The bruised, necrotic tissue is phagocytized by macrophages, and scar tissue formed by astrocyte proliferation persists as a crater. The direct contusion of the brain at the site of external force is referred to as a acceleration injury, whereas the opposite side of the brain receives the deceleration injury from rebound against the inner skull surfaces. As the brain strikes the rough surface of the cranial vault, brain tissue, blood vessels, nerve tracts, and other structures are bruised and torn, resulting in contusions and hematomas.

TIAs and cerebral vascular infarction (stroke) are often caused by atherosclerotic brain vessel occlusions that cause ischemic injuries. In mild concussion head injury, there may be momentary loss of consciousness without demonstrable neurologic symptoms or residual damage, except for possible residual amnesia. Status epilepticus is not related to this situation.

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7. Following a head injury, a client is diagnosed with a possible intracranial epidural hematoma. During the initial assessment, the client suddenly becomes unconscious.

Other clinical manifestations that correlate with this diagnosis may include: A) Ipsilateral pupil dilation B) Ipsilateral hemiparesis C) Diffuse venous bleeding from the nose D) Increased head circumference with hydrocephalus Ans: A Feedback: With rapidly developing unconsciousness, there are focal symptoms related to the area of the brain involved. These symptoms can include ipsilateral (same side) pupil dilation and contralateral (opposite side) hemiparesis. Because bleeding is arterial in origin, rapid compression of the brain occurs from the expanding hematoma. Communicating hydrocephalus occurs as the result of impaired reabsorption of cerebrospinal fluid (CSF) from the arachnoid villi into the venous system. This is unrelated to this situation.

8. A high school senior sustained a concussion during a football game. Which of the following signs and symptoms would indicate the presence of postconcussion syndrome in the days and weeks following his injury?

A) Headaches and memory lapses B) Recurrent nosebleeds and hypersomnia C) Unilateral weakness and decreased coordination D) Neck pain and decreased neck range of motion Ans: A Feedback: Postconcussion syndrome includes mild symptoms, such as headache, irritability, insomnia, and poor concentration and memory. Nosebleeds, hypersomnia, unilateral motor changes, and neck pain are indicative of more severe brain injury and/or soft tissue injury.

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9. Following a head injury on the football field, the medical team is assessing the player for injury. One of the earliest signs of decreased level of consciousness to assess for would be: A) Stupor B) Lethargy C) Delirium D) Inattention Ans: D Feedback: Consciousness is a state of awareness of self and environment. Any deficit in level of consciousness, from mild confusion to stupor or coma, indicates injury to either the RAS or to both cerebral hemispheres concurrently. A fully conscious person is totally aware of her or his surroundings. The earliest signs of diminution in level of consciousness are inattention, mild confusion, disorientation, and blunted responsiveness. With further deterioration, an individual under delirium becomes markedly inattentive and variably lethargic or agitated. Persons who cannot be fully aroused are obtunded, and those who remain in a sleep-like state are stuporous.

10. While lecturing to a group of physiology students, the instructor asks, “What metabolic factors cause vasodilation of cerebral vessels thereby increasing cerebral blood flow to the brain?” The student with the best response would be: A) Increased oxygen saturation B) Increased carbon dioxide level C) Decreased serum sodium level D) Decreased hydrogen ion concentration Ans: B Feedback: At least three metabolic factors affect cerebral blood flow: carbon dioxide, hydrogen ion, and oxygen concentration. Increased carbon dioxide provides a potent stimulus for vasodilation—a doubling of the PCO2 in the blood results in a doubling of cerebral blood flow. Increased hydrogen ion concentrations also increase cerebral blood flow, serving to wash away the neurally depressive acidic materials. Decreased oxygen concentration also increases cerebral blood flow. Low sodium is a hypoosmolar intravascular environment that will pull sodium out of the cells—a response unrelated to blood cell volume or flow.

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11. An elderly male client has been brought to the emergency department after experiencing stroke-like symptoms a few hours ago, and has been subsequently diagnosed with an ischemic stroke. The care team is eager to restore cerebral perfusion despite the likely death of the brain cells directly affected by the stroke. What is the rationale for the care team's emphasis on restoring circulation?

A) Failure to restore blood flow creates a severe risk for future transient ischemic attacks.

B) Necrosis will continue unabated throughout the brain unless blood flow is restored.

C) Cells of the penumbra may be saved from hypoxic damage if blood flow is promptly restored.

D) Unless blood flow is restored, the client faces the risk of progressing to hemorrhagic stroke.

Ans: C Feedback: Prompt return of circulation increases the chance that the cells of the penumbra will continue to survive. Cell death does not spread to areas that are not normally supplied by the affected vessel, and future risk of transient ischemic attacks (TIAs) is not an immediate priority. Ischemic stroke does not progress to hemorrhagic stroke because the two types have distinct etiologies.

12. A family brings their elderly mom to the emergency department. The client had a short period of time where she was confused, had slurred speech and appeared to have a weak arm. Now she is back to her normal self. Suspecting a transient ischemic attacks (TIAs), the health care provider will order diagnostic testing looking for: A) Aneurysm leakage B) Cause of minor residual deficits C) Diffuse cerebral electrical malfunctions D) Atherosclerotic lesions in cerebral vessels Ans: D Feedback: The traditional definition of TIAs as a neurologic deficit resolving within 24 hours was developed before the mechanisms of ischemic cell damage and the penumbra were known and before the newer, more advanced methods of neuroimaging became available. A more accurate definition now is a transient deficit without time limits, best described as a zone of penumbra without central infarction. TIAs are important because they may provide warning of impending stroke. The causes of TIAs are the same as those of ischemic stroke, and include atherosclerotic disease of cerebral vessels and emboli. The most common predisposing factors for cerebral hemorrhage are advancing age and hypertension; other causes include aneurysm rupture. Cerebral electrical malfunctions usually occur with seizure activity.

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13. A client's emergency magnetic resonance imaging (MRI) has been examined by the physician and tissue plasminogen activator (tPA) has been administered to the client.

What was this client's most likely diagnosis?

A) Status epilepticus B) Subarachnoid hemorrhage C) Ischemic stroke D) Encephalitis Ans: C Feedback: Thrombolytic therapy for the acute treatment of ischemic stroke consists of the intravenous administration of tPA. This drug would exacerbate a subarachnoid hemorrhage by inhibiting the clotting mechanism, and it is not relevant to the care of clients with encephalitis of status epilepticus.

14. A client has suffered a stroke that has affected his speech. The physician has identified the client as having expressive aphasia. Later in the day, the family asks the nurse to explain what this means. The most accurate response would be aphasia that is: A) Characterized by an inability to comprehend the speech of others or to comprehend written material B) Nearly normal speech except for difficulty with finding singular words C) Manifested as impaired repetition and speech riddled with letter substitutions, despite good comprehension and fluency D) Characterized by an inability to easily communicate spontaneously or translate thoughts or ideas into meaningful speech or writing Ans: D Feedback: Expressive or nonfluent aphasia is characterized by an inability to easily communicate spontaneously or translate thoughts or ideas into meaningful speech or writing.

Conduction aphasia is manifest as impaired repetition and speech riddled with letter substitutions, despite good comprehension and fluency. Anomic aphasia is speech that is nearly normal except for difficulty with finding singular words. Wernicke aphasia is characterized by an inability to comprehend the speech of others or to comprehend written material.

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15. A client has been diagnosed with a cerebral aneurysm and placed under close observation before treatment commences. Which of the following pathophysiologic conditions has contributed to this client's diagnosis?

A) Weakness in the muscular wall of an artery B) Impaired synthesis of clotting factors C) Deficits in the autonomic control of blood pressure D) Increased levels of cerebrospinal fluid Ans: A Feedback: Aneurysms are direct manifestations of a weakness that exists in the muscular wall of an arterial vessel. Hypertension is a significant risk factor, but autonomic contributions are not common. Levels of cerebrospinal fluid (CSF) and hypo- or hypercoagulability are not implicated in the pathogenesis of aneurysms.

16. 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.

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17. 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.

18. 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.

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19. 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.

20. 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.

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21. A client with a history of a seizure disorder has been observed suddenly and repetitively patting his knee. After stopping this repetitive action, the client appears confused but is oriented to person and place but not time. What type of seizure did this client most likely experience?

A) Tonic–clonic seizure B) Atonic seizure C) Myoclonic seizure D) Focal seizure with impairment to consciousness Ans: D Feedback: Focal seizures with impairment of consciousness, sometimes referred to as psychomotor seizures, are often accompanied by automatisms or repetitive nonpurposeful activities such as lip smacking, grimacing, patting, or rubbing clothing. Confusion during the postictal period (after a seizure) is common. Atonic seizures are characterized by loss of muscle tone, and myoclonic seizures involve brief involuntary muscle contractions induced by stimuli of cerebral origin. With tonic–clonic seizures, formerly called grand mal seizures, a person has a vague warning (probably a simple focal seizure) and experiences a sharp tonic contraction of the muscles with extension of the extremities and immediate loss of consciousness.

22. A client has started having uncontrolled seizures that are not responding to usual medications. Nursing working with the client must pay special attention to which of the following priority aspects of this clients care? Assessment of: A) ECG for arrhythmias B) Urine output and continence C) Ability to grasp hands and squeeze on command D) Respiratory status and oxygen saturation Ans: D Feedback: Tonic–clonic status epilepticus is a medical emergency and, if not promptly treated, may lead to respiratory failure and death. Treatment consists of appropriate life support measures. Airway/breathing is always the priority in this emergency situation.

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23. The health care provider for a client with degenerative Alzheimer-type dementia recognizes the client has moved from the initial stage to the moderate stage based on which of the following clinical manifestations? Select all that apply.

A) Extreme confusion and disorientation B) Incontinence of urine and bowel C) Need for direct supervision for ADLs D) Social withdrawal from all family and friends E) Inability to problem solve simple tasks Ans: A, C, E Feedback: Although different staging schemas exist, three broad stages of Alzheimer dementia have been identified, each of which is characterized by progressive degenerative changes. The early stage is characterized by short-term memory loss, lack of spontaneity, and social withdrawal. The moderate stage of dementia is marked by extreme confusion, disorientation, and personal hygiene (ADLs) is neglected. During this stage, there are also changes in higher cortical functioning needed for language, spatial relationships, and problem solving. In severe Alzheimer disease, in the terminal stage, the person typically becomes incontinent.

24. Which of the following statements by the husband of a client with Alzheimer disease demonstrates an accurate understanding of his wife's medication regimen?

A) “I'm really hoping these medications will slow down her mental losses.”

B) “We're both holding out hope that this medication will cure her Alzheimer's.”

C) “I know that this won't cure her, but we learned that it might prevent a bodily decline while she declines mentally.”

D) “I learned that if we are vigilant about her medication schedule, she may not experience the physical effects of her disease.”

Ans: A Feedback: There is presently no cure for Alzheimer disease. Medications do not directly address the physical manifestations of Alzheimer disease. Rather, drugs are used primarily to slow the progression and to control depression, agitation, or sleep disorders.

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25. A client with a long history of cigarette smoking and poorly controlled hypertension has experienced recent psychomotor deficits as a result of hemorrhagic brain damage. The client's psychomotor deficits are likely the result of: A) Alzheimer disease B) Frontotemporal dementia (FTD) C) Vascular dementia D) Wernicke-Korsakoff syndrome Ans: C Feedback: Vascular dementia is caused by brain injury resulting from ischemic or hemorrhagic damage. Smoking and hypertension are contributing factors, and slowness in psychomotor functioning is a main clinical feature of vascular dementia. The client's history and symptomatology are not characteristic of Alzheimer disease, FTD, or Wernicke-Korsakoff syndrome.

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1. Chapter 38 A client presents to the clinic complaining, “I have something in my eye.” When questioned, the client admits to a scratching and burning sensation and light sensitivity.

The health care provider suspects the client has developed: A) Conjunctivitis B) Retinal detachment C) Acute glaucoma D) Corneal edema Ans: A Feedback: Conjunctivitis causes bilateral tearing, itching, burning, foreign body sensation, and morning eyelash crusting and eye redness. The primary symptom of retinal detachment is painless changes in vision. Commonly, flashing lights or sparks, followed by small floaters or spots in the field of vision, are early symptoms. Attacks of glaucoma (increased intraocular pressure) are manifested by ocular pain, excruciating headache, blurred or iridescent vision, and corneal edema with hazy cornea, dilated (mydriasis), and fixed pupil; with repeated or prolonged attacks, the eye becomes reddened. With corneal edema, the cornea appears dull, uneven, and hazy; visual acuity decreases; and iridescent vision (i.e., rainbows around lights) occurs.

2. Which of the following people are at high risk for developing nonulcerative inflammation of the cornea? Select all that apply.

A) A welder with inadequate eye protection B) A contact lens wearer who is noncompliant with cleaning and sterilizing the lens C) A female who uses a tanning bed four to five times/week D) A person who touched the fever blister and then rubbed the eye E) A ski patrol who works 12 hours/day in bright, sunny mountain tops Ans: A, C, E Feedback: In nonulcerative keratitis, all the layers of the epithelium may be affected, but the epithelium remains intact. There are a number of causes of epithelial keratitis, including epidemic keratoconjunctivitis caused by adenoviruses 8 and 19 and ultraviolet (UV) light exposure keratitis. Most cases of UV keratitis occur in welders with inadequate eye protection, but may also occur with tanning booth and other UV lamp exposure, and from sun reflecting off snow. Most cases of herpes keratitis are caused by HSV type 1 (labial [lip] herpes) and is ulcerative in nature. Acanthamoeba keratitis is a rare but sight-threatening complication that typically occurs in people who wear soft contact lens, particularly overnight or without proper disinfection.

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3. During accommodation, pupillary dilation partially compensates for the reduced size of the retinal image by: A) Thickening the lens B) Contracting the ciliary muscle C) Increasing light entering the pupil D) Narrowing the palpebral opening Ans: C Feedback: Accommodation is the process whereby a clear image is maintained as gaze is shifted from far to near objects. During accommodation, pupillary dilation partially compensates for the reduced size of the retinal image by increasing the light entering the pupil. Accommodation requires convergence of the eyes, pupillary constriction, and thickening of the lens through contraction of the ciliary muscle, which is controlled mainly by the parasympathetic fibers of the oculomotor cranial nerve (CN III). A third component of accommodation involves reflex narrowing of the palpebral opening during near vision and widening during far vision.

4. A client develops fever, headache, and burning/itching in the periorbital area. After a few days, a vesicular rash appears around the eyelid margins. The health care provider will likely prescribe: A) Topical antimicrobial for infection caused by overuse of contact lens B) Oral antibiotics to treat chlamydial infection C) Topical mast cell stabilizer to treat allergies D) Antiviral medication for herpes zoster ophthalmicus Ans: D Feedback: Herpes zoster ophthalmicus usually presents with malaise, fever, headache, and burning and itching of the periorbital area. These symptoms commonly precede the ocular eruption by a day or two. The rash, which is initially vesicular, becomes pustular and then develops crusts. Treatment includes the use of oral and intravenous antiviral drugs.

Initiation of treatment within the first 72 hours after the appearance of the rash reduces the incidence of ocular complications but not the postherpetic neuralgia. Chlamydial conjunctivitis is commonly spread by contact with genital secretions. It is treated with antimicrobial medications. Causes of ulcerative keratitis include infectious agents, exposure to trauma, and use of extended-wear contact lenses. The first manifestations of recurrent herpes keratitis are irritation, photophobia, and tearing. A history of fever blisters or other herpetic infection is often noted. Allergic conjunctivitis encompasses a spectrum of conjunctival conditions usually characterized by itching. Allergic conjunctivitis also has been successfully treated with topical mast cell stabilizers, histamine type 1 (H1) receptor antagonists, and topical nonsteroidal anti-inflammatory drugs.

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5. Which of the following vision deficits is a clinician justified in attributing to the normal aging process?

A) Conjunctivitis B) Presbyopia C) Strabismus D) Angle-closure glaucoma Ans: B Feedback: The term presbyopia refers to a decrease in accommodation that occurs because of aging. Conjunctivitis, strabismus, and angle-closure glaucoma are considered abnormal and pathologic in clients of all ages.

6. A 78-year-old female client has been scheduled for outpatient cataract surgery. While taking a presurgery history, which statement by the client correlates to the surgical procedure?

A) “One of my eyes has redness and purulent drainage.”

B) “I had intense eye pain coupled with photosensitivity.”

C) “I have blurred vision in both my eyes and my visual is distorted.”

D) “I feel like I have a buildup of pressure in my eyeball.”

Ans: C Feedback: Age-related cataracts, which are the most common type, are characterized by increasingly blurred vision and visual distortion. Symptoms of conjunctivitis include a foreign body sensation, a scratching or burning sensation, itching, and photophobia or light sensitivity. Severe pain suggests corneal rather than conjunctival disease. A discharge, or exudate, may be present. It is usually watery, when the conjunctivitis is caused by allergy, a foreign body, or viral infection, and mucopurulent (mucus mixed with pus) in the presence of bacterial or fungal infection. Trauma that causes abrasions of the cornea can be extremely painful. Glaucoma is a chronic, pressure-induced degenerative neuropathy that produces changes in the optic nerve and visual field loss.

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7. Which pregnant female is at risk of having an infant born with congenital cataracts?

A) A first-time mother over the age of 35 B) A pregnant mother with baby number 2 on the way who tested positive for human papillomavirus (HPV) C) A diabetic mother who regulates her blood glucose levels with insulin D) A mother who is 34 weeks' pregnant diagnosed with preeclampsia Ans: C Feedback: Acquired congenital and infantile cataracts and other developmental defects of the ocular apparatus depend on the total dose of the agent and the embryonic stage at the time of exposure. During the last trimester of fetal life, genetically or environmentally influenced malformation of the superficial lens fibers can occur. Congenital lens opacities may occur in children of diabetic mothers. Mothers' age, HPV status, or preeclampsia does not place them at risk for giving birth to an infant with cataracts.

8. Diabetic and hypertensive retinopathy are both characterized by the appearance of: A) Macular edema B) Cloudy corneas C) Microinfarctions D) Intraretinal hemorrhages Ans: D Feedback: Diabetic (background) retinopathy involves thickening of the retinal capillary walls, ruptured capillaries, microaneurysms, intraretinal hemorrhages, cotton-wool exudates, and microinfarcts. Decreased vision in persons with background retinopathy is commonly due to macular edema secondary to leakage of plasma from the small macular blood vessels. Chronic systemic hypertension results in intraretinal arteriole thickening, reduced capillary perfusion pressure, microaneurysms, intraretinal hemorrhages, cotton-wool exudates, and edema. Malignant hypertension causes localized optic disk edema (papilledema) produced by escaped fluid. Cloudy corneas are characteristic of anterior chamber disorders rather than retinopathy.

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9. As part of the community health department, a nurse is educating a group of diabetic clients about prevention of blindness. Which of the following topics should be covered during this class? Select all that apply.

A) Importance of yearly eye exams B) Need to have liver enzymes checked annually C) Tight control of blood glucose levels D) Keep BP below 130.85 (Am. Heart Assoc. Guidelines) E) Never eat dessert when you have eaten pasta for the meal Ans: A, C, D Feedback: Current guidelines recommend that persons with diabetes have yearly eye examinations.

Preventing diabetic retinopathy from developing or progressing is considered the best approach to preserving vision. Growing evidence suggests that careful control of blood glucose levels in persons with diabetes mellitus may retard the onset and progression of retinopathy. There also is a need for intensive management of hypertension and hyperlipidemia, both of which have been shown to increase the risk of diabetic retinopathy in persons with diabetes.

10. A client seeks medical care when he wrecks his care because of poor eyesight. At the time of admission, his blood glucose level was 390 mg/dL. The client is diagnosed with diabetes (type 2). The ophthalmologist must perform an urgent intravitreal injection.

The nurse explains this to the client by stating the doctor will: A) Just put a couple of drops in each of your eyes B) Put a needle with syringe into your eyeball and inject some medication to decrease active bleeding.

C) Remove some of the vitreous from your eye by withdrawing it with a needle/syringe and then strip some of the membranes off your inner eye.

D) Use a laser to try to seal off any bleeding vessels in your eyeball.

Ans: B Feedback: People with type 2 diabetes may have retinopathy as a presenting symptom at the time of diagnosis. Intravitreal injections of anti-VEGF agents are also being used to reduce active neovascularization and vitreous hemorrhage. Other treatment strategies for diabetic retinopathy include laser photocoagulation applied directly to leaking microaneurysms and grid photocoagulation with a checkerboard pattern of laser burns applied to diffuse areas of leakage and thickening. Because laser photocoagulation destroys the proliferating vessels and the ischemic retina, it reduces the stimulus for further neovascularization. Vitrectomy may be used for removing vitreous hemorrhage and severing vitreoretinal membranes that develop.

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11. A 60-year-old client's long history of poorly controlled hypertension has culminated in a diagnosis of retinal detachment. What type of retinal detachment is this client most likely to have experienced?

A) Rhegmatogenous detachment B) Exudative retinal detachment C) Posterior vitreous detachment D) Traction retinal detachment Ans: B Feedback: Exudative (or serous) retinal detachment results from the accumulation of serous or hemorrhagic fluid in the subretinal space due to severe hypertension, inflammation, or neoplastic effusions. Rhegmatogenous detachment is a full-thickness break (“rhegma”) in the sensory retina, with the passage of liquefied vitreous through the break into the subretinal space. Persons with high grades of myopia or nearsightedness may have abnormalities in the peripheral retina that predispose to sudden detachment. In moderate to severe myopia, the anteroposterior length of the eye is increased, and the retina tends to be thinner and more prone to formation of a hole or tear. As a result, there is greater vitreoretinal traction, and posterior vitreous detachment may occur at a younger age than in persons without myopia. Traction retinal detachment occurs with mechanical forces on the retina, usually mediated by fibrotic tissue, resulting from previous hemorrhage (e.g., from diabetic retinopathy), injury, infection, or inflammation.

Intraocular surgery such as cataract extraction may produce traction on the peripheral retina that causes eventual detachment months or even years after surgery.

12. An elderly woman has been diagnosed with macular degeneration following a visit to an ophthalmologist. Which of the woman's following statements best demonstrates an accurate understanding of her new diagnosis?

A) “I suppose this goes to show that I should have controlled my blood pressure better.”

B) “I think this is something that I might have caught from my husband.”

C) “My friend had this problem and a transplant did wonders for her vision.”

D) “I suppose that this may be one of the things that happen when you get older.”

Ans: D Feedback: Although some risk factors have been identified for macular degeneration, most diagnoses are attributed to increased age. The pathogenesis does not involve infection or hypertension, and a corneal transplant is not a recognized treatment modality.

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13. A client has been diagnosed with open-angle glaucoma during routine eye exam. The client has been prescribed a topical b-adrenergic antagonist. Client teaching about how this drug works should include which of the following statements? -adrenergic antagonists: A) Cause an early decrease in production of aqueous humor by constricting the vessels supplying the ciliary body.

B) Lower intraocular pressure by decreasing aqueous humor production C) Reduce the secretion of aqueous humor D) Exert their effects by increasing the effects of acetylcholine, thereby increase aqueous outflow through contraction of the ciliary muscle and pupillary constriction Ans: B Feedback: Topical -adrenergic antagonists, which are thought to lower intraocular pressure by decreasing aqueous humor production, are usually the drugs of first choice. The -adrenergic agonists cause an early decrease in production of aqueous humor by constricting the vessels supplying the ciliary body. Carbonic anhydrase inhibitors reduce the secretion of aqueous humor. Cholinergic drugs exert their effects by increasing the effects of acetylcholine (a postganglionic neurotransmitter in the parasympathetic nervous system) and increase aqueous outflow through contraction of the ciliary muscle and pupillary constriction.

14. Which of the following clients are at risk for developing and acute episode of angle-closure glaucoma? Select all that apply.

A) A 60-year-old female emotionally devastated after divorcing her husband of 35 years B) A soldier ordered to stay in a pitch-black cave to observe enemy militants for an extended period of time C) A person with low dietary intake of lutein, omega-3 fatty acids, and zinc D) A person with a high grade of myopia E) A surgical client who has received many doses of IV atropine to keep heart rate above 50 Ans: A, B, E Feedback: Manifestations of acute angle-closure glaucoma are related to sudden, intermittent increases in intraocular pressure. These occur after prolonged periods in the dark, emotional upset, and other conditions that cause extensive and prolonged dilation of the pupil. Administration of pharmacologic agents, such as atropine, that cause pupillary dilation (mydriasis) also can precipitate an acute episode. Age-related macular degeneration (AMD) is the most common cause of reduced vision in the elderly. In addition to older age, identifiable risk factors include cigarette smoking, obesity, and low dietary intake of lutein, omega 3 fatty acids, zinc, and vitamins A, C, and E. Persons with high grades of myopia or nearsightedness may have abnormalities in the peripheral retina that predispose to sudden detachment.

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15. A client presents to the emergency department complaining of loss of part of his vision.

An MRI with contrast reveals multiple aneurysms of the circle of Willis. The client is diagnosed with “bitemporal heteronymous anopia.” For this client, what effect will this have on his vision?

A) With both eyes open, the client has full binocular visual fields B) Bilateral loss of peripheral vision on both sides with a narrow binocular field C) Total, irreversible blindness D) Loss of a quarter of the visual field in both eyes Ans: A Feedback: The loss of the temporal fields (nasal retina) of both eyes is called bitemporal heteronymous anopia. With both eyes open, the person with bilateral defects still has the full binocular visual field. The loss of the same half-fields in the two eyes is called a homonymous loss, and the abnormality is called homonymous hemianopia. Blindness in one eye is called anopia. If half of the visual field for one eye is lost, the defect is called hemianopia; if a quarter of the field is lost, it is called quadrantanopia. Loss of the temporal or peripheral visual fields on both sides results in a narrow binocular field, commonly called tunnel vision.

16. During a routine 2-month checkup at the pediatric clinic, a mother expresses concern that her son looks “cross-eyed.” She asks if she need to put patches over his good eye.

Assessment reveals full eye movement, and the child uses each eye independently. The health care provider explains that the best treatment for the infant's eye problem is: A) A prescription for drops to put in the eyes twice/day.

B) “Pretend like you are going to poke him in the eye so that he will blink more and tighten up some muscles.”

C) To buy some prescription eye glasses so that lazy eye will get stronger.

D) To prepare for some surgery to correct this problem early on to correct the eye muscle disorder.

Ans: D Feedback: The disorder may be nonaccommodative, accommodative, or a combination of the two.

Infantile esotropia is the most common cause of nonaccommodative strabismus. It occurs in the first 6 months of life, with large-angle deviations, in otherwise developmentally and neurologically normal infants. Eye movements are full, and the child often uses each eye independently to alter fixation (cross-fixation). Infantile esotropia is usually treated surgically by weakening the medial rectus muscle on each eye while the infant is under general anesthesia. Recurrences are common with infantile esotropia, and multiple surgeries are often required.

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17. In comparison to children with acute otitis media (AOM), those with otitis media with effusion (OME) have: A) Systemic infection B) Earache and fever C) Excess middle ear fluid D) Sensorineural hearing loss Ans: C Feedback: Otitis media with effusion (OME) is a condition in which the tympanic membrane is intact and there is an accumulation of fluid in the middle ear without fever or other signs or symptoms of infection. Acute otitis media (AOM) is characterized by otalgia (earache), fever, temporary conductive hearing loss, and excess middle ear fluid in combination with signs and symptoms of an acute or systemic infection.

18. A new mother brings her infant to the clinic reporting that the child is not sleeping or eating much. Upon assessment, the health care provider notes that the infant's ear canal is reddened with a bulging tympanic membrane. Which other data collected would lead to the diagnosis of acute otitis media (AOM)? Select all that apply.

A) “Yes, he has been pulling at his ear.”

B) “We like to throw him up in the air hoping any water in his ear will drain.”

C) “He's been very irritable and fussy the past couple of days.”

D) “When I dropped a pan on the floor, he jumped.”

E) “He jabbers all the time usually.”

Ans: A, C Feedback: AOM is characterized by an acute onset of otalgia (ear pain), fever, and hearing loss.

Younger children often have nonspecific signs and symptoms that manifest as ear tugging, irritability, nighttime awakening, and poor feeding. Key diagnostic criteria include ear pain that interferes with activity or sleep, tympanic membrane erythema (redness), and middle ear effusion. A child with otitis media with effusion (OME) may develop delayed speech and language skills.

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19. A client presents to the ENT clinic with some vague signs/symptoms. Which complaints would lead the health care provider to suspect the client has otosclerosis? Select all that apply.

A) Inability to hear whispering.

B) Inability to hear when talking on the telephone.

C) When chewing food, sounds are much intensified.

D) In a noisy environment has a hard time hearing unless the health care provider speaks directly into the client's ear canal.

E) The person's own voice sounds unusually loud.

Ans: A, C, E Feedback: The symptoms of otosclerosis involve an insidious hearing loss. Initially, the affected person is unable to hear a whisper or someone speaking at a distance. In the earliest stages, the person's own voice sounds unusually loud, and the sound of chewing becomes intensified. Because of bone conduction, most of these persons can hear fairly well on the telephone, which provides an amplified signal. Many are able to hear better in a noisy environment. The pressure of otosclerotic bone on inner ear structures or the vestibulocochlear nerve (cranial nerve VIII) may contribute to the development of tinnitus, sensorineural hearing loss, and vertigo.

20. Frustrated by her worsening tinnitus, a 55-year-old female client has sought care. Which of the following teaching points should the clinician provide to the client?

A) “I know this can be very difficult to live with, but it normally fades over time.”

B) “I will prescribe some medication that will probably help quite well.”

C) “This might be a sign of a more serious neurologic problem that we will assess for.”

D) “Initially, there are some changes in your diet that you should implement.”

Ans: D Feedback: Tinnitus is not necessarily self-limiting, although it is not normally an indicator of neurologic disease. Pharmacologic treatments are limited, but dietary changes have met with success in many clients.

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21. One of the causes of conductive hearing loss is: A) Sudden loud noise B) Ototoxic medication C) Auditory nerve damage D) Excess middle ear fluid Ans: D Feedback: Conductive hearing loss occurs when auditory stimuli are not adequately transmitted through the auditory canal, tympanic membrane, middle ear, or ossicle chain to the inner ear; it is usually the result of middle ear fluid or infections. Other causes include ear canal cerumen, or foreign bodies, tympanic membrane thickening or damage, or bony structure (ossicles and oval window) damage of the middle ear caused by otosclerosis or Paget disease. Sensorineural deafness occurs when sound waves are conducted to the inner ear but abnormalities of the cochlear apparatus or auditory nerve decrease or distort the transfer of information to the brain. Causes of sensorineural deafness include genetic, infectious, traumatic loud noises, and ototoxic factors.

22. A female client with rheumatoid arthritis has taken high doses of aspirin for several years to control inflammatory pain. Which of the following statements leads the health care provider to suspect the client has developed ototoxicity?

A) “I can't go to the movies anymore. It's so noisy, I miss half the words.”

B) “I've been getting dizzy and light-headed. I seem to have a constant ringing in my ear.”

C) “I almost got hit by a garbage truck. I didn't hear its backup beeper.”

D) “When my grandchildren whisper, I can't hear a word they are saying.”

Ans: B Feedback: Ototoxicity results in sensorineural hearing loss. Vestibular symptoms of ototoxicity include light-headedness, giddiness, and dizziness; if toxicity is severe, cochlear symptoms consisting of tinnitus or hearing loss occur. The symptoms of drug-induced hearing loss may be transient, as often is the case with salicylates and diuretics, or they may be permanent. Hearing loss in the elderly is further characterized by reduced hearing sensitivity and speech understanding in noisy environments, slowed central processing of acoustic information, and impaired localization of sound sources.

High-frequency warning sounds, such as beepers, turn signals, and escaping steam, are not heard and localized, with potentially dangerous results. Clinical measures for hearing loss such as whispered voice tests and finger friction tests are reportedly imprecise and are not reliable methods for screening.

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23. Parents with a profoundly deaf child ask, “How can you test such a young infant for hearing loss?” The health care provider will likely explain which of the following testing procedures? Select all that apply.

A) Tuning fork B) Audioscope C) EEG with auditory brain stem–evoked responses (ABRs) D) Playing music and slowly increasing the sound until response is elicited E) PET scanning Ans: A, B, C Feedback: Tuning forks are used to differentiate conductive and sensorineural hearing loss.

Audioscopes can be used to assess a person's ability to hear pure tones at 1000 to 2000 Hz (usual speech frequencies). The ABR uses electroencephalographic (EEG) electrodes and high-gain amplifiers to produce a record of brain wave activity elicited during repeated acoustic stimulations of either or both ears. It involves subjecting the ear to loud clicks and using a computer to analyze nerve impulses as they are processed in the midbrain. Imaging studies such as computed tomography (CT) scans and magnetic resonance imaging (MRI) can be done to determine the site of a lesion (if tumor is suspected) and the extent of damage.

24. While on a cruise to the Caribbean, a person develops “motion sickness” with associated malaise, and nausea/vomiting. The nurse notes the client's BP is 88/52; pulse is 110; and skin moist with perspiration. The client diagnosis related to the clinical manifestations would most likely be: A) Light-headedness B) Vertigo C) Syncope D) Dizzy Ans: B Feedback: Vertigo can result from peripheral or central vestibular disorders (proprioception) unrelated to hearing loss. Vertigo is a vestibular disorder in which a unique illusion of motion occurs. Persons with vertigo frequently describe it as a sensation of spinning or tumbling, a “to-and-fro” motion, or falling forward or backward. Light-headedness, faintness, and unsteadiness are different in that the person perceives weakness yet still has a sense of balance. Syncope (loss of consciousness) is not directly associated with the sensation of vertigo. An inability to maintain normal gait may be described as dizziness despite the absence of objective vertigo.

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25. Which of the following signs and symptoms is most indicative of Ménière disease?

A) Rotary vertigo and tinnitus B) Nausea and vomiting C) Progressive hearing loss and frequent falls D) Otalgia and recurrent otitis media Ans: A Feedback: Ménière disease is characterized by fluctuating episodes of tinnitus, feelings of ear fullness, and violent rotary vertigo (room spinning) that often renders the person unable to sit or walk. Nausea and vomiting, hearing loss, and falls may accompany the disease, but these signs and symptoms are less definitive than frequent episodes of rotary vertigo accompanied by tinnitus.

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1. Chapter 39 Which of the following physiologic processes results from the synthesis and release of testosterone?

A) Protein catabolism B) Musculoskeletal growth C) Release of luteinizing hormone (LH) D) Prostatic hyperplasia Ans: B Feedback: Among the numerous effects of testosterone are the promotion of musculoskeletal growth in particular and protein anabolism in general. LH and FSH precede the synthesis and release of testosterone, whereas prostatic hyperplasia is not a normal effect of testosterone.

2. A 41-year-old male client is planning on having a vasectomy. While explaining this surgery to the client, the health care worker will include which physiologic principle as the basis for this contraception technique?

A) “Spermatogenesis is inhibited because sex hormones no longer stimulate the Sertoli cells.”

B) “Spermatozoa can no longer reach the epididymis and do not survive.”

C) “The rete testis becomes inhospitable to sperm.”

D) “Sperm can no longer pass through the ductus deferens.”

Ans: D Feedback: When the male ejaculates, the smooth muscle in the wall of the epididymis contracts vigorously, moving sperm into the next segment of the ductal system, the ductus deferens, also called the vas deferens. A vasectomy severs this conduit, rendering the male effectively infertile within a few weeks of the procedure. The procedure has no hormonal effect and neither the epididymis nor the rete testis is altered.

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3. A client has been diagnosed with an anterior pituitary tumor, and synthesis and release of follicle-stimulating hormone has become deranged. What are the potential consequences of this alteration in endocrine function?

A) Dysfunction of spermatogenesis B) Overproduction of luteinizing hormone C) Inhibition of testosterone synthesis D) Impaired detumescence Ans: A Feedback: Two gonadotropic hormones are secreted by the pituitary gland: FSH and luteinizing hormone (LH). In the male, LH also is called interstitial cell–stimulating hormone. The production of testosterone by the interstitial cells of Leydig is regulated by LH. FSH binds selectively to Sertoli cells surrounding the seminiferous tubules, where it functions in the initiation of spermatogenesis. FSH does not directly affect the production of LH, since both are produced by the anterior pituitary. FSH does not stimulate testosterone synthesis, and impaired detumescence is unlikely to be a direct consequence of changes in FSH synthesis and release.

4. While discussing the physiological process behind penile erection, the anatomy and physiology instructor mentions that what substance is released to facilitate smooth muscle relaxation and shunting of blood into the sinusoids?

A) Norepinephrine B) Nitroglycerine C) Nitric oxide D) Nicotinic acid Ans: C Feedback: Parasympathetic innervation must be intact and nitric oxide synthesis must be active for erection to occur. Parasympathetic stimulation results in release of nitric oxide, a nonadrenergic–noncholinergic neurotransmitter, which causes relaxation of the trabecular smooth muscle of the corpora cavernosa. This relaxation permits inflow of blood into the sinuses of the cavernosa at pressures approaching those of the arterial system. The nicotinic acid in cigarette smoke can induce vasoconstriction and penile venous leakage because of its effects on cavernous smooth muscle. Nitroglycerine is a vasodilator that has no effect on trabecular smooth muscle. A norepinephrine action is vasoconstriction, rather than relaxation, as part of sympathetic nervous system response.

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5. Common risk factors associated with erectile dysfunction due to generalized penile arterial insufficiency include: A) Cryptorchidism B) Cigarette smoking C) Testicular torsion D) Benign prostate hypertrophy Ans: B Feedback: Common risk factors for generalized penile arterial insufficiency include hypertension, hyperlipidemia, cigarette smoking, diabetes mellitus, and pelvic irradiation. Cigarette smoking induces vasoconstriction and penile venous leakage because of its effects on cavernous smooth muscle. Cryptorchidism is a major risk factor for testicular cancer.

Benign prostate hypertrophy (BPH) is a risk factor for ejaculatory pathway obstruction rather than erectile difficulties. With testicular torsion, testicular arterial perfusion is impaired.

6. 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.

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7. 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.

8. 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.

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9. 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.

10. 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.

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11. Which of the following disorders of the male genitourinary system creates the most urgent need for prompt and aggressive surgical treatment?

A) Spermatocele B) Benign prostatic hyperplasia (BPH) C) Intravaginal testicular torsion D) Erectile dysfunction Ans: C Feedback: Although all of the noted health problems warrant monitoring and possible treatment, intravaginal testicular torsion is an emergency that requires prompt surgery to save the torsed testicle.

12. A client arrives in the emergency department complaining of severe testicular pain associated with nausea and vomiting. Their pulse rate is 120 beats/minute. Physical exam reveals an enlarged testis that is painful to palpation. The nurse suspects: A) Inguinal hernia B) Cancer of the scrotum C) Testicular aneurysm D) Testicular torsion Ans: D Feedback: With testicular torsion, the testis rotates about the distal spermatic cord, obstructs perfusion through the testicular arteries and spermatic veins, and obstructs nerve conduction. The torsion obstructs venous drainage, with resultant edema and hemorrhage, and subsequent arterial obstruction. The dartos muscle separates the two testes and responds to changes in temperature by contracting when cold and relaxing when warm. Most squamous cell cancers of the scrotum occur after 60 years of age and are linked to poor hygiene, chronic inflammation, exposure to ultraviolet A radiation, or human papilloma virus (HPV). After descent of the testes, the inguinal canal normally closes almost completely; failure of this canal to close predisposes to the development of an inguinal hernia later in life.

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13. A client comes to the college campus nurse complaining of unilateral pain, swelling, and redness on his scrotal area. The nurse knows these clinical manifestations are likely caused by: A) Syphilis B) Testicular torsion C) Epididymitis D) Ticks bites Ans: C Feedback: Epididymitis is characterized by unilateral pain and swelling, accompanied by erythema and edema of the overlying scrotal skin that develops over a period of 24 to 48 hours.

Initially, the swelling and induration are limited to the epididymis. Syphilis is a sexually transmitted disease that is contagious and caused by a spirochete (Treponema pallidum).

If left untreated it can produce chancres, rashes, and systemic lesions in a clinical course with three stages continued over many years. Twisting of the spermatic cord (which is very painful) with a resulting compromise of the blood supply to the testis is known as testicular torsion. There is no indication that the client has experienced a tick bite.

14. A 30-year-old man has been diagnosed with mumps orchitis. The nurse should educate the client that which of the following complications may occur?

A) Erectile dysfunction B) Hematocele formation C) Sterility D) Penile atrophy Ans: C Feedback: The residual effects seen after the acute phase of mumps orchitis include hyalinization of the seminiferous tubules and atrophy of the testes, along with impaired spermatogenesis that has the potential to result in sterility. Spermatogenesis is irreversibly impaired in approximately 30% of testes damaged by mumps orchitis.

Penile atrophy, hematuria, and hematocele are not among the signs, symptoms, and sequelae of mumps orchitis.

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15. After seeking care due to recent history of testicular enlargement and scrotal pain, a 22-year-old college student has been diagnosed with testicular cancer. Which of the client's following statements indicates the need for further teaching?

A) “I can't shake this feeling like I've received a death sentence.”

B) “I have to admit that the prospect of losing a testicle is a bit overwhelming.”

C) “I really hope the cancer hasn't spread anywhere, because I've read that it's a possibility.”

D) “I guess there's some solace in the fact that this cancer wasn't a result of an unhealthy lifestyle.”

Ans: A Feedback: Testicular cancer has the potential for metastasis, but outcomes are positive for most clients and survival rates are high. With appropriate treatment, the prognosis for men with testicular cancer is excellent. Orchiectomy remains the standard treatment, and the pathogenesis of testicular cancer is not thought to be related to lifestyle factors.

16. Which of the following clients is at high risk for developing acute bacterial prostatitis?

A) A middle-aged male with prostate hyperplasia B) A fifth grade male diagnosed with acute pyelonephritis C) An elderly male diagnosed with frequent UTIs testing positive for gram-negative rods D) A sickle cell anemia client complaining of prolonged erection lasting less than 4 hours Ans: C Feedback: The most likely etiology of acute bacterial prostatitis is an ascending urethral infection or reflux of infected urine into the prostatic ducts. E. coli, other gram-negative rods, and enterococci, organisms known to cause urethritis are the most common infectious agents, rather than a descending bacterial infection from the kidneys (as in pyelonephritis). Benign prostatic hyperplasia (BPH) is an age-related, nonmalignant enlargement of the prostate gland caused by overgrowth of the prostate mucosal glands.

Prolonged erection does not increase the probability of developing acute bacteria prostatitis.

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17. Men older than age 50 are at high risk for prostatic hypertrophy with complications that include: A) Hypospadias B) Scrotal edema C) Urine retention D) Testicular cancer Ans: C Feedback: Benign prostatic hypertrophy (BPH) is a common disorder in men over 50; because the prostate encircles the urethra, BPH exerts its effect through obstruction of urinary outflow from the bladder. Hypospadias is a congenital condition in which the termination of the urethra is on the ventral surface of the penis. Scrotal edema is often the result of testicular disease or inflammation rather than prostate enlargement. Often the first sign of testicular cancer is a slight enlargement of the testicle that may be accompanied by some degree of discomfort.

18. When evaluating a client with suspected benign prostatic hypertrophy (BPH), the health care worker should collect data related to which of the following signs/symptoms?

Select all that apply.

A) Frequency of erectile dysfunction B) Enlarged inguinal lymph nodes C) Urinary frequency issues D) Weak urine stream E) Straining to empty the bladder Ans: C, D, E Feedback: It is now thought that the single most important factor in the evaluation and treatment of BPH is the man's own personal experiences related to the disorder. The American Urological Association Symptom Index consists of seven questions about symptoms regarding incomplete emptying, frequency, intermittency, urgency, weak stream, straining, and nocturia. Erectile dysfunction may develop secondary to the androgen hormone imbalances associated with BPH. Enlarged lymph nodes usually relates to a regional infection.

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19. Which of the following assessments is most likely to reveal a potential exacerbation in a 70-year-old client's diagnosis of benign prostatic hyperplasia (BPH)?

A) Urine testing for microalbuminuria B) Blood test for white blood cells and differential C) Digital rectal examination D) Sperm morphology testing Ans: C Feedback: The diagnosis of BPH is based on history, physical examination, digital rectal examination, urinalysis, blood tests for serum creatinine and prostate-specific antigen (PSA), and urine flow rate. The digital rectal examination is used to examine the external surface and size of the prostate. An enlarged prostate found during a digital rectal examination does not always correlate with the degree of urinary obstruction.

Some men can have greatly enlarged prostate glands with no urinary obstruction, but others may have severe symptoms without a palpable enlargement of the prostate.

Proteinuria, increased WBCs, and changes in sperm morphology are not associated with BPH.

20. An elderly male client has been diagnosed with prostate cancer. However, because he has a history of heart failure with an ejection fraction of 20% and chronic obstructive pulmonary disease due to many years of smoking, the client is not a candidate for major surgery. Which of the following treatments should the nurse anticipate being utilized for this client?

A) Transurethral prostatectomy (TURP) that only utilizes epidural blocks and small amounts of Versed and Fentanyl B) Stent placed to widen and maintain the patency of the urethra C) Teaching the client how to perform a straight catheterization every time they feel the need to empty their bladder D) Brachytherapy inserted into the penis and instilled into the prostate tissue Ans: B Feedback: The surgical removal of an enlarged prostate can be accomplished by the transurethral, suprapubic, or perineal approach. Currently, transurethral prostatectomy (TURP) is the most commonly used technique. For men who have heart or lung disease or a condition that precludes major surgery, a stent may be used to widen and maintain the patency of the urethra. A stent is a device made of tubular mesh that is inserted under local or regional anesthesia. Within several months, the lining of the urethra grows to cover the inside of the stent. It would be highly unlikely for the client to be asked to straight cath for urination. Brachytherapy would not be a treatment of choice since it would block the passage of urine from the bladder.

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21. Which of the following statements about screening for prostate cancer is most accurate?

A) Digital rectal examination detects the majority of new cases of prostate cancer.

B) A positive prostate-specific antigen (PSA) test is definitive for prostate cancer.

C) BPH and prostatitis can confound prostate screening results.

D) Digital rectal examination and PSA testing have been proven ineffective.

Ans: C Feedback: PSA is a glycoprotein secreted into the cytoplasm of benign and malignant prostatic cells that is not found in other normal tissues or tumors. However, a positive PSA test indicates only the possible presence of prostate cancer. It also can be positive in cases of BPH and prostatitis. Detection using digital rectal examination varies from 1.5% to 7%.

Screening remains somewhat controversial, but it has not been proven wholly ineffective.

22. Which of the following diagnoses is most likely to require surgical correction?

A) Hypospadias B) Orchitis C) Erectile dysfunction D) Spermatocele Ans: A Feedback: Hypospadias is a congenital disorder of the penis resulting from embryologic defects in the development of the urethral groove and penile urethra; surgery is the treatment of choice for hypospadias. Orchitis, erectile dysfunction (ED), and spermatocele rarely require surgical intervention.

23. A 17-year-old male has developed phimosis to the point that he is having difficulty voiding. The nurse should prepare this teenager for: A) Radiation therapy to loosen the foreskin B) Circumcision C) Injection of lidocaine into the head of the penis D) Traumatic retraction of the foreskin Ans: B Feedback: Phimosis refers to a tightening of the prepuce or penile foreskin that prevents its retraction over the glans. If symptomatic phimosis occurs after childhood, it can cause difficulty with voiding or sexual activity. Circumcision is then the treatment of choice.

Radiation therapy is utilized for cancer treatment. Lidocaine and forceful retraction of the foreskin is not a standard treatment for phimosis.

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24. During physical exam of a newborn, the nurse palpates the scrotal sac and only locates one testicle. Which statement about undescended testicles is most accurate?

A) “The child can become infertile later in life as a result of decreased sperm count.”

B) “This is more common in full-term infants when compared to premature births.”

C) “This may be a precursor to the development of prostate cancer later in life.”

D) “The child will need surgery to move the testes back into the scrotal sac since they rarely descend spontaneously.”

Ans: A Feedback: The consequences of cryptorchidism include infertility, testicular torsion, testicular (rather than prostate) malignancy, and the possible psychological effects of an empty scrotum. Males with cryptorchidism usually have decreased sperm counts, poorer-quality sperm, and lower fertility rates than do men whose testicles descend normally. Spontaneous descent often occurs during the first 3 months of life, and by 6 months of age, the incidence decreases to 0.8%. Spontaneous descent rarely occurs after 4 months of age.

25. Which of the following statements are accurate when it comes to changes in the male reproductive system as one ages? Select all that apply.

A) Androgen hormone levels increase with age.

B) Sexual energy levels decrease as one ages with decreasing testosterone levels.

C) The testes become smaller and lose their firmness.

D) The prostate gland enlarges with age.

E) The force of ejaculation increases with age.

Ans: B, C, D Feedback: Male sex hormone levels, particularly testosterone, decrease with age. The sex hormones play a part in the structure and function of the reproductive system and other body systems from conception to old age; they affect protein synthesis, salt and water balance, bone growth, and cardiovascular function. Decreasing levels of testosterone affect sexual energy, muscle strength, and the genital tissues. The testes become smaller and lose their firmness. The prostate gland enlarges, and its contractions become weaker. The force of ejaculation also decreases because of a reduction in the volume and viscosity of the seminal fluid.

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1. Chapter 40 Which of the following physiologic processes is caused by estrogens?

A) Increased release of gonadotropin-releasing hormone (GnRH) B) Stimulation of lactation in the postpartum period C) Promotion of ovarian follicle growth D) Progesterone synthesis Ans: C Feedback: Among the effects of estrogens is the promotion of ovarian follicle growth. Increased estrogen levels normally have an inhibitory effect on GnRH levels, whereas progesterone synthesis is not a result of estrogen's. Lactation is stimulated by prolactin.

2. Progesterone maintains pregnancy but also has which of the following local effects on the body? Select all that apply.

A) Decrease in absorption of sodium B) Increase in basal body temperature C) Increase in secretion of aldosterone by the adrenal cortex D) Relaxation of smooth muscle Ans: B, C, D Feedback: Progesterone can compete with aldosterone at the level of the renal tubule, causing a decrease in sodium reabsorption, with a resultant increase in secretion of aldosterone by the adrenal cortex (as occurs in pregnancy). Although the mechanism is uncertain, progesterone increases basal body temperature and is responsible for the increase in body temperature that occurs with ovulation. Smooth muscle relaxation under the influence of progesterone plays an important role in maintaining pregnancy.

3. Which of the following clinical manifestations is most likely to accompany a diagnosis of vulvodynia?

A) Vulvar pain B) Purulent discharge C) Urinary incontinence D) Open lesions on the surface of the vulva Ans: A Feedback: Pain is the defining characteristic of vulvodynia. Contributing factors, such as wounds or lesions, are absent. Incontinence does not normally accompany vulvodynia, and there is an absence of purulent discharge, since the etiology is noninfectious.

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4. A 21-year-old college student has sought care because of the vaginal burning, itching, and redness that have become worse in recent weeks. Which of the clinician's assessment questions is most likely to apply to a diagnosis of vaginitis?

A) “Have your periods been regular in the last few months?”

B) “Have you ever had a sexually transmitted infection?”

C) “Are you using oral contraceptives?”

D) “Have you ever been pregnant?”

Ans: B Feedback: In women of childbearing years, causes of vaginitis are often a manifestation of some organisms that can be transmitted sexually. The use of oral contraceptives and menstrual disorders are not associated with the incidence of vaginitis, and previous pregnancies are not identified as risk factors or causes.

5. A client visited her health care provider and was diagnosed with acute cervicitis. A clinical manifestation that accompanies acute cervicitis may include: A) Abscess formation B) Mucopurulent drainage C) Thick gray-white plaques D) Persistent pruritic vulvitis Ans: B Feedback: With acute cervicitis, the cervix becomes reddened and edematous; irritation from the infection results in copious mucopurulent drainage and leukorrhea. Bartholin gland obstruction causes a cyst to form, becomes purulent, and results in abscess formation.

Lichen simplex chronicus lesions are labial thick, gray-white plaques. Squamous cell vulvar carcinoma is characterized by a recurrent, persistent, pruritic vulvitis, sometimes as the only complaint.

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6. When educating a group of teenagers about sexually transmitted infections (STIs), the school nurse also mentions that cervical cancer has been associated with which of the following viral infections?

A) Chlamydia trachomatis B) Herpes simplex C) Human papilloma D) Varicella zoster Ans: C Feedback: Carcinoma of the cervix is often considered a sexually transmitted disease. A preponderance of evidence suggests a causal link between human papilloma virus (HPV) infection and cervical cancer. Herpes simplex II and Chlamydia trachomatis cause infections that are considered sexually transmitted infections (STIs) and are unrelated to neoplastic changes of the cervix. Herpes varicella zoster is secondary chickenpox, also known as shingles, which forms along a dermatome path.

7. A 29-year-old client had a Papanicolaou smear performed during her most recent visit to her primary care provider. This diagnostic procedure aims to identify: A) Atypical cervix cellular changes B) Human papillomavirus (HPV) antibodies C) Cervical polyps D) Lesions at the transformation zone Ans: A Feedback: The primary purpose of a Pap smear is to obtain cytology samples from the cervix to examine the cervical cells for atypical changes. These precancerous changes represent a continuum of morphologic changes with indistinct boundaries that may gradually progress to cancer in situ and then to invasive cancer. The performance of a Pap smear allows for visualization of the cervix, but the primary diagnostic purpose is not the identification of lesions and polyps. Cytology samples are not tested for HPV antibodies.

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8. A client asks the health care provider to, “Explain this brachytherapy they want to do for my cervical cancer again.” The response should include which of the following statements?

A) “They will insert a radioactive device into your vagina, position it next to the cervix, so that curative levels of radiation are directly on the cancer site.”

B) “The physician will take you to surgery, place your legs in the stirrups, and irrigate your entire vaginal cavity with radioactive water. Then they will pack your vaginal with sterile packing.”

C) “You will go to the x-ray department where they will insert a device in your vagina until it touches the cervix and then turn on a laser.”

D) “You will come to the radiation department daily for at least 4 weeks where they will insert a device and shine a beam on your cervical cancer area, hoping for it to burn the cancer off.”

Ans: A Feedback: External-beam irradiation and intracavitary irradiation or brachytherapy (i.e., insertion of radioactive materials into the body) can be used in the treatment of cervical cancer.

Intracavitary radiation provides direct access to the central lesion and increases the tolerance of the cervix and surrounding tissues, permitting curative levels of radiation to be used. None of the other answers describe this process. It usually is inserted in radiology, and then the client is transported to a private room until an allotted timeframe.

9. A client visits the OB/GYN clinic complaining of low abdominal pain, purulent cervical discharge, and painful intercourse. The health care worker (HCW) diagnoses pelvic inflammatory disease. The HCW educates the client about that fact that this disease may be associated with: A) Chronic endometriosis B) Ruptured tubal pregnancy C) STI polymicrobial infection D) Serous luteal ovarian cysts Ans: C Feedback: Pelvic inflammatory disease (PID) is an inflammation and polymicrobial infection of the upper reproductive tract that involves the uterus (endometritis), fallopian tubes (salpingitis), or ovaries (oophoritis) associated with sexually transmitted and endogenous organisms. Endometriosis is the condition in which functional endometrial tissue is found in ectopic sites outside the uterus; the displaced endometrial tissue may cause localized inflammation. Ruptured tubal pregnancy causes salpingitis and inflammation unrelated to sexually transmitted disease (STD) infections. Benign ovarian epithelial tumors are almost always serous or mucinous. Serous (fluid-filled) luteal or follicular ovarian cysts are noninfective, are noninflammatory, and frequently resolve spontaneously without treatment.

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10. Endometriosis is characterized by painful hemorrhagic lesions in the pelvis, which may develop into which of the following potential complications?

A) Pelvic adhesions B) Endometrial cancer C) Candidiasis vaginitis D) Bladder herniation Ans: A Feedback: Endometriosis is the condition in which functional endometrial tissue is found in ectopic sites outside the uterus. Endometriosis usually becomes apparent in the reproductive years when the lesions are stimulated by ovarian hormones in the same way as normal endometrium, becoming proliferative, then secretory, and finally undergoing menstrual breakdown. Bleeding into the surrounding structures can cause pain and the development of significant pelvic adhesions. Endometrial cancer often develops as a result of prolonged estrogenic stimulation and/or unopposed estrogen therapy with excessive growth (i.e., hyperplasia) of the endometrium inside the uterus. Candidiasis vaginitis is a common yeast infection unrelated to intrapelvic endometriosis. Bladder herniation, cystocele, happens when bladder muscle support weakens with age or multiple births.

11. A client is complaining to the health care provider about several vague signs/symptoms.

Which of the following raises a “red flag” indicating the client may have developed endometrial cancer?

A) Lumps palpated in her breasts B) Small, atrophied ovaries C) Painless abnormal bleeding D) Difficulty emptying the bladder Ans: C Feedback: The major symptom of endometrial hyperplasia or overt endometrial cancer is abnormal, painless bleeding. Abnormal bleeding is an early warning sign of endometrial cancer in up to 90% of women, and because endometrial cancer tends to be slow growing in its early stages, the chances of cure are good if prompt medical care is sought. Fibrocystic changes, formerly called fibrocystic breast disease, are benign irregular fibrous breast lesions. Ovaries normally atrophy with age. Difficulty emptying the bladder may indicate bladder cancer or cystocele.

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12. A client comes to the OB/GYN clinic complaining of difficulty in emptying the bladder and frequency and urgency of urination. After examination, the health care provider will likely diagnose: A) Rectocele B) Cystocele C) Endometritis D) Prolapsed uterus Ans: B Feedback: Cystocele is herniation of the bladder into the vagina that occurs when the normal muscle support for the bladder is weakened, the bladder sags below the uterus, herniates through the anterior vaginal wall, and a cystocele forms. The symptoms include difficulty in emptying the bladder, frequency and urgency of urination, and stress incontinence. Rectocele is herniation of the rectum into the vagina; symptoms include discomfort because of the protrusion of the rectum and difficulty in defecation. Uterine prolapse is the bulging of the uterus into the vagina that occurs when the primary supportive ligaments are stretched; symptoms result from irritation of the exposed mucous membranes of the cervix and vagina and the discomfort of the protruding mass.

Endometritis symptoms include abnormal vaginal bleeding, mild to severe uterine tenderness, fever, malaise, and foul-smelling discharge.

13. As a result of endocrine disorder, the client with polycystic ovary syndrome will like exhibit which of the following clinical manifestations? Select all that apply.

A) Male pattern baldness B) Metabolic syndrome with insulin resistance C) Irregular menstrual cycles D) Infections of the cervix E) BP 100/70s, low normal Ans: A, B, C Feedback: Women with PCOS typically have abnormal gonadotropin levels, a problem that is manifested by increased release of LH in relation to FSH release. This causes an increase in production of androstenedione and testosterone by the theca cells of the ovary. PCOS is a common endocrine disorder affecting 5% to 10% of women of reproductive age and is a frequent source of chronic anovulation. The disorder is characterized by varying degrees of menstrual irregularity, signs of hyperandrogenism (acne and hirsutism or male pattern hair loss), infertility, and hyperinsulinemia or insulin resistance. A substantial number of women who are diagnosed with PCOS are obese, and most have polycystic ovaries. Hypertension is also common in women with PCOS.

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14. When explaining polycystic ovary syndrome (PCOS) to a newly diagnosed client, the health care worker states, “This ovarian dysfunction is caused by: A) Absent FSH.” B) Insulin deficit.”

C) Elevated LH.” D) Low androgen.”

Ans: C Feedback: The underlying etiology of the disorder is unknown, although most women have altered gonadotropin levels. Most women with PCOS have elevated luteinizing hormone (LH) levels with normal estrogen and follicle-stimulating hormone (FSH) production. This altered LH/FSH ratio often is used as a diagnostic criterion for this condition. The elevated LH level also results in increased androgen production. Hyperinsulinemia may also lead to the excess androgen production; the overall goal of PCOS treatment is to suppress the insulin-facilitated, LH-driven androgen production.

15. While taking the history of a female client complaining of irregular, very painful bleeding occurring after menopause, the health care provider is alert to which of the following high-risk indicators of ovarian cancer?

A) Never had any children B) Lactation history C) Mammary duct ectasia D) Oral contraceptive use for many years Ans: A Feedback: A family history of cancer, particularly breast and ovarian cancer, and nulliparity (not been pregnant) increase the risk of developing ovarian cancer, whereas oral contraceptive use, pregnancy, and lactation decrease the risk. There are no effective screening methods for ovarian cancer, and most cancers of the ovary produce no symptoms. Ductal ectasia manifests in older women as a spontaneous, intermittent, usually unilateral, grayish green nipple discharge.

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16. Which of the following complaints by middle-aged women should prompt a care provider to assess for the possibility of ovarian cancer?

A) “I'm having a lot of vaginal discharge lately and it's quite foul.”

B) “My periods have become quite irregular since last winter.”

C) “I have a sharp, stabbing pain on my side for the last few days.”

D) “I'm having a lot of indigestion and bloating, which I've never had before.”

Ans: D Feedback: Symptoms of ovarian cancer are frequently misattributed to other health problems because they tend to be vague in nature; these include dyspepsia and bloating. Changes in menstrual pattern, severe pain, and vaginal discharge are not typically associated with ovarian cancer, especially in earlier stages.

17. Which of the following would be considered a structural abnormality or disease process that could cause menstrual pain known as secondary dysmenorrhea? Select all that apply.

A) Endometriosis B) Uterine fibroids C) Cervicitis D) Cystocele E) Rectocele Ans: A, B Feedback: Secondary dysmenorrhea is menstrual pain caused by structural abnormalities or disease processes such as endometriosis, uterine fibroids, adenomyosis, pelvic adhesions, IUDs, or PID. In women with secondary dysmenorrhea, the pain often lasts longer than the menstrual period; it may begin before menstrual bleeding begins; and it may become worse during menstruation. Cervicitis is an acute or chronic inflammation of the cervix.

Acute cervicitis may result from the direct infection of the cervix, or it may occur secondary to a vaginal or uterine infection. Cystocele is a herniation of the bladder into the vagina. It occurs when the normal muscle support for the bladder is weakened, and the bladder sags below the uterus. This causes the bladder to herniate into the vagina due to the force of gravity and pressures from coughing, lifting, or straining at stool.

Rectocele is the herniation of the rectum into the vagina.

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18. A college student presents to the nurse's office complaining of premenstrual syndrome.

Which of the following clinical manifestations would confirm this diagnosis? Select all that apply.

A) Painful, edematous breasts B) Burning during urination C) Abdominal bloating D) Thick, cheesy vaginal secretions E) Painful intercourse Ans: A, C Feedback: Physical symptoms of PMS include painful and swollen breasts, bloating, abdominal pain, headache, and backache. Burning with urination could be caused by a vaginal or bladder infection. A thick, cheesy, vaginal secretion is usually associated with a yeast infection.

19. Which of the following physiologic changes results in menopause?

A) Changes in anterior pituitary function that alter ovarian hormone production B) Gradual resistance of ovarian target cells to LH and FSH stimulation C) Cessation of ovarian function and decreased estrogen levels D) Decreased levels of gonadotropin-releasing hormone (GnRH) Ans: C Feedback: The physiology of menopause involves a gradual cessation of ovarian function and resultant diminished levels of estrogen. The process is not rooted in pituitary or hypothalamic function, and it does not occur because of resistance by ovarian target cells.

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20. While breast-feeding her 3-month-old infant, the mother notices the breast area is hard, inflamed, and tender to touch. The clinic nurse explains that this is likely caused by: A) Intraductal papillomas B) Secretory cell hyperplasia C) Fibrocystic tissue changes D) Ascending bacterial infection Ans: D Feedback: Mastitis is inflammation of the breast. In the lactating woman, inflammation results from an ascending infection that travels from the nipple to the ductal structures. The most common organisms isolated are Staphylococcus aureus and Streptococcus.

Fibrocystic changes, formerly called fibrocystic breast disease, are nondiscrete nodules in a woman without breast disease. The mammary alveoli are lined with secretory cells capable of producing milk or fluid under the proper hormonal conditions. The route of descent of milk and other breast secretions is from alveoli to duct, to intralobar duct, to lactiferous duct and reservoir, to nipple. Intraductal papillomas are benign epithelial tissue tumors that manifest with a bloody nipple discharge.

21. Which of the following processes is a component of the pathogenesis of proliferative breast lesions without atypia?

A) Growth of ductile or lobular epithelial cells B) Cystic dilation of terminal ducts C) Increase in fibrous breast tissue D) Fat necrosis leading to lesion formation Ans: A Feedback: Proliferative lesions without atypia are characterized by proliferation of ductile or lobular epithelial cells. Dilation of the terminal milk ducts and a general increase in fibrous breast tissue are associated with fibrocystic breast changes. Fat necrosis is not implicated in the development of proliferative breast lesions without atypia.

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22. While undergoing annual breast exam assessing for any manifestations of breast cancer, the nurse will discuss which of the following factors that place the client at high risk for cancer? Select all that apply.

A) Late menopause B) First child born when she was 40 years old C) History of STIs and frequent vaginitis D) Multiple pregnancies E) Currently smokes approximately 2 packs/day of cigarettes Ans: A, B, E Feedback: Risk factors for breast cancer include sex, increasing age, personal or family history of breast cancer (i.e., at highest risk are those with multiple affected first-order relatives), history of benign breast disease (i.e., primary “atypical” hyperplasia), and hormonal influences that promote breast maturation and may increase the chance of cell mutation (i.e., early menarche, late menopause, and no term pregnancies or first child after 30 years of age). Modifiable risk factors include obesity (particularly after menopause), physical inactivity, caffeine—moderate to heavy consumption—cigarette smoking, and long-term use of postmenopausal hormone therapy. Women with sexually transmitted diseases (STDs) may have high-risk behaviors that can increase their chances of having reproductive organ and possible oral or nipple infection, rather than breast tumors.

23. A client with a family history of breast cancer has just learned that she carries the BRCA1 and BRCA2 mutation. When educating this client about follow-up care, which of the following statements would be most appropriate?

A) “You do not have to worry about passing this on to your adult female children.”

B) “You should schedule a bilateral mastectomy today.”

C) “You should have more frequent breast evaluations using an MRI rather than standard mammography.”

D) “You should ask your doctor to order a PET scan to see if you have any cancer lesions anywhere else in your body.”

Ans: C Feedback: Mutations in two breast cancer susceptibility genes—BRCA1 on chromosome 17 and BRCA2 on chromosome 13—may account for most inherited forms of breast cancer. A woman with known mutations in BRCA1 has a lifetime risk of approximately 57% for breast cancer and approximately 40% for ovarian cancer. BRCA2 is another susceptibility gene that elevates lifetime breast cancer risk to 49% and ovarian cancer risk to 18%. Breast evaluation using MRI is generally preferred over standard mammography for these women because of its enhanced sensitivity and lack of radiation exposure, which may be safer for them. Prophylactic surgery, in the form of bilateral mastectomy, bilateral oophorectomy, or both, has been shown to decrease the risk of developing cancer. These controversial surgeries can have physical and psychological side effects that warrant careful consideration before proceeding.

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24. A nurse is conducting a healthy living workshop for a group of women in their 20s.

Which of the following screening recommendations should the nurse provide to the participants?

A) Monthly breast self-examination (BSE) B) BSE or mammography each year starting at age 40 C) Annual clinical breast examination until age 65 D) Clinical breast examination every 3 years until age 40 Ans: D Feedback: In 2003, the American Cancer Society dropped its recommendation that all women perform regular, systematic self-examination. Women should have a clinical examination by a trained health professional at least every 3 years between 20 and 40 years of age and annually after 40 years of age. Mammogram screenings should be done annually by age 40.

25. A 59-year-old woman with a recent diagnosis of breast cancer has begun a course of hormone therapy. What is the goal of this pharmacologic treatment?

A) Blocking the effects of progesterone on tumor growth B) Increasing serum hormone levels to promote tumor cell lysis C) Blocking the entry of malignant cells into the axillary lymph nodes D) Blocking effects of estrogen on the growth of malignant cells Ans: D Feedback: Hormone therapy is used to block the effects of estrogen on the growth of breast cancer cells. Among the most common drugs used for hormone therapy is tamoxifen, a nonsteroidal antiestrogen that binds to estrogen receptors and blocks the effects of estrogens on the growth of malignant cells in the breast. Such drugs do not directly block axillary node involvement or induce tumor cell lysis.

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1. Chapter 41 Which of the following phenomena is thought to underlie the decreased reported incidence of some sexually transmitted infections (STIs)?

A) Increased knowledge of the correct use of condoms B) Increased public funding for health promotion activities C) Decreased reporting of cases of certain STIs D) Decreased numbers of sexual partners among young adults Ans: C Feedback: The actual incidence and prevalence of some STIs are thought to exceed reported rates.

Consequently, apparent decreases are not thought to reflect reality. This trend in reported incidence is not attributed to changes in condom use, health promotion, or decreased numbers of sexual partners.

2. A 22-year-old client has presented to her primary care provider for her scheduled Pap smear. Abnormal results of this diagnostic test may imply infection with: A) Human papillomavirus (HPV) B) Chlamydia trachomatis C) Candida albicans D) Trichomonas vaginalis Ans: A Feedback: Although a Pap smear does not test directly for HPV, dysplasia of cervical cells is strongly associated with HPV infection. An abnormal Pap smear is not indicative of chlamydial infection, trichomoniasis, or candidiasis.

3. A female receives a PAP smear result indicating she has human papillomavirus (HPV) infection. As part of her education, the nurse will emphasize the need for continued follow-up since HPV is directly associated with: A) Uterine cancer B) Cervical dysplasia C) Genital herpes lesions D) Urinary tract infections Ans: B Feedback: A relation between HPV and genital neoplasms has become increasingly apparent since the mid-1970s. HPV infection can be detected in cervical Papanicolaou (Pap) smears, with the first neoplastic changes noted on the Pap smear termed dysplasia. Testicular cancer is not associated with HPV. Although genital herpes (HSV) is also a sexually transmitted disease, it is a common cause of genital ulcers rather than cancer. Bacteria are the usual cause of urinary tract infections, rather than anogenital warts.

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4. A female college student is distressed at the recent appearance of genital warts, an assessment finding that her care provider has confirmed as attributable to human papillomavirus (HPV) infection. Which of the following information should the care provider give the client?

A) “There is a chance that these will clear up on their own without any treatment.”

B) “It's important to start treatment soon, so I will prescribe you pills today.”

C) “Unfortunately, this is going to greatly increase your chance of developing pelvic inflammatory disease.”

D) “I'd like to give you an HPV vaccination if that's okay with you.”

Ans: A Feedback: Genital warts may resolve spontaneously, although this does not preclude recurrence.

Many individuals will clear the virus and become negative within 1 to 2 years; it is unclear if development of an effective immune response completely clears the infection.

Pharmacologic treatments are topical, and vaccination is ineffective after infection has occurred. HPV infection is not correlated with pelvic inflammatory disease (PID).

5. A client with herpes simplex virus (HSV) presents to the clinic stating, “I can stop taking my drugs because I'm cured. My lesions are gone.” The health care provider bases his or her response knowing the pathophysiology behind the disappearance of HSV symptoms infection relates to: A) Replication of the squamous epithelium B) Periods of latency in the nervous system C) Inhibition of cell-mediated immunity D) Production of exotoxins Ans: B Feedback: The clinical course of HSV infection is a product of the virus's ability to remain latent in the dorsal root ganglia for long periods. Latency refers to the ability to maintain disease potential in the absence of clinical signs and symptoms. When latent, the immune system is ineffective, but the virus does not actively inhibit the cell-mediated immune system. HSV does not produce exotoxins, and replication of squamous epithelium accounts for the warts caused by HSV.

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6. While in its dormant state, herpes simplex virus resides and replicates in the: A) Local lymph nodes B) Subcutaneous tissue C) Mucous membrane D) Dorsal root ganglia Ans: D Feedback: In genital herpes, the virus ascends through the peripheral nerves to the sacral dorsal root ganglia. The virus can remain dormant in the dorsal root ganglia, or it can reactivate, in which case the viral particles are transported back down the nerve root to the skin, where they multiply and cause a lesion to develop. During the dormant or latent period, the virus replicates in a different manner so that the immune system or available treatments have no effect on it. Local lymph nodes respond to the inflammation of reactivation; the mucous membrane becomes erythematous and painful when lesions form; subcutaneous tissue is not damaged by the vesicles and shallow ulcerations.

7. The primary reason genital herpes has reached epidemic proportions throughout the world relates to the fact that: A) A large percentage (70%) of those infected experience no symptoms of the disease.

B) The lesions (LSILs) occur on the cervix and can only be detected by a Pap test.

C) Lesions take a long time to incubate and the small papules are usually located inside the vagina.

D) The organism spreads upward to the prostate gland in males and fallopian tubes in females.

Ans: A Feedback: Persons infected with HSV-1 remain at risk for acquiring HSV-2. Most cases of HSV-2 infection are subclinical, manifesting as asymptomatic or symptomatic but unrecognized infections. These subclinical infections can occur in people who have never had a symptomatic outbreak or they can occur between recognized clinical recurrences. Up to 70% of genital herpes is spread through asymptomatic shedding by people who do not realize they have the infection. Transient HPV infections can develop low-grade squamous intraepithelial lesions (LSILs) of the cervix as detected on a Pap test, colposcopy, or biopsy. Lesions of LGV can incubate for a few days to several weeks and thereafter cause small, painless papules or vesicles that may go undetected. If untreated, gonorrhea spreads from its initial sites upward into the genital tract. In males, it spreads to the prostate and epididymis; in females, it commonly moves to the fallopian tubes.

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8. Which of the following signs and symptoms is most clearly suggestive of primary genital herpes in a male client?

A) Presence of purulent, whitish discharge from the penis B) Emergence of hard, painless nodules on the shaft of the penis C) Itching, pain, and the emergence of pustules on the penis D) Production of cloudy, foul-smelling urine Ans: C Feedback: The initial symptoms of primary genital herpes infection include tingling, itching, and pain in the genital area, followed by eruption of small pustules and vesicles. In men, the infection can cause urethritis and lesions of the penis and scrotum. Rectal and perianal infections are possible with anal contact. Firm, subcutaneous nodules are not associated with herpes simplex virus (HSV), and the production of penile discharge and cloudy urine is not suggestive of the disease.

9. The physiological reasoning behind giving acyclovir, an antiviral medication, to a client diagnosed with genital herpes would include the fact that these drugs: A) Attack the cell wall and totally destroy the virus, thus curing the client B) Interfere with viral DNA replication, which can decrease the frequency of recurrences C) Will prevent the organism from developing a resistance to the treatment protocols D) Can be obtained without a prescription and usually applied topically Ans: B Feedback: There is no known cure for genital herpes, and the methods of treatment are largely symptomatic. The oral antiviral drugs acyclovir, valacyclovir, and famciclovir have become the cornerstone for management of genital herpes. By interfering with viral DNA replication, these drugs decrease the frequency of recurrences, shorten the duration of active lesions, reduce the number of new lesions formed, and decrease viral shedding. There are no FDA-approved PCR tests for chancroids. The chancroid organism has shown resistance to treatment with sulfamethoxazole alone and to tetracycline. Uncomplicated cases of candidiasis (not herpes) are treated with antifungal medications (e.g., clotrimazole, miconazole) that are available as topical preparations (creams or suppositories) that can be obtained without a prescription.

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10. When educating a teenager diagnosed with genital herpes (herpes simplex virus type 2, HSV-2), the health care provider needs to inform her of the importance of careful follow-up since she may be at greater risk for future development of: A) Cervical cancer B) HIV transmission C) Localized necrosis D) Urinary tract infection Ans: B Feedback: As with other ulcerative STIs, genital herpes (HSV-2) increases the risk of HIV transmission and is believed to play an important role in the heterosexual spread of HIV. There is no known cure for genital herpes, and the methods of treatment are largely symptomatic. Human papillomavirus (HPV), rather than HSV, is considered a cause of cervical cancer. Although HSV can reoccur, the lesions resolve and heal completely without tissue necrosis or scarring. Urinary tract infections are associated with bacterial vaginosis/vaginitis STIs.

11. Of the following STIs, for which STI should the nurse anticipate a prescription for antibiotics such as tetracycline or doxycycline since this infection will respond to antibiotic treatment?

A) Human papillomavirus (HPV) infection B) Herpes simplex virus type 2 (HSV-2) infection C) Candidiasis D) Lymphogranuloma venereum (LGV) Ans: D Feedback: Because HSV-2 and HPV infections and candidiasis have nonbacterial etiologies, these infections are insensitive to antibiotics. Lymphogranuloma venereum (LGV) is an acute and chronic venereal disease caused by Chlamydia trachomatis and is consequently sensitive to antibiotics.

12. Which of the following assessment questions is most likely to address the causation of a woman's new case of candidiasis?

A) “Have you recently begun a new sexual relationship?”

B) “Have you been on antibiotics recently?”

C) “Have you noticed any new growths on your vagina in recent months?”

D) “Do you use condoms during sexual activity?”

Ans: B Feedback: Recent antibiotic therapy frequently underlies causes of candidiasis. The disease is not normally transmitted by sexual contact, and tissue growth is not an associated sign.

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13. A woman who has developed vulvovaginal candidiasis will likely go to her health care provider complaining of: Select all that apply.

A) Redness B) Edema C) Frothy, foul-smelling discharge D) Painful urination E) Pustules on labia Ans: A, B, D Feedback: Women with vulvovaginal candidiasis commonly complain of vulvovaginal pruritus accompanied by irritation, erythema, swelling, dysuria, and dyspareunia. The characteristic discharge, when present, is usually thick, white, and odorless.

Trichomoniasis manifestations include presentation with copious, frothy, malodorous green or yellow discharge.

14. The most prevalent vaginal infection to be spread through sexual contact is: A) Candidiasis B) Trichomoniasis C) Vulvovaginitis D) Bacterial vaginosis Ans: B Feedback: Candidiasis is a yeast infection with a white cheesy discharge that causes vulvovaginitis.

Bacterial vaginosis is a nonspecific type of infection that produces a characteristic fishy-smelling discharge, the result of an imbalance of the normal vaginal flora. These infections are not normally spread by sexual contact. Trichomoniasis is usually spread through sexual contact.

15. A client presents to the GYN clinic complaining of large amounts of frothy yellow-green discharge that smells very foul. Immediately, the health care provider is thinking this client most likely has: A) Candidiasis B) Trichomoniasis C) Bacterial vaginosis D) Chlamydial infection Ans: B Feedback: Trichomoniasis causes a copious, frothy, malodorous, green or yellow discharge. The characteristic vaginal discharge of candidiasis, when present, is usually odorless, thick, and cheesy. The predominant symptom of bacterial vaginosis is a thin, grayish white discharge that has a foul, fishy odor. Chlamydial STD may be asymptomatic, but most women have mucopurulent drainage or hypertrophic cervical changes on examination.

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16. 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.

17. 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, the test is reliable only when a specimen with actively motile T. pallidum is examined immediately by a trained microscopist. It does, however, evoke a humoral immune response and production of antibodies that provide the basis for serologic tests.

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18. A couple presents to an infertility clinic. The health care provider will focus testing on which of the following sexually transmitted infections (STIs) that is very damaging to the reproductive system but rarely exhibits symptoms of infection?

A) Chlamydial infection B) Herpes simplex virus infection C) Gonorrhea D) Syphilis Ans: A Feedback: Women with chlamydial infection may be asymptomatic and may unknowingly experience damage to the reproductive system. A large number of cases go unreported because most people with chlamydial infection are asymptomatic and do not seek testing. Herpes simplex virus (HSV), syphilis, and gonorrhea consistently produce symptoms in infected women.

19. During infertility workup, the client is diagnosed with chlamydial infection. The health care provider will especially be looking for which complication of chlamydial infections that can interfere with egg transportation?

A) Uterine cancer B) Fallopian tube damage C) Amenorrhea D) Vaginal adhesions Ans: B Feedback: Chlamydia causes a wide variety of genitourinary infections; Chlamydia trachomatis infection is the most common reportable sexually transmitted infection (STI) in the United States. In women, untreated infection can lead to severe reproductive complications, including infertility, pelvic inflammatory disease, ectopic pregnancy, and chronic pelvic pain, and in men, it can cause prostatitis and epididymitis with subsequent infertility. Chlamydial infections are not associated with any reproductive cancers or amenorrhea.

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20. A sexually transmitted infection that is caused by a microorganism with two morphologically distinct forms is: A) Chancroid B) Candidiasis C) Trichomonas vaginalis D) Chlamydia Ans: D Feedback: Chlamydia exists in two morphologically distinct forms during its unique life—a small infectious elementary body and a large noninfectious reticulate body. T. vaginalis is a large anaerobic, pear-shaped, flagellated protozoan. Chancroid is a disease of the external genitalia and lymph nodes caused by the gram-negative bacterium Haemophilus ducreyi. Candida albicans is the most commonly identified organism in vaginal candidiasis (yeast infection), but other candidal species, such as Candida glabrata and Candida tropicalis may also be present.

21. A client presents to a STI clinic. Her primary complaint is related to purulent exudate and bleeding after intercourse. The health care worker will primarily focus on the diagnosis of which STI? A) Gonorrhea B) Chlamydial infection C) Human papillomavirus infection D) Genital herpes simplex virus infection Ans: A Feedback: The gonococcus is a pyogenic (i.e., pus-forming), gram-negative diplococcus that evokes inflammatory reactions characterized by purulent exudates. Internal human papillomavirus (HPV) condylomata acuminata warts are cauliflower-shaped lesions that affect the mucous membranes of the vagina, urethra, anus, or mouth. The initial symptoms of primary genital herpes (herpes simplex virus, HSV) infections include tingling, itching, and pain in the genital area, followed by eruption of small pustules and vesicles.

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22. A male diagnosed with gonorrhea will likely complain of which of the following clinical manifestations? Select all that apply.

A) Creamy, yellow discharge B) Pain in the urethra with urination C) Difficulty starting a stream of urine D) “Fish”-smelling discharge from the penis E) Diffuse pelvic pain Ans: A, B Feedback: In men, the initial symptoms of gonorrhea include urethral pain and a creamy, yellow, sometimes bloody, discharge. Candidiasis, trichomoniasis, and bacterial vaginosis are vaginal infections that can be sexually transmitted, and the male partner usually is asymptomatic. Chancroid causes genital ulcers; the lesions begin as macules, progress to pustules, and then rupture.

23. A female client presents an STD clinic. She is in the first trimester of pregnancy and has tested positive for gonorrhea. Because strains of N. gonorrhoeae have become resistant to penicillin, the current treatment recommendation includes: A) High-dose cefixime given in a single dose B) Ten-day supply of Flagyl C) Doxycycline over the course of 1 week D) No treatment until after the baby is born Ans: A Feedback: The current treatment recommendation to combat penicillin- and tetracycline-resistant strains of gonorrhea is ceftriaxone or cefixime in a single injection. While a single injection of cefixime is still the standard treatment, some strains of N. gonorrhoeae have begun to show resistance to this dose. Metronidazole (Flagyl) is one treatment of choice against anaerobic protozoans, which can cure Trichomonas vaginalis. The treatment of choice for syphilis is penicillin. Tetracycline or doxycycline is used for treatment in persons who are sensitive to penicillin, but these medications cannot be used in pregnancy. Obviously, the client will receive treatment. However, at time of delivery, the infant will be tested and treated as necessary.

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24. Which of the following events is associated with the primary stage of syphilis?

A) Development of gummas B) Development of central nervous system lesions C) Palmar rash D) Genital chancres Ans: D Feedback: Primary syphilis is characterized by the appearance of a chancre at the site of exposure.

A rash on the palms is associated with secondary syphilis, whereas gummas and central nervous system (CNS) lesions are indicative of tertiary syphilis.

25. An elderly female has slowly developed dementia and loss of vision. She is being evaluated for nursing home placement. Routine admission blood work reveals that the client tested positive for which STI associated with her current symptoms?

A) Tertiary syphilis B) Chlamydial C) Gonorrhea D) Human papillomavirus infection Ans: A Feedback: Tertiary syphilis is a delayed response of the untreated disease. The symptomatic tertiary stage frequently affects the cardiovascular system, central nervous system, liver, bones, and testes. In women, chlamydial infections may cause urinary frequency, dysuria, and vaginal discharge. In women, gonorrhea has recognizable symptoms, which include unusual genital or urinary discharge, dysuria, dyspareunia, pelvic pain or tenderness, unusual vaginal bleeding (including bleeding after intercourse), and fever.

HPV infection is associated with genital warts that typically present as soft, raised, fleshy lesions on the external genitalia, including the penis, vulva, scrotum, perineum, and perianal skin. External warts may appear as small bumps, or they may be flat, rough surfaced, or pedunculated.

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1. Chapter 42 A gymnastics student lands awkwardly and hurts her ankle. After MRI scan, it was revealed that she has a torn cartilage. The health care worker states it may take up to 3 to 4 months for this injury to heal. The basic physiologic reason behind the prolonged recovery is due to the fact that cartilage is/has primarily: A) The main secretor of an extracellular matrix B) Avascular C) Low tensile strength D) Lacking minerals Ans: B Feedback: Cartilage is avascular tissue, a fact that stands in contrast to bone tissue. Both bone and cartilage contain cells that secrete an extracellular matrix, which forms the structure of the tissue. Cartilage is more flexible than bone, but it also exhibits considerable tensile strength. Cartilage repair is a particularly slow process and may in fact not occur in some cases. In contrast to cartilage, the extracellular matrix of bone is mineralized, producing a hard tissue capable of providing support for the body and protection for its vital structures.

2. Hyaline cartilage is a firm but flexible type of connective tissue that is essential for: A) Calcium salt storage B) Growth of long bones C) Bone surface perfusion D) Reduced friction on tendons Ans: B Feedback: Hyaline cartilage is essential for growth before and after birth. As long bones grow in length, the deeper layers of cartilage cells in the growth plate multiply and enlarge, pushing the articular cartilage farther away from the metaphysis and diaphysis. Because cartilage has no blood vessels, this tissue fluid allows diffusion with blood vessels outside the cartilage. Cartilage dies if it becomes calcified. Bursae are located near joints and contain synovial fluid; their purpose is to prevent friction on a tendon.

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3. When discussing the interior quality of bones, the science instructor mentions that spongy bone has which of the following unique qualities? Select all that apply.

A) Rigidity B) Thickness C) A growth plate D) Tensile strength E) Weight-bearing properties Ans: D, E Feedback: Cancellous (spongy) bone is relatively light and composed of trabeculae of bone that form a lattice-like pattern. Its structure is such that it has considerable tensile strength and weight-bearing properties. Compact (cortical) bone forms the outer shell of a bone and has a densely packed calcified matrix that makes it more rigid than cancellous bone, without excessive thickness. Although the cancellous bone contains osteocytes to maintain the bony matrix, active bone growth occurs at the epiphyseal growth plate.

4. When describing the covering on bones to the students, the instructor asks, “Why is periosteum an important part of the bone covering?” The student responses should mention which of the following? It: A) Is composed of a single layer of osteoprogenitor cells B) Is the site of red blood cell development C) Supplies yellow bone marrow to assist with adipose cell production D) Contains blood vessels that assist with providing nutrition to bone tissue Ans: D Feedback: Bones are covered, except at their articular ends, by a periosteum membrane. The periosteum contains blood vessels and acts as an anchorage point for blood vessels as they enter and leave the bone. The endosteum is the membrane that is considerably thinner than the periosteum and is composed of a single layer of flattened osteoprogenitor cells and small amounts of connective tissue. Red bone marrow contains developing red blood cells and is the site of blood cell formation. Yellow bone marrow is composed largely of adipose cells. At birth, nearly all of the marrow is red and hematopoietically active.

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5. A long bone, such as the humerus of the upper arm, has which of the following structural characteristics?

A) A perichondrium that overlies most of the bone surface B) A durable outer shell made of cancellous bone C) A diaphysis at each end D) An endosteum composed of osteogenic cells Ans: D Feedback: The endosteum is the membrane that lines the spaces of spongy bone, the marrow cavities, and the haversian canals of compact bone. It is composed mainly of osteoprogenitor cells that contribute to the growth and remodeling of bone and that are necessary for bone repair. The principle functions of the periosteum and endosteum are the nutrition of bone tissue and continuous supply of new osteoblasts for repair and growth of bone. The perichondrium lines cartilage, not bone, and the outer shell of long bones is compact, or cortical, bone. The diaphysis is the medial section of long bone; an epiphysis is found at each end of the bone.

6. A client has fractured his sternum when his chest hit the steering wheel during an accident. Which of the following statements most accurately describes the physiologic function of bone marrow?

A) Hematopoiesis takes place in red bone marrow.

B) Yellow bone marrow predominates in infants.

C) By adulthood, all red bone marrow has been replaced by yellow bone marrow.

D) Yellow bone marrow is hematopoietically active in infants, but not in adults.

Ans: A Feedback: Blood cell production takes place exclusively in red bone marrow, which predominates in infants and decreases (but not disappears) with age. Yellow bone marrow is composed primarily of adipose tissue and is not hematopoietically active. As the need for RBC production decreases during postnatal life, red marrow is gradually replaced with yellow bone marrow in most of the bones. In adults, red marrow persists in the vertebrae, ribs, sternum, and ilea.

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7. Which of the following would be considered physiologic characteristics of immature or woven bone? It: Select all that apply.

A) Has low tensile strength B) Serves as temporary scaffolding for support C) Serves as weight-bearing pillar D) Is only found in mature adults E) Is found in parts of a healing fracture Ans: A, B, E Feedback: Immature or woven bone, consisting of trabeculae, looks like poorly organized bone. It is deposited more rapidly than lamellar bone, has low tensile strength, and serves as temporary scaffolding for support. It is found in the developing fetus, in areas surrounding tumors and infections, and as part of a healing fracture. Laminar or mature bone is composed largely of cylinder-shaped units of calcified matrix, called osteons, that are oriented parallel to the long axis of the bone. Functionally, osteons can be thought of as tiny weight-bearing pillars.

8. A physiology instructor asks the class, “What role do osteoblasts play in the physiology of bone tissue?” The student with the best answer would be: A) Differentiation into mature bone cells B) Synthesis and secretion of the bone matrix C) Maintenance of calcium balance D) Resorption of the bone matrix Ans: B Feedback: Osteoblasts are bone-building cells that synthesize and secrete the bone matrix.

Osteogenic cells differentiate into mature bone cells, whereas osteocytes and osteoclasts maintain calcium balance. The bone matrix is reabsorbed by osteoclasts.

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9. Which of the following serves as a communicating channel for exchange of nutrients and metabolites between the osteocytes and the blood vessels on the surface of the bone layer?

A) Woven bone B) Volkmann canals C) Osteons D) Canaliculi Ans: D Feedback: Extracellular fluid-filled passageways permeate the calcified matrix and connect with the lacunae of adjacent osteocytes. These passageways are called canaliculi. Because diffusion does not occur through the calcified matrix of bone, the canaliculi serve as communicating channels for the exchange of nutrients and metabolites between the osteocytes and the blood vessels on the surface of the bone layer. Woven bone is deposited more rapidly than lamellar bone, has low tensile strength, and serves as temporary scaffolding for support. Laminar or mature bone is composed largely of cylinder-shaped units of calcified matrix, called osteons, that are oriented parallel to the long axis of the bone. Canals of a second type called perforating, or Volkmann, canals lie at right angles to the long axis of the bone, connecting the vascular and nerve supplies of the periosteum and medullary cavity.

10. In third-world countries, many young children with severe vitamin C deficiency will exhibit: A) Impaired formation of the organic matrix B) Calcification of new bone growth C) Growth plate separation D) Widening of the cortex Ans: A Feedback: Scurvy (i.e., vitamin C deficiency) impairs the formation of the organic matrix of bone, causing slowing of growth at the epiphyseal plate and cessation of diaphyseal growth. In rickets (i.e., vitamin D deficiency), calcification of the newly developed bone is impaired. Epiphyseal separation can occur in children as the result of trauma; blood vessels that nourish the epiphysis rupture, causing cessation of growth and a shortened extremity. Bone growth in diameter occurs as concentric rings containing osteocytes are added to the bone surface cortex, unrelated to vitamin deficiency.

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11. Which of the following statements about bone mass and the elderly is accurate?

A) Bone mass is increased with aging due to all the wear and tear of the joints.

B) Once skeletal growth has been attained, there is no longer any replacement or repair.

C) Bone resorption and formation are no longer perfectly coupled, and bone mass is lost.

D) Hormones, like PTH, are much slower to be released as one ages.

Ans: C Feedback: In the adult, the length of one sequence (i.e., bone resorption and formation) is approximately 4 months. Ideally, the replaced bone should equal the absorbed bone. If it does not, there is a net loss of bone. In the elderly, for example, bone resorption and formation no longer are perfectly coupled, and bone mass is lost. Once skeletal growth has attained its adult size, the breakdown and renewal of bone that is responsible for skeletal maintenance is initiated at sites that require replacement or repair. This process is called bone remodeling. As long as the parathyroid glands are healthy, they will remain as important regulators of calcium and phosphate levels in the blood.

12. An increase in the level of RANKL would result in: A) Fusing of the epiphysis and metaphysis in long bones B) Changes in the rate of bone remodeling C) Decreased production of PTH D) Increased vitamin D activation Ans: B Feedback: Correct regulation of the RANKL/RANK/OPG pathway is necessary for normal bone remodeling and a balance between bone resorption and bone formation. The pathway in general, and levels of RANKL in particular, does not directly influence levels of PTH and vitamin D. RANKL has no bearing on the fusing of epiphyses and metaphyses.

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13. While discussing the role of parathyroid glands in bone formation, the instructor will mention which of the following statements? To maintain adequate serum calcium levels, parathyroid hormone: Select all that apply.

A) Activates vitamin D to increase intestinal absorption of calcium B) Reduces serum phosphate levels C) Facilitates release of calcium from the bone D) Stimulates the kidneys to hold on to more sodium E) Reduces tubular reabsorption of phosphates Ans: A, B, C Feedback: Parathyroid hormone (PTH) maintains serum calcium levels by initiation of calcium release from bone, by conservation of calcium by the kidney, by enhanced intestinal absorption of calcium through activation of vitamin D, and by reduction of serum phosphate levels. Calcium is immediately released from the canaliculi and bone cells; a more prolonged release of calcium and phosphate is mediated by increased osteoclast activity.

14. While discussing hormonal control of bone formation, one should note that which hormone lowers blood calcium levels and decreases bone resorption?

A) Vitamin D B) Calcitonin C) Prolactin D) Phosphate Ans: B Feedback: Whereas parathyroid hormone (PTH) increases blood calcium levels, the hormone calcitonin lowers blood calcium levels by inhibiting the release of calcium from bone into the extracellular fluid and by decreasing bone resorption. Vitamin D functions as a hormone in regulating body calcium; it increases calcium absorption from the intestine and promotes the actions of PTH on bone. PTH and prolactin stimulate vitamin D production by the kidney. Changes in the concentration of phosphate ions may affect serum calcium levels due to their inverse relationship. Phosphate is not a hormone.

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15. Which of the following food items are considered an important dietary source of vitamin D? Select all that apply.

A) Fish B) Cottage cheese C) Irradiated milk D) Mozzarella cheese sticks E) Apples Ans: A, C Feedback: Intestinal absorption occurs mainly in the jejunum and includes vitamin D2 and vitamin D3. The most important dietary sources of vitamin D are fish, liver, and irradiated milk.

Because vitamin D is fat soluble, its absorption is mediated by bile salts and occurs by means of the lymphatic vessels.

16. Which of the following joints is classified as a synarthrosis?

A) The joint between two vertebrae B) The joint between the femur and the pelvis C) The joint between the humerus and the radius and ulna D) An interphalangeal joint of the hand (knuckle) Ans: A Feedback: Synarthroses are joints that lack a joint cavity and move a little or not at all, such as the vertebral bodies joined by intervertebral disks. The hip joint, elbow, and knuckles are all moveable synovial joints.

17. While comparing and contrasting joints, the instructor mentions that the primary role of fibrocartilage includes: Select all that apply.

A) Absorption of physical shock B) Provision of flexibility C) Facilitation of long bone growth D) Tissue hydration E) Rigidity Ans: A, B Feedback: The fibrocartilaginous intervertebral disks between the vertebrae consist of binding connective tissue that holds the vertebrae together. These joints provide strength and shock absorption as well as considerable flexibility. Fibrocartilage is less flexible than other types of cartilage, and hyaline cartilage, not fibrocartilage, contributes to bone growth. Fibrocartilage does not contribute to tissue hydration.

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18. In contrast to synarthrosis joints, which synovial joints allow for movement in all directions?

A) Knee joints B) Elbow joints C) Shoulder joints D) Vertebrocostal joints Ans: C Feedback: Although as a group they are classified as freely moveable, synovial joints include planar joints, which allow almost no movement (e.g., vertebrocostal joint), and hinge joints, which allow angular movement in one plane (e.g., interphalangeal, knee, and ankle joints). Only the ball-and-socket joints permit movement in all directions (e.g., shoulder or hip joint).

19. While explaining the role of synovial fluid, the instructor rewards which student for identifying an accurate response? Select all that apply.

A) Supplies nutrient B) Forces water out of the cartilage matrix C) Supplies O2 to chondrocytes D) Brings cells to phagocytize debris in joints E) Lubricates the joint Ans: A, C, D, E Feedback: The synovium secretes a slippery fluid with the consistency of egg white called synovial fluid. In addition to supplying nutrients and oxygen to the chondrocytes in the articular cartilage, this fluid serves as a lubricant for the joint. Moreover, macrophages in the synovial fluid act to phagocytize debris in the joint space. Matrix components function as a mechanical spring. When pressure is applied, water is forced out of the cartilage matrix into the synovial fluid. When the pressure is released, water is attracted back into the collagen matrix. These water movements, which are brought about by the use of a joint, are essential for the delivery of nutrients and the exchange of carbon dioxide, oxygen, and other molecules between the synovial fluid and articular cartilage.

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20. Intercellular collagen fibers provide what function for tendons and ligaments?

A) Elastic recoil B) Shape flexibility C) Tensile strength D) Inorganic calcium Ans: C Feedback: Intercellular fibers found in skeletal tissue are mainly collagenous and elastic. Collagen is an inelastic and insoluble fibrous protein that has great tensile strength. Elastin is the major component of flexible elastic fibers that allows the fibers to stretch and rapidly recoil when tension is released. The intercellular matrix, rather than fiber, contains organic matter (collagen fibers in an amorphous ground substance) and inorganic matter (several forms of calcium).

21. A basketball player fell awkwardly when attempting to claim a rebound, a mishap that resulted in a tear to the anterior cruciate ligament (ACL) of his left knee. The school nurses will anticipate the player to exhibit which of the following clinical manifestations? Select all that apply.

A) Immoveable (locked) knee joint B) Intense pain C) Abscess formation D) Edema (swelling) of the knee E) Large hematoma on the anterior knee surface Ans: B, D Feedback: Ligaments are pliable enough to permit movement at the joints, but they tear rather than stretch when exposed to excess stress. Torn ligaments are extremely painful and accompanied by local swelling. Torn ligaments do not form abscesses or large hematomas.

22. How are the oxygenation needs of the articulating areas in a synovial joint met?

A) Capillaries release oxygenated blood into the synovial cavity at a controlled rate.

B) The cartilage of the articulating areas uses anaerobic metabolism exclusively.

C) Oxygen is provided to the articulating areas indirectly by synovial fluid.

D) The epiphyses of long bones provide oxygen to the articulating areas.

Ans: C Feedback: The articulating areas are nourished indirectly by the synovial fluid that is distributed over the surface of the articular cartilage. Blood is not normally released into the synovial cavity, and the cells of the articulating areas are not capable of anaerobic metabolism. The epiphyses of long bones do not provide oxygen to the articulating areas in a synovial joint.

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23. A client with a history of osteoarthritis in his hip, which he refers to as “bad hip,” is also complaining of knee pain. The physiological principle behind this would include the fact that: A) All joints of an extremity are innervated by the same peripheral nerves as they travel down the limb.

B) If the hip is dislocated, then the knee is not staying in the correct alignment.

C) There is more than likely a tear in the synovial membrane, which is impacting the amount of plasma diffusing between the vessels and the joint.

D) Synovial tissue has received an injury that is referring pain to the knee.

Ans: A Feedback: The nerve supply to joints is provided by the same nerve trunks that supply the muscles that move the joints. These nerve trunks also supply the skin over the joints. As a rule, all the joints of an extremity are innervated by the same peripheral nerves as they travel down an extremity. The blood supply to a joint arises from blood vessels that enter the subchondral bone at or near the attachment of the joint capsule and form an arterial circle around the joint. The synovial membrane has a rich blood supply, and constituents of plasma diffuse rapidly between these vessels and the joint cavity. Because many of the capillaries are near the surface of the synovium, blood may escape into the synovial fluid after relatively minor injuries. Healing and repair of the synovial membrane usually are rapid and complete. This is important because synovial tissue is injured in many surgical procedures that involve the joint.

24. While lifting weights during football season, a player hears a loud “pop.” This is primarily associated with a loss of which function?

A) Autonomic nerve fibers B) Supporting bursa sacs C) Reflexive proprioception D) Elastic articular cartilage Ans: C Feedback: Tendons and ligaments of the joint capsule connect muscles and bones, are sensitive to position and movement, and have reflexive proprioceptor responses to adjust and maintain supporting muscle tension for the joint. The joint capsule synovial membrane is innervated only by autonomic fibers that control blood flow. Bursae, closed sacs of synovial fluid, prevent friction in areas where tendons are deflected over bone, rather than maintaining muscle support. Cartilage is devoid of blood vessels and nerves; elastic-type cartilage is found in areas such as the ear.

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25. Magnetic resonance imaging of a client's knee has revealed the presence of bursitis. The nurse should anticipate performing which intervention for bursitis?

A) Applying Buck's traction with 10-pound weights B) Placing an ice pack on the knee to decrease swelling C) Administering an antihistamine like Benadryl to minimize inflammation D) Obtaining a surgical permit to repair the bursae Ans: B Feedback: Bursae contain synovial fluid, and they exist to prevent friction on a tendon. They are necessary in areas where pressure is exerted because of close approximation of joint structures. Bursae may become injured or inflamed, causing discomfort, swelling, and limitation in movement of the involved area. Buck's traction, Benadryl, and surgery are not the standard treatment for bursitis.

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1. Chapter 43 A child in gymnastics class has fallen off the balance beam and hurt her ankle. X-rays are negative for fracture, so the health care provider has diagnosed a severe sprain.

Which of the following treatment measures should be taught to the family and child?

Select all that apply.

A) Immobilization for several weeks B) Elevate the ankle on pillows C) Apply ice packs to the ankle D) Perform active and passive range-of-motion exercises daily Ans: A, B, C Feedback: The treatment of sprains involves rest, ice, compression, and elevation (RICE). For an injured extremity such as the ankle, elevation of the injured body part followed by local application of cold may be sufficient. Compression, accomplished through the use of adhesive wraps, helps to reduce swelling and provide support. In a sprain, the affected joint is immobilized for several weeks.

2. A college baseball player has seen his season cut short by a rotator cuff injury. Rotator cuff injuries are frequent because of: A) The inherent instability of the shoulder B) The absence of ligaments at the glenohumeral joint C) The vulnerability of the shoulder menisci D) The large mass of the humeral head Ans: A Feedback: The complexity and flexibility of the shoulder also mean that it is one of the more unstable joints. This makes it extremely vulnerable to injuries, including sprains, dislocations, and degenerative processes such as rotator cuff disorders. The glenohumeral joint contains ligaments, although menisci do not exist in the shoulder.

The anatomy of the humerus does not account for the weakness of the joint.

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3. Which of the following clients would be considered high risk for falling and fracturing a hip?

A) A 54-year-old male with obesity and short stature B) A 36-year-old female whose diet consists of excessive sugar intake C) A 77-year-old male with hearing impairment and corrective eye lenses D) An 81-year-old female taking medication for chronic osteoporosis Ans: D Feedback: Risk factors for hip fracture include excessive consumption of alcohol and caffeine (rather than sugar), physical inactivity, low body weight, tall stature, use of certain psychotropic drugs, residence in an institution, visual impairment (rather than hearing), and dementia. Osteoporosis weakens the bone and is an important contributing factor.

Most hip fractures result from falls.

4. Which of the following clients presenting to the emergency department would most likely be diagnosed with a pathologic stress fracture?

A) A teenager who fell of a ladder and hit the concrete driveway, landing on his hip B) A postmenopausal female who was diagnosed with breast cancer with metastasis to bone C) A competitive volleyball player diving to retrieve a volley and landing on his hip D) A weight lifter who bench-presses 200 kg lost balance and fell to the side, landing on his hip Ans: B Feedback: A pathologic stress fracture occurs in bones that already are weakened by disease or tumors. Fractures of this type may occur spontaneously with little or no stress. The underlying disease state can be local, as with infections, cysts, or tumors, or it can be generalized, as in osteoporosis, Paget disease, or disseminated tumors. A fatigue fracture results from repeated excessive wear on a bone. The most common fractures are those resulting from sudden direct impact, such as from a fall or blow, or indirect, such as a massive muscle contraction injury.

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5. A client presents to the emergency department following an accident where he fell off a chair. He reports hip numbness, increasing pain, and muscle cramping. The triage nurse suspects: A) Dislocated joint B) Osteosarcoma C) Osteomyelitis D) Closed hip fracture Ans: D Feedback: Shortly after a fracture has occurred, nerve function at the fracture site may be temporarily lost. The area may become numb, and the surrounding muscles may become flaccid. After this brief period, the pain sensation returns and with it muscle spasms and contractions of the surrounding muscles. There are pain, tenderness at the site of bone disruption, swelling, loss of function, deformity of the affected part, and abnormal mobility.

6. Following a fracture, the nurse is educating the client and his family about bone healing.

The nurse begins by stating: A) “In order to initiate the cellular events essential to bone healing, within a day or so, your body will develop a blood clot at the fracture site.”

B) “The first thing that will happen is your body will form a soft tissue callus around the fracture site.”

C) “Your body will first absorb any excess bone fragments that occurred as a result of the break.”

D) “Just like on your hands after hard work, your body will begin the healing process by forming a callus at the fracture site.”

Ans: A Feedback: There are essentially four stages involved in bone healing: hematoma formation, fibrocartilaginous callus development, ossification, and remodeling. Hematoma formation is thought to be necessary for the initiation of the cellular events essential to bone healing. As the result of hematoma formation, clotting factors remain in the injured area to initiate the formation of a fibrin meshwork, which serves as a framework for the growth of fibroblasts and new capillary buds.

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7. A client's clavicular fracture has healed in the weeks following a bicycle accident.

Which of the following events takes place in the remodeling stage of bone healing?

A) Formation of granulation tissue B) Development of fibrocartilage that resembles the appearance of the original bone C) Deposition of mineral salts into the callus D) Reduction in the size of the callus Ans: D Feedback: Remodeling involves resorption of the excess bony callus that develops in the marrow space and encircles the external aspect of the fracture site. As the callus matures and transmits weight-bearing forces, the portions that are not stressed are resorbed. As a result, the callus is reduced in size until the shape and outline of the bone have been reestablished. Formation of granulation tissue, the development of fibrocartilage, and the deposition of mineral salts all precede the remodeling stage.

8. Which of the following factors may adversely affect bone healing and therefore place the client at risk for long-term problems? Select all that apply.

A) Immobilization due to skeletal traction B) Walking with a walker with minimal weight bearing on affected side C) Delayed union at the fracture site within a period considered the normal healing time D) History of uncontrolled diabetes mellitus with associated circulatory problems Ans: C, D Feedback: Delayed union is the failure of a fracture to unite within the normal period (e.g., 20 weeks for a fracture of the tibia or femur in an adult). Malunion is caused by inadequate reduction or malalignment of the fracture. For healing to occur, the bone needs to be aligned and immobilized to maintain the alignment during bone remodeling. Individual factors that may delay bone healing are the client's age; current medications; debilitating diseases, such as diabetes and rheumatoid arthritis; local stress around the fracture site; circulatory problems and coagulation disorders; and poor nutrition. Weight bearing helps to maintain some area muscle tone while the bone is immobilized, avoiding muscle atrophy and loss of range of motion.

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9. The client has a fractured tibia. After the cast is applied, he is at high risk for compartment syndrome caused by: A) Inflammation B) Joint immobility C) Muscle atrophy D) Extremity elevation Ans: A Feedback: One of the most important causes of compartment syndrome is bleeding and edema caused by fractures and bone surgery. Compartment syndrome can result from a decrease in compartment size caused by constrictive dressings and casts, increased content volume caused by inflammation, swelling, bleeding, and venous obstruction, or a combination of the two factors. Muscle atrophy decreases volume of contents; casting (rather than immobility caused by the cast) can compress the compartment. Extremity elevation enhances venous return and decreases edema.

10. A child has been hospitalized for the treatment of hematogenous osteomyelitis. The defining characteristic of this type of osteomyelitis is: A) The presence of dead bone tissue B) Introduction of microorganisms from the bloodstream C) Bacterial proliferation in the absence of the classic signs of infection D) Destruction of the vascular network in the endosteum Ans: B Feedback: Hematogenous osteomyelitis originates with infectious organisms that reach the bone through the bloodstream. Dead bone tissue is indicative of osteonecrosis, not osteomyelitis. Hematogenous osteomyelitis is normally accompanied by the classic signs and symptoms of infection; the destruction of the vascular network in the endosteum is not a hallmark of the hematogenous variant of osteomyelitis.

11. The distinguishing characteristic of chronic osteomyelitis is the presence of: A) Sequestrum bone B) Abscess formation C) Severe bone pain D) External drainage Ans: A Feedback: The hallmark feature of chronic osteomyelitis is the presence of sequestrum, or dead bone that has separated from the surrounding living bone. Chronic osteomyelitis may be the result of delayed or inadequate treatment of acute hematogenous osteomyelitis or osteomyelitis caused by direct contamination of bone. Acute osteomyelitis is usually caused by bacteria. Bone abscesses and fissure formation to the skin surface, with external exudate drainage, are characteristic of severe acute or chronic osteomyelitis.

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12. Following a knee replacement surgery, a nurse's next door neighbor asks, “I don't think I am healing right. Can you come look at my knee?” Upon assessment, the nurse notices the client is warm to touch and has a fever; the incision is inflamed and not well approximated with foul-smelling drainage around the incision line. At this point, the nurse tells the client she needs to go see her surgeon because the client may have: A) Contaminated the wound with MRSA B) Osteomyelitis C) An abscess in the pocket of the incision D) Potential bone cancer Ans: B Feedback: Osteomyelitis after trauma or bone surgery usually is associated with persistent or recurrent fever, increased pain at the operative or trauma site, and poor incisional healing, which often is accompanied by continued wound drainage and wound separation. Prosthetic joint infections often present with joint pain, fever, and cutaneous drainage. There is no indication the client has developed a bone cancer.

13. A client is experiencing severe pain in his back to the point of being immobile and running a temperature. The client also has swelling in his lower back (vertebrae).

Following biopsy, the results show spinal tuberculosis. The nurse will anticipate explaining which priority intervention to this client?

A) Drain the abscess in the lower back B) Administer the four-drug antimicrobial medications C) Locate a chiropractor for pain control D) Log-roll the client while he is on bedrest Ans: B Feedback: Because there are no specific radiographic findings in tubercular osteomyelitis, the diagnosis is usually made by tissue biopsy or culture findings. In spinal tuberculosis, a computed tomography (CT)-guided biopsy is often used. The mainstay of treatment for tubercular osteomyelitis remains the appropriate three- or four-drug antimicrobial therapy based on current guidelines. Conservative treatment is usually as effective as surgery, especially for earlier and milder cases.

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14. While taking a client history, which of the following findings may lead the nurse to suspect the client is at risk for development of osteonecrosis?

A) Previous stress fracture in the hips B) Bacterial infection in the knee following total knee replacement C) Synovial inflammation with painful swelling and warm to touch D) Bone marrow ischemia due to radiation therapy for cancer Ans: D Feedback: Osteonecrosis refers to necrosis or death of bone and marrow in the absence of infection. All forms of bone necrosis result from ischemia; one of the most common causes is associated with administration of corticosteroids. The site of the lesion is related to ischemia of the vessels involved, rather than a bone fracture or joint area inflammation.

15. Following a lengthy series of diagnostic tests, a client's chronic hip pain has been attributed to advanced osteonecrosis. What treatment is this client most likely to require?

A) Joint replacement surgery B) Intravenous antibiotics C) Injections of corticosteroids into the synovial space D) Transfusion of packed red blood cells Ans: A Feedback: Advanced osteonecrosis often necessitates joint replacement surgery, since necrotic bone cannot be rehabilitated. Osteonecrosis is noninfectious in etiology, so antibiotics are not normally necessary. Steroid injections will not restore the affected bone, and blood transfusions do not address the cause of consequences of the problem.

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16. While explaining to a group of nursing students the difference between benign and malignant bone tumors, the instructor will emphasize that a benign tumor: Select all that apply.

A) Is associated with constant, deep aching pain that does not go away with rest B) May be asymptomatic and detected incidentally C) Is a painful mass that is detected on a long bone and seems to be increasing in size D) May cause the client to have a pathological fracture Ans: B, D Feedback: There are three major manifestations of bone tumors: pain, presence of a mass, and impairment of function. Although benign tumors are frequently asymptomatic and are detected as an incidental finding, malignant tumors are associated with constant, deep aching pain that does not go away with rest and is present at night. A mass or hard lump may be the first sign of a bone tumor. A malignant tumor is suspected when a painful mass exists that is enlarging or eroding the cortex of the bone. Benign and malignant tumors may cause the bone to erode to the point where it cannot withstand the strain of ordinary use. A sudden increase in pain followed by trivial trauma that is preceded by a history of mild, dull aching pain is suggestive of a pathologic fracture.

17. A client presents to a health care clinic reporting sudden onset of deep, localized pain and swelling in her proximal femur. The client is currently undergoing diagnostic workup for suspected lung cancer. The nurse suspects the client may have developed which of the following neoplasms of the skeletal system?

A) Exostosis B) Osteochondroma C) Endochondroma D) Osteosarcoma Ans: D Feedback: Osteosarcoma is an aggressive and highly malignant bone tumor that normally requires surgery and chemotherapy. Exostosis and osteochondroma are synonymous terms for types of benign neoplasms that often require no treatment. Endochondroma is also benign and may self-resolve.

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18. Which of the following lab results may be associated with metastatic bone disease?

Select all that apply.

A) Elevated alkaline phosphatase B) Decreased creatinine levels C) High serum calcium levels D) Lower serum phosphate levels Ans: A, C Feedback: Although any cancer can ultimately involve the skeleton, tumors that frequently spread to the skeletal system are those of the breast, lung, prostate, kidney, and thyroid. Serum levels of alkaline phosphatase and calcium often are elevated in persons with metastatic bone disease. Creatinine levels are not affected by this diagnosis.

19. A client with a diagnosis of small cell lung carcinoma has developed bone metastases, a finding that has prompted a series of new interventions. What are the primary goals of the treatment regimen for this client's bone cancer?

A) Prevention of brain metastasis and early identification of osteonecrosis B) Promotion of bone remodeling at tumor sites through calcium and vitamin D supplements C) Prevention of pathologic fractures and maximization of function D) Pain management and prevention of osteomyelitis Ans: C Feedback: The primary goals in treatment of metastatic bone disease are to prevent pathologic fractures and promote survival with maximum functioning, allowing the person to maintain as much mobility and pain control as possible. Osteonecrosis, osteomyelitis, and brain metastasis are not typical sequelae of bone metastasis. Tumor sites do not normally undergo remodeling, and dietary supplements alone would not foster this process.

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20. A couple has just learned that their newborn infant has been diagnosed with osteogenesis imperfecta, and they have responded by seeking out as much information as possible about their child's diagnosis. What should the clinician teach the couple about their child's health problem?

A) “This is something that your child may have inherited from one or both of you.”

B) “This might have been caused by something you were exposed to during the early part of your pregnancy.”

C) “You'll have to be vigilant of your child's safety for the next few years, but the disease often resolves spontaneously.”

D) “With aggressive treatment, most children with osteogenesis imperfecta are cured within several months.”

Ans: A Feedback: Osteogenesis imperfecta can be inherited as an autosomal recessive or dominant trait; environmental factors are not thought to cause the disease. It is not self-limiting, and there is no known cure.

21. Which of the following assessment findings on an infant lead the nurse to suspect developmental dysplasia of the hip (DDH), formerly known as congenital hip dislocation? Select all that apply.

A) Gluteal fold asymmetry B) Shortening of the thigh, so the knee on affected side is higher C) Joint capsule tightness to the point that there is no normal range of motion D) Delayed crawling on the knees Ans: A, B Feedback: In infants, signs of possible DDH include asymmetry of the hip or gluteal folds, shortening of the thigh so that one knee (on the affected side) is higher than the other knee, and limited abduction of the affected hip. Instability of the hip may produce a delay in walking. In less severe cases, the hip joint may be unstable, with excessive laxity of the joint capsule.

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22. Assessment of a newborn infant reveals the presence of developmental dysplasia of the hip (DDH) that is currently demonstrated by subluxation of the baby's hip joint and a general laxity in the baby's ligaments. What measures should be emphasized in this infant's treatment?

A) Corticosteroid therapy B) Close observation C) Open reduction D) Joint reconstruction Ans: B Feedback: Less severe cases of DDH in which dislocation is not present often resolve spontaneously and do not require surgical correction. If the condition does not resolve, a Pavlik harness is used on newborns (up to 6 months) to maintain the femoral head in the acetabulum. Pharmacologic treatments are not central to the management of DDH.

23. An infant is born with a clubfoot. The nurse should anticipate which of the following treatment measures may be instituted?

A) Surgery prior to leaving the hospital B) Administration of muscle-relaxing medications C) Skeletal traction with pins inserted into affected bones D) Serial manipulations and casting Ans: D Feedback: Treatment of clubfoot is begun as soon as the diagnosis is made. When treatment is initiated during the first few weeks of life, a nonoperative procedure may be effective.

Serial manipulations and casting are used gently to correct each component of the deformity. Surgery, muscle-relaxing medications, and skeletal traction are not primary treatment for clubfoots.

24. A child with a diagnosis of Legg-Calvé-Perthes disease will exhibit: A) Defective synthesis of type I collagen B) Congenital dislocation of the acetabulofemoral joint C) Necrosis of the proximal femoral head D) Intoeing due to metatarsus adductus Ans: C Feedback: Legg-Calvé-Perthes disease is an idiopathic osteonecrotic disease of the proximal (capital) femoral epiphysis. DDH involves congenital dislocation of the acetabulofemoral joint, whereas defective synthesis of type I collagen accounts for the pathologic effects of osteogenesis imperfecta. Intoeing is neither a cause nor a consequence of Legg-Calvé-Perthes disease.

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25. While explaining to the parents of a child diagnosed with postural scoliosis, the nurse will emphasize which of the following concepts? This form of scoliosis: A) Compresses vertebrae, causing nerve damage in distal limbs B) Can be corrected with bending and active/passive exercises C) Is congenital in nature and responds poorly to treatment measures D) Is often a long, C-shaped curve from the cervical area to sacral region and is very painful Ans: B Feedback: With postural scoliosis, there is a small curve that corrects with bending. It can be corrected with passive and active exercises. Structural scoliosis does not correct with bending. It is a fixed deformity classified according to the cause: congenital, neuromuscular, and idiopathic. Congenital scoliosis is caused by disturbances in vertebral development during the 6th to 8th week of embryologic development. In neuromuscular scoliosis, there is often a long, C-shaped curve from the cervical to the sacral region. It is seen in children with cerebral palsy, in whom severe deformity may make treatment difficult.

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1. Chapter 44 Disorders that affect cortical bone typically result in: A) Fractures of long bones B) Impaired collagen synthesis C) Infection D) Vertebral fractures Ans: A Feedback: Disorders in which cortical bone is defective or reduced in mass lead to fractures of the long bones, whereas those of cancellous bone lead preferentially to vertebral fractures.

Neither process directly causes impaired collagen synthesis or infection.

2. The condition that contributes to the pathology of all metabolic bone diseases is: A) Impaired vitamin D synthesis B) Osteosarcoma C) Infection D) Osteopenia Ans: D Feedback: Osteopenia is a condition that is common to all metabolic bone diseases. Metabolic diseases are noninfectious and are not neoplastic. Impaired vitamin D synthesis can cause osteopenia, but this phenomenon is not common to all metabolic bone diseases.

3. A female athlete has been diagnosed with amenorrhea due to intense training for a spot on the Olympic swimming team. As a health care provider, which of the following should be implemented to prevent premature osteoporosis?

A) Encourage a minimum of 10 hours of sleep/night.

B) Increase dietary intake of protein and iron.

C) Calcium/vitamin D supplements to support BMD. D) Watch sodium intake and eat a carb-consistent diet with lots of fruits.

Ans: C Feedback: The female athlete triad, a pattern of disordered eating that leads to amenorrhea and eventually premature osteoporosis, is being seen increasingly in female athletes because of an increased prevalence of eating disorders. Poor nutrition, combined with intense exercise training, can lead to decrease in the critical body fat–to–muscle ratio needed for normal menses and estrogen production by the ovary. The lack of estrogen combined with the lack of calcium and vitamin D from dietary deficiencies results in a loss of bone density and increased risk of fractures. Older athletes are at high risk for osteoarthritis, a degenerative joint disorder that is unrelated loss of bone density.

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4. For many clients, the first indication that they have osteoporosis is: A) Bone pain that is not alleviated by rest B) A bone fracture C) Craving high-calcium foods D) Decrease in range of motion in the hip and knee joints Ans: B Feedback: Osteoporosis is usually a silent disorder. Often, the first manifestations of the disorder are those that accompany a skeletal fracture—a vertebral compression fracture or fracture of the hip, pelvis, humerus, or other bones. The onset of the disease is not typically marked by pain or decreased range of motion. Clients with osteoporosis are not noted to crave foods that are high in calcium.

5. Which of the following measures should a public health nurse recommend to middle-aged women to reduce their chances of developing osteoporosis later in life?

A) Weight control and daily use of low-dose corticosteroids B) Genetic testing and range-of-motion exercises C) Calcium supplementation and regular physical activity D) Increased fluid intake and use of vitamin D supplements Ans: C Feedback: Although the use of vitamin D supplements may be of preventative value for some clients, the primary prevention measures for osteoporosis include calcium supplementation and regular exercise. Genetic testing and increased fluid intake are not relevant measures, and corticosteroids are a risk factor for osteoporosis.

6. A 77-year-old woman has been admitted to the geriatric medical unit of the hospital for the treatment of pneumonia. The nurse providing care for the client notes the presence of nasal calcitonin, vitamin D, and calcium chloride on the client's medication administration record. The nurse should conclude that this client likely has a history of: A) Scleroderma B) Osteoarthritis C) Rheumatoid arthritis D) Osteoporosis Ans: D Feedback: Common pharmacologic treatments for osteoporosis include nasal calcitonin, vitamin D supplements, and calcium supplements. This combination of drugs does not address the etiology or manifestations of scleroderma, osteoarthritis, or rheumatoid arthritis.

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7. Which of the following clients are at risk for developing osteomalacia? Select all that apply.

A) An elderly female who “can't stand to drink milk” and refuses calcium supplements since she has a history of kidney stones B) A person who lives in a colder region of the northwest who doesn't get out much during the winter months for fear of falling C) A middle-aged adult with acute renal insufficiency caused by decreased cardiac output prior to having a coronary bypass graft surgery D) A young 30-year-old African American diagnosed with hypertension who is noncompliant related to taking medication and prescribed diet restrictions E) A female client whose father had a genetic predisposition to primary hyperparathyroidism resulting in increased calcium resorption from the bone Ans: A, B, E Feedback: In contrast to osteoporosis (which causes a loss of total bone mass), osteomalacia causes defective mineralization but not the loss of bone matrix. The incidence of osteomalacia is high among the elderly because of diets deficient in calcium and vitamin D. Melanin is extremely efficient in absorbing UVB radiation; thus, decreased skin pigmentation markedly reduces vitamin D synthesis. There also is a greater incidence of osteomalacia in the colder regions of the world, particularly during the winter months when UVB radiation is inadequate to allow skin synthesis of vitamin D. Acute renal insufficiency and uncontrolled hypertension do not relate to defective bone mineralization.

8. A client presented to the emergency department after getting “hit in the head with a baseball” while watching his grandson play. An x-ray of the head reveals poor quality of bone. The ED physician suspects the client has Paget disease. Which of the following signs/symptoms helps confirm this diagnosis? Select all that apply.

A) “I've had a lot of headaches lately.”

B) “Every now and then, I get a ringing in my ears.”

C) “Do you see my knuckles…they have big growths on them.”

D) “My thumb joint has been cracking every time I rotate it.”

E) “I have gotten dizzy and had to sit down while shopping.”

Ans: A, B, E Feedback: Skeletal expansion and distortion may be obvious if the disease affects the skull, jaw, clavicle, or long bones of the leg. Involvement of the skull causes headaches, intermittent tinnitus (ringing in the ears), vertigo (dizziness), and eventual hearing loss.

The abnormal knuckles and thumb joint are related to arthritis.

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9. An elderly resident of an assisted-living facility has had his mobility and independence significantly impaired by the progression of his rheumatoid arthritis (RA). What is the primary pathophysiologic process that has contributed to this client's decline in health?

A) A mismatch between bone resorption and remodeling B) Immunologically mediated joint inflammation C) Excessive collagen production and deposition D) Cytokine release following mechanical joint injury Ans: B Feedback: The pathogenesis of RA can be viewed as an aberrant immune response that leads to synovial inflammation and destruction of the joint architecture. Paget disease is caused by abnormal bone resorption and remodeling, whereas collagen deposition underlies scleroderma. Osteoarthritis is believed to be initiated by mechanical injury and subsequent cytokine release.

10. A feature of rheumatoid arthritis that differentiates it from other forms of inflammatory arthritis is the development of: A) Pannus tissue B) Tophus deposits C) Subluxations D) Autoantibodies Ans: A Feedback: Pannus is a feature of rheumatoid arthritis that differentiates it from other forms of inflammatory arthritis. Pannus, destructive vascular granulation tissue, extends from the synovium to involve the unprotected bone at the junction between cartilage and subchondral bone. Systemic lupus erythematosus (SLE) is characterized by the formation of autoantibodies and immune complexes. RA and SLE are characterized by subluxation of the carpometacarpal joint and other joints. With acute gouty arthritis, there are recurrent attacks of severe articular and periarticular inflammation, resulting in tophus formation (accumulation of crystalline deposits) in articular surfaces, bones, soft tissue, and cartilage.

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11. A client presents to the orthopedic clinic for evaluation since the primary care provider thinks the client may have rheumatoid arthritis (RA). Which statement by the client correlates with the diagnosis of RA? Select all that apply.

A) “I'm having a hard time opening doors since it hurts so bad.”

B) “Look, I didn't button all my shirt buttons…it just hurts too much and look at the swelling in my hands.”

C) “Look how my hand is deformed. My doctor calls it 'hyperextension.'”

D) “Just look at my face. It looks like I have varicose veins on my cheeks.”

E) “Every time I get something out of the freezer, my hands turn reddish purple in color.”

Ans: A, B, C Feedback: Rheumatoid arthritis (RA) joint involvement usually is symmetric and polyarticular.

Pain with turning door knobs, opening jars, and buttoning shirts is commonly reported due to swelling of the wrists and small joints of the hand. Hyperextension of the PIP joint and partial flexion of the distal interphalangeal (DIP) joint is called a swan neck deformity. As the RA inflammatory process progresses, synovial cells and subsynovial tissues undergo reactive hyperplasia. With osteoarthritis (OA), joint changes result from the inflammation caused when the cartilage attempts to repair itself, creating osteophytes or spurs. Raynaud phenomenon (a vascular disorder characterized by reversible vasospasm of the arteries supplying the fingers) and telangiectasia (dilated skin capillaries) are characteristic of scleroderma.

12. A health care provider suspects a female client (who has had vague complaints over the past several months) may be developing systemic lupus erythematosus (SLE). Which clinical manifestations would correlate with this diagnosis? Select all that apply.

A) Arthralgia B) Tendon rupture C) Facial hair growth D) Uncontrolled hypertension related to pyelonephritis E) Chest pain that increases with each deep breath Ans: A, B, E Feedback: Arthralgias and arthritis are among the most commonly occurring early symptoms of SLE. Pulmonary involvement is manifested primarily by pleural effusions and/or pleuritis. Pleural effusions are typically small, bilateral, and exudative. Up to 50% of persons with SLE develop pleuritis (chest pain that increases with each deep breath), which is manifested by pleuritic chest pain. Later manifestations include rupture of the Achilles tendons, hair loss, and forms of glomerulonephritis (rather than pyelonephritis).

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13. Which of the following signs and symptoms should prompt a 29-year-old woman's primary care provider to assess for systemic lupus erythematosus (SLE)?

A) Chronic nausea and vomiting that is unresponsive to antiemetics B) Joint pain and increased creatinine and blood urea nitrogen C) A history of thromboembolic events and varicose veins D) Dysmenorrhea and recent spontaneous abortion Ans: B Feedback: Renal involvement occurs in approximately one half to two thirds of persons with SLE, and arthralgia is a common early symptom of the disease. Although the manifestations of SLE are diffuse, these do not typically include alterations in hemostasis, gastrointestinal symptoms, dysmenorrhea, or miscarriage.

14. While explaining the physiology behind systemic sclerosis (scleroderma), the instructor states, “One of the hallmarks of scleroderma is: A) Activation of fibroblasts, resulting in fibrosis B) The development of thin fragile skin C) Development of a collagen deficiency D) Avascular necrosis of the femoral head Ans: A Feedback: Systemic sclerosis, sometimes called scleroderma, is an autoimmune disease of connective tissue characterized by excessive collagen deposition in the skin (with fibrotic thickening) and internal organs, such as the lungs, gastrointestinal tract, heart, and kidneys. Almost all persons with scleroderma develop polyarthritis and Raynaud phenomenon. Musculoskeletal manifestations of systemic lupus erythematosus (SLE), rather than systemic sclerosis, include rupture of the intrapatellar and Achilles tendons and avascular necrosis, frequently of the femoral head. RA granulomatous lesions have a central core of fibrinoid necrosis that is made up of a mixture of fibrin and other proteins such as degraded collagen.

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15. After numerous trips to the physician's office, a client is diagnosed with diffuse scleroderma based on which of the following clinical manifestations? Select all that apply.

A) Protruding eyeball with very red, inflamed eyes and associated photophobia.

B) Difficulty swallowing resulting in weight loss due to malabsorption.

C) Spider veins on the face and chest.

D) Hands turn bluish purple when getting items out of the freezer.

E) Inability to walk long distances with severe leg cramping in calf muscles.

Ans: B, C, D Feedback: Some persons with scleroderma have limited involvement and may develop the CREST syndrome, characterized by a combination of calcinosis (i.e., calcium deposits in the subcutaneous tissue that erupt through the skin), Raynaud phenomenon (a vascular disorder characterized by reversible vasospasm of the arteries supplying the fingers), esophageal dysmotility, sclerodactyly (localized scleroderma of the fingers), and telangiectasia (dilated skin capillaries). Protruding eyeball is related to hyperthyroidism, and inability to walk distances without cramping is known as claudication caused by poor circulation.

16. A client presents to the pain clinic for a steroid injection into the spine due to increasing pain around the joints. The health care provider tells the client, “You have inflammation where your tendons/ligaments insert into the bone. This injection should help.” The nurse assisting with the procedure recognizes this to be characteristic of: A) Sacroiliitis B) Calcinosis C) Excessive bone turnover D) Autoimmune etiology Ans: A Feedback: Sacroiliitis is a pathologic hallmark of the spondyloarthropathies. Calcinosis is associated with scleroderma. The spondyloarthropathies do not involve bone turnover, and an autoimmune etiology has not been demonstrated.

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17. A young adult male client presents to the orthopedic clinic complaining of “stiffening of the spine.” The health care provider orders some diagnostic lab work. Which lab result leads the health care worker to diagnose ankylosing spondylitis?

A) Elevated serum calcium level of 15.1 mg/dL B) Severe decrease in red blood cells associated with decreased iron levels C) Presence of HLA-B27 allele marker D) Elevated serum uric acid level Ans: C Feedback: The HLA-B27 antigen remains one of the best-known examples of an association between a disease and a hereditary marker; approximately 90% of those with ankylosing spondylitis possess the HLA-B27 antigen. Primary gout is often caused by an inborn error in metabolism and is characterized primarily by hyperuricemia and gout. The person also may have a mild normocytic normochromic anemia but not iron deficiency anemia.

18. A 26-year-old woman has sought care for increasing pain at the back of her ankle and the bottom of her foot over the past 2 weeks. The client states that she is generally in good health, although she completed a course of antibiotics for a chlamydial infection 6 weeks earlier. This client's recent history suggests the possibility of: A) Systemic sclerosis B) Ankylosing spondylitis C) Osteoarthritis D) Reactive arthritis Ans: D Feedback: Reactive arthritis may be triggered by infections such as that caused by Chlamydia trachomatis. The Achilles tendon and plantar fascia are the most common sites of involvement, and this is nearly always accompanied by pain. Osteoarthritis, systemic sclerosis, and ankylosing spondylitis are not suggested by this specific chain of events.

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19. A female client presents to the orthopedic clinic for evaluation. The primary care provider told her she has a “spur” on her joint. She asks, “Why did this happen? I guess I just didn't exercise enough.” The nurse recognizes this to be a later structural change of osteoarthritis (OA), where the client no longer has a “shock absorber,” culminating in: A) Osteonecrosis and loss of synovial fluid B) Formation of tophi in the synovial space C) Osteophyte formation and erosion of cartilage D) Separation of the epiphyseal plate Ans: C Feedback: As OA progresses, cartilage is lost and osteophytes, or spurs, develop on the surface of the articulating bones. Osteonecrosis does not typically develop, and synovial fluid is not lost. Tophi are associated with gout, not OA, and the epiphyseal plate does not separate in the course of OA.

20. An adult female client visits with her health care provider about pain in her hand. She describes it as an audible grinding and cracking sound, especially in her thumb. “I had to buy an automatic jar opener…I just can't grasp and open a jar…it just hurts too badly.” The health care provider suspects the client has a degenerative form of joint disease that is often evidenced by: A) Rheumatoid arthritis B) Systemic lupus erythematosus C) Osteoarthritis D) Ankylosing spondylitis Ans: C Feedback: In osteoarthritis (OA) syndrome, crepitus and grinding may be evident when the osteoarthritic joint is moved. OA joint enlargement results from new bone formation and the joint feels hard, in contrast to the soft, spongy feeling characteristic of the joint in rheumatoid arthritis (RA). The person with ankylosing spondylitis typically reports low back pain, which becomes worse when resting, particularly when lying in bed.

Systemic lupus erythematosus (SLE) is characterized by the formation of autoantibodies and immune complexes (type III hypersensitivity). SLE has the capacity to affect many different body systems, including the musculoskeletal system, skin, cardiovascular system, lungs, kidneys, central nervous system (CNS), and red blood cells and platelets.

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21. A clinic nurse plans care for a newly diagnosed osteoarthritis client. Which of the following items should this client be provided with educational materials? Select all that apply.

A) Splints to protect and rest the involved joint B) Use of heat and cold when appropriate for muscle spasms and pain C) How to use a cane or walker if hip/knees joints are involved D) High dose of daily glucosamine and chondroitin E) Narcotics to help control nighttime pain Ans: A, B, C Feedback: Physical measures are aimed at improving the supporting structures of the joint and strengthening opposing muscle groups involved in cushioning weight-bearing forces.

This includes a balance of rest and exercise, use of splints to protect and rest the joint, use of heat and cold to relieve pain and muscle spasm, and adjusting the activities of daily living. The involved joint should not be further abused, and steps should be taken to protect and rest it. These include weight reduction (when weight-bearing surfaces are involved) and the use of a cane or walker if the hips and knees are involved.

A recent multicenter trial funded by the National Institutes of Health found that glucosamine and chondroitin (alone or in combination) were no better than placebo in reducing pain in the total group of persons with knee pain. Narcotics are usually not the pain medication of choice for OA.

22. A 55-year-old male client has reported joint pain in his feet. Which of the following blood work results should prompt further testing to rule out primary gout?

A) Increased C-reactive protein (CRP) B) Increased serum uric acid C) Increased polymorphonuclear leukocytes D) Increased serum cortisol Ans: B Feedback: Although hyperuricemia is not diagnostic of gout, it is suggestive and should prompt further assessment. Increases in CRP, polymorphonuclear leukocytes, and cortisol levels are not as closely associated with the body's response to gout.

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23. When explaining to the client diagnosed with gout how the xanthine oxidase inhibitors work to help treat gout, the health care provider would include which of the following data? Allopurinol: A) Blocks the production of uric acid by the body B) Increases elimination of uric acid by the kidneys C) Prevents flare-up during the first few months of starting medication D) Can be given intravenously to rapidly decrease serum uric acid levels Ans: A Feedback: Xanthine oxidase inhibitors block the synthesis of uric acid. In this classification, the most commonly prescribed to lower urate levels is allopurinol. The uricosuric agents prevent the tubular reabsorption of urate and increase its excretion in the urine. Uricase agents convert insoluble uric acid to a soluble product than can be excreted easily.

Pegloticase is an infusible uricase agent that works rapidly to reduce serum uric acid.

24. When comparing a child's clinical manifestations with that of oligoarthritis versus systemic onset, the health care provider diagnoses this in your 4-year-old child with oligoarthritis based on which of the following clinical findings?

A) Right knee is warm and painful when putting it through normal range of motion.

B) Faint, red macular rash noted over entire body.

C) Rash is diffuse with severe itching.

D) Daily has an intermittent elevated temperature.

Ans: A Feedback: Oligoarthritis, which is the most common type of JIA, predominantly affects joints of the lower extremities, usually the knees or ankle. Involvement of upper extremity large joints and the hip is rarely a presenting sign. Often a single joint is affected at onset.

Children with this form of JIA are usually younger (1 to 5 years at onset) and are often rheumatoid factor (RF) positive. The symptoms of systemic JIA include a daily intermittent high fever, which usually is accompanied by a characteristic faint, erythematous, macular rash. The rash is not pruritic.

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25. An elderly female complains about waking up one morning with pain/stiffness in her neck/shoulders. Lab work reveals an elevated erythrocyte sedimentation rate (ESR). The physician gives the client a 3-day trial of prednisone, which significantly improves the pain. The health care provider correlates this information and diagnoses which of the following disorders?

A) Polymyalgia rheumatica B) Psoriatic arthritis C) Reiter syndrome D) Ankylosing spondylitis Ans: A Feedback: Polymyalgia rheumatica is a common syndrome of older clients, rarely occurring before 50 years and usually after 60 years of age. Reiter syndrome, psoriatic arthritis, and ankylosing spondylitis may occur at younger ages.

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1. Chapter 45 Which of the following would be considered functions of the skin? Select all that apply.

A) Protection against physical injury B) Protection from an invasion of microbes C) Regulation of acid–base balance D) Regulation of metabolism E) Synthesis of vitamin D Ans: A, B, E Feedback: Besides providing a covering for the entire body surface, the skin performs many other functions, including protection against physical injury, sunlight, and microorganisms; prevention of loss of fluids from the internal environment; regulation of body temperature; continual reception of sensations from the environment, such as touch, temperature, and pain; and synthesis of vitamin D through the action of sunlight on the skin. Acid–base regulation occurs primarily in the lungs and kidneys. Metabolic rate is regulated by many hormones, not the skin.

2. Which of the following clients would experience an accelerated rate of cell division in the stratum germinativum layer?

A) A stroke client who is incontinent of stool and bladder B) A motorcycle accident client with large abrasions on the lower limbs C) A young athlete who experienced a torn cartilage in the knee D) A pregnant client who has developed dark purple stretch marks on the abdomen Ans: B Feedback: The deepest layer, the stratum germinativum, consists of a single layer of basal cells that are attached to the basal lamina in the basement membrane zone. The basal cells are the only epidermal cells that are mitotically active. It normally takes 3 to 4 weeks for the epidermis to replicate itself. The rate of cell division in the stratum germinativum is greatly accelerated when the outer layers of the epidermis are stripped away as occurs in abrasions and burns. The outer epidermis, which is avascular, is composed of four to five layers of stratified squamous epithelial cells, predominantly keratinocytes, which are formed in the deepest layer of the epidermis and migrate to the skin surface to replace cells that are lost during normal skin shedding. These are most affected by incontinence. Stretch marks are similar to stratum granulosum cells that have a dark staining granule of keratohyalin.

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3. A skin care consultant informs the client that he needs to bath and use a soft cloth to remove dead cells on the skin surface. The rationale for this action is based on the fact that A) All layers of epidermis undergo rapid mitosis.

B) Cells of the stratum spinosum will turn into prickle cells if not removed by bathing.

C) A basal cell is mitotically active and pushes older dead cells to the skin's surface.

D) Keratinocytes will turn to fibrous protein tissue if not removed by bathing.

Ans: C Feedback: The basal cells are the only epidermal cells that are mitotically active. All cells of the epidermis arise from this layer. As new cells form in the basal layer, the older cells change shape and are pushed upward toward the skin surface. The second layer, the stratum spinosum, is two to four layers thick. The cells of this layer are commonly referred to as prickle cells because they develop a spiny appearance as their cell borders interact. The keratinocytes are the predominant cell type of the epidermis. They produce a fibrous protein called keratin, which is essential to the protective function of skin and may be involved in the immune system and wound healing.

4. When talking to a group of teenagers about ways to protect against skin damage from ultraviolet radiation, the nurse should discuss which of the following tissues/cells?

A) Melanocytes B) Langerhans C) Subcutaneous fat D) Protein granule Ans: A Feedback: In addition to the keratinocytes, the epidermis has melanin pigment–producing melanocytes that protect against ultraviolet radiation and Langerhans cells that link the epidermis to the immune system. Subcutaneous tissue contains fat and binds the dermis to underlying body tissues. The third keratinocyte layer, the stratum granulosum, is composed of flat cells containing protein granules called keratohyalin granules.

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5. A teenager has just been told by the dermatologist that he is high risk for developing skin cancer since he has natural red hair and fair skin. The physiology behind this statement may be due to the: A) Oversecretion of eumelanin, a brown-black pigment that causes tans B) Enhanced photoreactivity of pheomalanin, as compared to eumelanin C) Lack of pheomelanin pigmentation, which protects against skin cancer formation D) Increased susceptibility to photosensitivity due to oversecretion of melanin Ans: B Feedback: There are two major forms of melanin: eumelanin and pheomelanin. Exposure to the sun's ultraviolet rays increases the production of eumelanin, a brownish black pigment, which causes tanning to occur. An enhanced photoreactivity of the red melanin, pheomelanin, compared to the black melanin, eumelanin, is commonly invoked to explain why fair-skinned individuals are more susceptible to skin cancers. The primary function of such melanin is to protect the skin by absorbing and scattering harmful ultraviolet rays, which are implicated in skin cancers. Localized concentrations of eumelanin are responsible for the formation of freckles and moles. This does not mean that they will develop skin cancer. Pheomelanin, a reddish yellow pigment, provides color to the body when it is concentrated, primarily in the lips, nipples, glans penis, and vaginal areas. Photosensitivity refers to abnormal sensitivity (not reactivity) of the skin to ultraviolet light, usually following exposure to certain oral or topical drugs or to other sensitizing chemicals and resulting in accelerated burning and blistering of the skin.

Both types of melanin are found in hair, particularly red hair. It has been suggested that the reason fair-haired individuals are more susceptible to skin cancers may be due to the enhanced photoreactivity of pheomelanin, as compared to eumelanin.

6. A school student with a rash goes to the school nurse for evaluation. The nurse suspects the student has contact dermatitis. The primary cell responsible for this delayed-type hypersensitivity reaction is: A) Merkel cells B) Reticular dermis C) Langerhans cells D) Dermal dendrocytes Ans: C Feedback: As antigen-presenting cells, the Langerhans cells are involved in delayed-type hypersensitivity reactions such as contact dermatitis and other cell-mediated immune responses in the skin; their dendritic processes extend through keratinocytes, forming a network to bind and process antigen. Merkel cells provide sensory information to the skin. In the dermis, the reticular dermis is a complex meshwork of three-dimensional collagen bundles that contain dermal dendrocytes, which have phagocytic properties.

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7. Which of the following statements about temperature regulation and skin is accurate?

A) Since the skin is avascular, it is the subcutaneous layer that primarily is responsible for temperature control.

B) Arteriovenous anastomoses between an artery and a vein within the skin layer are important for temperature regulation.

C) It is primarily the arteries that bring blood from the heart that keeps the body temperature within a normal range.

D) The lymphatic system of the skin is primarily responsible for heating and cooling the skin.

Ans: B Feedback: The skin is richly supplied with arteriovenous anastomoses in which blood flows directly between an artery and a vein, bypassing the capillary circulation. These anastomoses are important for temperature regulation. The lymphatic system of the skin, which aids in combating certain skin infections, also is limited to the dermis.

8. A teenager with bullous pemphigoid on the thighs asks, “What causes this blistering?”

The best response by the nurse would be: A) “Your body has developed antibodies against basement membrane proteins.”

B) “You have been eating too much candy with large amounts of triglycerides.”

C) “The contraction of your arrector pili muscles causes this.”

D) “The lymph vessels are inflamed and responsible for this enlargement.”

Ans: A Feedback: The basement membrane zone is often involved in skin disorders that cause bullae or blister formation. One of these disorders, bullous pemphigoid, is a blistering disease caused by antibodies against basement membrane proteins. The thighs and flexor tendons are most commonly affected. The disease is self-limited but chronic, and the person's general health is unaffected. The sympathetic nervous system controls the arrector pili (pilomotor) muscles that cause elevation of hairs on the skin. Contraction of these muscles tends to cause the skin to dimple, producing “goose bumps.” The basal cells of the epidermis project into the papillary dermis, forming rete ridges. Lymph vessels and nerve tissue also are found in this layer.

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9. With eyes closed, an object is placed in a student's hand. The instructor asks the student to identify the object. When he does so correctly, this is primarily the responsibility of: A) Meissner corpuscles B) Conical projections C) Prickle cell lesions D) Krause end bulbs Ans: A Feedback: Meissner corpuscles are encapsulated mechanoreceptors specialized for tactile discrimination. They are concentrated on the fingertips and palms of the hands, where they account for about half of the tactile receptors. The skin is also supplied by Krause end bulbs, nerve endings contained in a cylindrical or oval capsule. They are found most frequently in the oral cavity, conjunctiva, and genitalia. Although their function is uncertain, they are thought to act as mechanoreceptors and heat detectors. The stratum spinosum is two to four layers thick, consisting of cells commonly referred to as prickle cells because they develop a spiny appearance as their cell borders interact. The papillary dermis lies adjacent to the epidermis and is densely covered with conical projections called dermal papillae.

10. Which of the following characteristics differentiates apocrine sweat glands from eccrine sweat glands?

A) Apocrine secretions contain oils.

B) Apocrine secretions help maintain skin pH. C) Apocrine glands are more numerous and widely distributed than eccrine glands.

D) Apocrine glands are primarily thermoregulatory.

Ans: A Feedback: The major difference between apocrine glands and the eccrine glands is that apocrine glands secrete an oily substance. Apocrine glands are less widely distributed than eccrine glands, and they do not contribute as significantly to thermoregulation. Neither is a major contributor to skin pH.

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11. When asked to name the parts of the pilosebaceous unit of the skin, which student has the correct answer?

A) Eccrine secretions B) Sebaceous glands C) Keratinized plates D) Connective tissues Ans: B Feedback: Most hair follicles are associated with sebaceous glands, and these structures combine to form the pilosebaceous unit. The nails are hardened keratinized plates. Eccrine sweat glands transport sweat to the outer skin surface to regulate body temperature. The subcutaneous tissue layer consists primarily of fat and connective tissues that lend support to the vascular and neural structures supplying the outer layers of the skin.

12. While lecturing about frostbite, the instructor asks the students, “Which substance prevents undue evaporation from the stratum corneum during the cold winter weather which then helps conserve body heat?” The most correct student answer is: A) A Langerhans cell, which produces antigen-presenting cells B) An eccrine sweat gland C) A nerve ending D) Sebum, secreted by the sebaceous gland Ans: D Feedback: Sebum lubricates the hair and skin, prevents undue evaporation of moisture from the stratum corneum during cold weather, and helps to conserve body heat. Langerhans cells are dendritic cells that reside principally in the stratum spinosum of the epidermis and play a major role in the functioning of the skin's immune system. Their major function is to phagocytose and process foreign antigens. Most hair follicles are associated with sebaceous glands, and these structures combine to form the pilosebaceous unit. Langerhans cells are not paired with hair follicles, and apocrine, not eccrine, glands are often associated with a hair follicle. Nerve endings are widely distributed throughout the skin, but these are not paired with hair follicles.

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13. When asking pathophysiology students, “Why do sebaceous glands secrete sebum?” the student with the correct answer would be: A) To lubricate skin and hair B) To supply energy in the form of fibrous protein C) To increase water amounts released via perspiration D) To supply a nutritional source for vitamin D Ans: A Feedback: Sebaceous glands secrete sebum, an oily mixture consisting of lipids, including triglycerides, cholesterol, and wax, that lubricates hair and skin. Keratinocytes of the epidermis produce a fibrous protein called keratin, which is essential to the protective function of skin. Sweat glands produce watery secretions. The dermis supports the epidermis and serves as its primary source of nutrition.

14. A 14-year-old presents to the dermatologist clinic with a severe case of acne. The nurse explains that this acne is a result of inflamed A) Follicular bulbs B) Dermal papillae C) Apocrine glands D) Sebaceous glands Ans: D Feedback: The sebaceous glands are the structures that become inflamed in acne. Growth of the hair is centered in the bulb (i.e., the base) of the hair follicle, which is just one part of the hair structure. Apocrine sweat glands are located deep in the dermal layer and open through a hair follicle. Dermal papillae minimize separation of the dermis and the epidermis and contain capillary venules that nourish the epidermal layers of the skin.

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15. In science class, a group of sixth graders are “freaked out” when they learn that nails grow continuously and are the end product of which of the following components?

A) Hypertrophy of arrector pili muscle B) Anagen follicles C) Telogen phase D) Dead cells pushed outward from the nail matrix Ans: D Feedback: Like hair, nails are the end product of dead matrix cells that are pushed outward from the nail matrix. Unlike hair, nails grow continuously rather than cyclically. The arrector pili muscle, located under the sebaceous gland, provides a thermoregulatory function by contracting to cause goose bumps. Anagen hair has long inner roots and outer root sheaths, is deeply rooted in the dermis, is difficult to detach, and does not come out with regular brushing. Telogen hair has short, white, club-shaped roots. With formation of new anagen hair below the root, the developing follicle will eventually replace the telogen hair, leading to the shedding of approximately 50 to 100 hairs a day.

16. In third-world countries, many children experience uncontrolled itching and scratching, which may develop into: A) Blisters B) Vesicles C) Lichenification D) Ulcers Ans: C Feedback: Repeated rubbing and scratching can lead to lichenification (thickened and roughened skin characterized by prominent skin markings caused by repeated scratching or rubbing) or excoriation (lesion caused by breakage of the epidermis, producing a raw linear area). Blisters are circumscribed elevations of the skin caused by fluid under or within the epidermis. Pustules are circumscribed pus-filled elevations of the skin.

Vesicles are small (<1.0 cm in diameter). An ulcer is a skin defect in which there has been loss of the epidermis and papillary layer of the dermis.

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17. A 22-year-old male college student has presented to his campus medical clinic distraught at the emergence of numerous small blisters on the shaft of his penis. On examination, the clinician notes that the lesions are between 2 and 4 mm in diameter and are filled with serous fluid. The clinician would document the presence of: A) Pustules B) Macules C) Vesicles D) Papules Ans: C Feedback: Vesicles are less than 1 cm in diameter and filled with serous fluid, such as the lesions typical of herpes simplex. Macules are small variations in skin color that are nonpalpable, while pustules are filled with pus. Papules are small, solid masses.

18. While breaking in a new pair of shoes, a client develops a large (1.0 cm) blister filled with clear fluid. The dermatologist diagnoses this as: A) Bullae B) Wheal C) Nodule D) Vesicle Ans: A Feedback: Bullae are large (1.0 cm or larger in diameter) fluid-filled blisters, whereas vesicles are small (<1.0 cm in diameter). Nodules are solid marble-like lesions (>0.5 cm) that are deeper and firmer than a papule. A wheal is a somewhat irregular, relatively transient area of localized skin edema, such as a mosquito bite.

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19. A client complains to the health care provider that he keeps getting hard skin on the sides of the great and little toes when he wears certain pairs of shoes. This is probably caused by ill-fitting shoes putting pressure on certain areas of the foot and would be called a: A) Blister B) Corn C) Callus D) Hematoma Ans: B Feedback: Corns (helomas) are small, well-circumscribed, conical, keratinous thickenings of the skin. They usually appear on the toes from rubbing or ill-fitting shoes. The corn may be either hard (heloma durum) with a central hard, horny core or soft (heloma molle), as commonly seen between the toes. Blisters are circumscribed elevations of the skin caused by fluid under or within the epidermis. A callus is a hyperkeratotic plaque of skin that develops because of chronic pressure or friction. Hematomas are a mass of blood caused by a break in a blood vessel under the skin.

20. When explaining why some children have albinism, the science teacher explains that which enzyme is needed for synthesis of melanin?

A) Laminim B) Tyrosinase C) Bradykinin D) Pheomalanin Ans: B Feedback: Although there are more than 10 different types of albinism, the most common type is recessively inherited oculocutaneous albinism, in which there is a normal number of melanocytes, but they lack tyrosinase, the enzyme needed for synthesis of melanin. The lamina lucida consists of fine anchoring filaments and a cell adhesion glycoprotein, called laminin, which plays a role in the organization of the macromolecules in the basement membrane zone and promotes attachment of cells to the extracellular matrix.

Many chemicals have been found to produce the itch sensation, including histamine, serotonin, and cytokines. Substances such as bradykinin and bile salts act locally to stimulate the itch sensation. Localized concentrations of eumelanin are also responsible for the formation of freckles and moles. Pheomelanin, a reddish yellow pigment, is particularly concentrated in the lips, nipples, glans penis, and vagina.

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21. Which of the following skin disorders is likely to result from the localized lack of melanin production by melanocytes?

A) Rash B) Bullae C) Vitiligo D) Melasma Ans: C Feedback: In cases of vitiligo, depigmented areas may contain no melanocytes, greatly altered or decreased amounts of melanocytes, or, in some cases, melanocytes that no longer produce melanin. Melasma results from increased pigmentation, and neither bullae nor rashes are consequences of alteration in melanocyte function.

22. Following a camping trip, a client returns with multiple “bug bites” and skin rashes. The nurse should encourage which of the following interventions to decrease pruritus to prevent further spread of the rashes? Select all that apply.

A) Obtain a prescription for opioids, so the client can sleep uninterrupted.

B) Rub areas with the hand rather than using long fingernails.

C) Take lots of very warm, soothing oatmeal baths.

D) Use topical corticosteroid creams.

E) Take antihistamines like Benadryl, especially at bedtime.

Ans: B, D, E Feedback: Pruritus, or the unpleasant sensation of itch, is a symptom common to many skin disorders leading to the desire to scratch. Measures such as using the entire hand to rub over large areas and keeping the fingernails trimmed often can relieve itch and prevent skin damage. Self-limited or seasonal cases of pruritus may respond to treatment measures such as moisturizing lotions, bath oils, and the use of humidifiers. Because vasodilation tends to increase itching, cold applications may provide relief. Cool showers before bed, light sleepwear, and cool home temperatures also may be helpful.

Mild cutaneous disorders, such as bug bites, are mediated by histamine; therefore, topical antihistamines tend to be the treatment of choice. Topical corticosteroids are effective as antipruritics, particularly when used for urticaria (hives) or insect bites.

Opioids are for pain control and not itching. Very warm baths would increase the itching rather than decrease it.

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23. Due to the increasing dryness of her skin in recent years, a 70-year-old woman has needed to reduce the number of baths that she takes. Which of the following factors has resulted in this age-related change in skin function?

A) Slower keratinization B) Changes in sebaceous secretions C) Dehydration of epidermal cells D) Increased production of bile salts Ans: B Feedback: The effects of aging on skin dryness include a change in the composition of sebaceous gland secretions and a decrease in the secretion of moisture from the sweat glands.

Changes in the composition of keratinocytes and the process of keratinization do not account for the drier skin that accompanies aging. Deposition of bile salts on the skin surface causes pruritus and dry skin, but this is a pathologic process rather than an age-related change.

24. One of the best products for extremely dry skin on the elbows would be to apply which type of dressing?

A) An occlusive with petroleum material mixed in the cream B) A humectant lotion that contains a -hydroxy acid C) A lotion that has a corticosteroid in it D) A cream that has a lidocaine product mixed with it Ans: A Feedback: Occlusives are thick creams that contain petroleum or some other moisture-proof material. They prevent water loss from the skin. They are the most effective agents for relieving skin dryness. Humectants are the additives in lotions, such as a-hydroxy acids and urea, that draw out water from the deeper skin layers and hold it on the skin surface.

However, the water that is drawn to the skin is transepidermal water, not atmospheric water; thus, continued evaporation from the skin can actually exacerbate dryness. -Hydroxy acids are derived from fruits, hence the abundance of fruit additives in over-the-counter shampoos and lotions. Lotion or cream additives include corticosteroids or mild anesthetics, such as camphor, menthol, lidocaine, or benzocaine.

These agents work by suppressing itching while moisturizing the skin.

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25. A dermatologist is explaining to a client the advantages of using a lotion that can draw out water to the skin surface. The nurse knows the technical term for this lotion is a/an: A) Occlusive B) Humectant C) Emollient D) Xerosis Ans: A Feedback: Humectants are the additives in lotions, such as -hydroxy acids and urea, that draw out water from the deeper skin layers and hold it on the skin surface. Emollients are fatty acid–containing lotions that replenish the oils on the skin surface but usually do not leave a residue on the skin. They have a short duration of action and need to be applied frequently. Urea is a nitrogenous substance that has been quite effective in reducing xerosis when combined with lotions. It is a humectant at lower concentrations (10%), but in higher concentrations (20%–30%), it is mildly keratolytic. Occlusives are thick creams that contain petroleum or some other moisture-proof material. They prevent water loss from the skin.

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1. Chapter 46 A client is exhibiting manifestations of superficial dermatophytosis of the skin with skin scaling and nail disintegration. Based on these findings, the nurse can anticipate that the client will be prescribed: Select all that apply.

A) An antifungal like ketoconazole B) An antibiotic like tetracycline C) Topical corticosteroid D) An antihistamine like Benadryl Ans: A, C Feedback: The fungi that cause superficial mycoses are called dermatophytes and require keratin for growth. Therefore, these fungi do not infect deeper body tissues or mucosal surfaces.

The dermatophytes emit an enzyme that enables them to digest keratin, which results in superficial skin scaling, nail disintegration, or hair breakage, depending on the location of the infection. The principal agents are the azoles (ketoconazole, miconazole, clotrimazole, etc.) and the allylamines (naftifine and terbinafine). Both act by inhibiting the synthesis of ergosterol, which is an essential part of fungal cell membranes. Topical corticosteroids may be used in conjunction with topical antifungal agents to relieve itching and erythema secondary to inflammation. Antibiotics are not effective for fungal infections, and antihistamines are usually reserved for itching, which is not characteristic of this disease.

2. The clinic health care worker notices that a client has a fungal infection on her nails that looks like the fungus is digesting the nail keratin. The nail appears opaque and white in color. The client states she has had this for years. The health care worker suspects the client has: A) Candidiasis B) Cellulitis C) Onychomycosis D) Tinea corporis Ans: C Feedback: Onychomycosis often begins at the tip of the nail, where the fungus digests the nail keratin. Initially, the nail appears opaque, white, or silvery. The nail then turns yellow or brown and remains unchanged for years. Gradually, the nail thickens and cracks as the infection spreads. Candidiasis (moniliasis) is a fungal infection caused by C. albicans.

This yeast-like fungus is a normal inhabitant of the gastrointestinal tract, mouth, and vagina. Cellulitis is a deeper infection affecting the dermis and subcutaneous tissues.

The lesion consists of an expanding red, swollen, tender plaque with an indefinite border, covering a variety of widths. Cellulitis is frequently accompanied by fever, erythema, heat, edema, and pain. Tinea corporis (ringworm of the body) are oval or circular patches on exposed skin surfaces and the trunk, back, or buttocks.

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3. Which of the following clients would be predisposed to developing a yeast-like Candida albicans fungal infection?

A) A diabetic male child with circular patches on the arms B) An immunosuppressed cancer client with maculopapular satellite lesions C) A high school football player with fungal spores cultured on the feet D) A dance instructor with a rash on the hands described as raised borders Ans: B Feedback: In addition to microscopic analysis of skin scrapings for tinea fungal spores, a candidal infection often can be differentiated from a tinea infection by the presence of maculopapular satellite lesions found outside the clearly demarcated borders. Some persons are predisposed to candidal infections by conditions such as diabetes mellitus, antibiotic therapy, pregnancy, oral contraceptive use, poor nutrition, and immunosuppressive diseases. The most common types of tinea lesions are oval or circular patches with raised red borders consisting of vesicles, papules, or pustules on exposed skin surfaces.

4. A teenager reports ugly warts that have invaded her hands. She wants them gone before prom season. The nurse will likely be explaining which of the following treatment measures to this teenager?

A) How to apply steroid creams and Band-Aids B) Applying a keratolytic agent like salicylic acid C) Taking a pair of tweezers and pulling the wart off D) How to safely use cryotherapy at home Ans: B Feedback: Verrucae, or warts, are common, benign papillomas caused by DNA-containing human papillomavirus (HPV) that invade the superficial skin keratinocytes. Removal is usually done by applying a keratolytic agent, such as salicylic acid, which works by dissolving intercellular cement and producing desquamation of the horny layer of skin without affecting normal epidermal cells. Steroid creams will not help with removal of a wart.

Pulling the wart off is not recommended. Cryotherapy may be needed, but this is performed in a doctor's office.

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5. Which of the following disorders of the skin is most likely to respond to treatment with systemic antibiotics?

A) Acne vulgaris B) Urticaria C) Atopic dermatitis D) Verrucae Ans: A Feedback: The etiology of acne vulgaris is bacterial, and some clients may require treatment with systemic antibiotics. Urticaria (hives) and atopic dermatitis result from allergic and hypersensitivity processes. Verrucae, or warts, are of viral origin and thus unresponsive to antibiotic therapy.

6. A teenager with rosacea should be educated that in addition to the “blush appearance” on the face, she should also assess for which of the following additional complications?

Select all that apply.

A) Inflamed and tender axillary lymph nodes B) Eye problems C) Edema of the eyelids D) Large abscesses on the upper arms and neck Ans: B, C Feedback: Rosacea is a chronic skin disorder of middle-aged and older persons. The blush eventually becomes a permanent, dark-red erythema on the nose and cheeks that sometimes extends to the forehead and chin. Ocular problems occur in at least 50% of persons with rosacea. Prominent symptoms include eyes that are itchy, burning, or dry; a gritty or foreign body sensation; and erythema and swelling of the eyelid. Acne conglobata occurs later in life as a severe, chronic form of acne. Comedones, papules, pustules, nodules, abscesses, cysts, and scars occur on the back, buttocks, and chest.

Lesions occur to a lesser extent on the abdomen, shoulders, neck, face, upper arms, and thighs. The comedones or cysts have multiple openings, large abscesses, and interconnecting sinuses.

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7. Atopic dermatitis can be described as: Select all that apply.

A) Vesicle formation B) Oozing C) Round, erythematous papules that enlarge and coalesce D) Raised wheals with associated itching Ans: A, B Feedback: The lesions of atopic dermatitis are usually characterized by vesicle formation, oozing, and crusting with excoriations. The lesions of erythema multiforme are round, erythematous papules that enlarge and coalesce, changing to concentric zones of color appearing as “target” or “iris” lesions. Urticaria, or hives, is a common skin disorder characterized by the development of edematous wheals accompanied by intense itching.

8. A client has been admitted to the intensive care unit of the hospital after developing toxic epidermal necrolysis (TEN) consequent to the administration of a sulfonamide antibiotic. What pathophysiologic phenomenon is likely the greatest immediate threat to this client's health?

A) The development of bacterial cellulitis on compromised skin surfaces B) Fluid and electrolyte imbalances resulting from the loss skin integrity C) A cascading autoimmune response that may result in shock D) The presence of diffuse lesions and skin sloughing on the client's mucous membranes Ans: D Feedback: TEN is manifested by large areas of denuded skin resulting from separation at the basement membrane. This sloughing and necrosis can be fatal if it occurs in the airway and on the other mucous membranes. Infection and fluid and electrolyte imbalances may occur, but the most immediate threat results from the immediate consequences of skin sloughing. A cascading autoimmune response does not occur in TEN.

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9. Papulosquamous dermatoses, such as psoriasis, are a group of skin disorders characterized by: A) Scaling papules B) Granular scabbing C) Raised red borders D) Nodular ulcerations Ans: A Feedback: Papulosquamous dermatoses are a group of skin disorders characterized by scaling papules and plaques. Nodular ulcerative type is a frequently occurring type of basal cell carcinoma. Squamous cell carcinoma is a red-scaling, keratotic, slightly elevated lesion that later grows outward, with large ulcerations and crusts with raised, erythematous borders. Varicella (chickenpox) is caused by the varicella-zoster virus; characteristic skin lesion occurs in three stages: macule, vesicle, and granular scab.

10. Dry, itchy plaques on her elbows and knees have prompted a 23-year-old woman to seek care. The clinician has subsequently diagnosed the client with psoriasis, a disorder that results from: A) Increased epidermal cell turnover B) An IgE-mediated immune reaction C) Hormonal influences on sebaceous gland activity D) Human papillomaviruses (HPV) Ans: A Feedback: Psoriasis is characterized by increased epidermal cell turnover with marked epidermal thickening, a process called hyperkeratosis. Hives are caused by an IgE-mediated immune reaction, and HPV causes warts. Dysfunction of the sebaceous glands results in acne.

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11. What process accounts for the damaging effects of the sun's radiation?

A) Initiation of an autoimmune response B) Compensatory increases in melanin production C) Damage to epidermal cell DNA and free radical production D) Hyperkeratinization and the formation of microscopic, subcutaneous lesions Ans: C Feedback: Ultraviolet B (UVB) radiation is primarily responsible for sunburns, and it acts mainly on the cells in the basal layer of the epidermis, producing direct damage to the DNA and other nuclear proteins. It also provokes free radical production and induces a significant reduction in skin antioxidants, impairing the ability of the skin to protect itself against the free radicals that are generated. UV radiation does not provoke an autoimmune response or hyperkeratinization, although there is an inflammatory response. Increased melanin production is a protective mechanism and does not participate in the deleterious effects of UV radiation.

12. Which of the following clinical manifestations would lead the health care provider to diagnose the sunburn as severe?

A) Skin is red and warm to touch.

B) Some peeling and itching occur several days after the initial burn.

C) There is blistering of the skin and associated fever and chills.

D) There is a pruritic rash over the sunburned skin area.

Ans: C Feedback: Sunburn ranges from mild to severe. Mild sunburn consists of various degrees of skin redness. The burn continues to develop for 24 to 72 hours, occasionally followed by peeling skin in 3 to 8 days. Some peeling and itching may continue for several weeks.

Inflammation, blistering, weakness, chills, fever, malaise, and pain often accompany severe forms of sunburn.

13. A thermal burn described as involving the entire epidermis and dermis is classified as: A) Full third degree B) Deep first degree C) Partial second degree D) Full-thickness second degree Ans: D Feedback: Second-degree full-thickness burns involve the entire epidermis and dermis.

First-degree burns (superficial partial-thickness burns) involve only the outer layers of the epidermis. Second-degree partial-thickness burns involve the epidermis and various degrees of the dermis. Third-degree full-thickness burns extend into the subcutaneous tissue and may involve muscle and bone.

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14. A 44-year-old man has been brought to the emergency department with severe electrical burns resulting from a workplace accident. The most immediate threat to this client's survival at this time is: A) Infection B) Hemodynamic instability C) Acute pain D) Decreased protein synthesis and impaired healing Ans: B Feedback: Although infection and the potential for sepsis are highly significant risks for clients with burns, the most immediate threat is hemodynamic instability. Pain control is essential, but inadequate pain control does not pose a direct threat to survival. The healing process is a later priority.

15. A child has been admitted to the burn unit after pulling a pan of hot water off the stove.

Given the fact that there is primarily second- and third-degree burns, the health care worker should prioritize care to focus on which of the following? Select all that apply.

A) Focus on replacing fluids that have been lost from the vascular, interstitial, and cellular compartments.

B) Assess for indications that the child's airway has been compromised by assessing breath sounds and voice quality.

C) Maintain sterile field when doing dressing changes and debridement.

D) Withhold foods/nutrition since the GI tract may have slowed down in response to stress.

E) Minimize pain medication administration to not compromise the child's respiratory effort.

Ans: A, B, C Feedback: Fluid is lost from the vascular, interstitial, and cellular compartments. Because of a loss of vascular volume, major burn victims often present in the emergency department in a form of hypovolemic shock. Manifestations of inhalation injury include hoarseness, drooling and inability to handle secretions, hacking cough, and labored, shallow breathing. Immunologically, the skin is the body's first line of defense. When the skin is no longer intact, the body is open to bacterial infection. The stress of burn injury increases metabolic and nutritional requirements; therefore, nutrition should not be withheld. Pain medication should be titrated to the child's need.

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16. Which of the following actions could result in pressure ulcer formation?

A) Pulling a stroke client up in bed B) Turning a client from side to side every 2 hours C) Allowing a client to side up in a chair at mealtime D) Applying powder to buttocks area when diaphoresis has become a problem Ans: A Feedback: Factors contributing to the development of pressure ulcers include external pressure that compresses blood vessels and friction and shearing forces that tear and injure blood vessels. Shearing forces are caused by the sliding of one tissue layer over another with stretching and angulation of blood vessels, causing injury and thrombosis. Shear occurs when the skeleton moves, but the skin remains fixed to an external surface, such as occurs with transfer from a stretcher to a bed or pulling a person up in bed. Whether a person is sitting or lying down, the weight of the body is borne by tissues covering the bony prominences. Moisture contributes to pressure ulcer formation by weakening the cell wall of individual skin cells and by changing the protective pH of the skin.

17. Which of the following actions involves the greatest risk of skin shearing?

A) Inserting a peripheral intravenous catheter B) Rolling the client from a supine to side-lying position C) Pulling the client up in bed D) Helping the client ambulate after surgery Ans: C Feedback: Shear occurs when the skeleton moves, but the skin remains fixed to an external surface, such as occurs with transfer from a stretcher to a bed or pulling a person up in bed.

Rolling a client, starting an IV catheter, or assisting with mobilization does not pose a risk of skin shearing.

18. A 79-year-old client has been confined to bed after a severe hemorrhagic stroke that has caused hemiplegia. Which of the following measures should his care team prioritize in the prevention of pressure ulcers?

A) Prophylactic antibiotics B) Repositioning the client on a scheduled basis C) Applying protective dressings to vulnerable areas D) Parenteral nutrition Ans: B Feedback: Although adequate nutrition is important in both the prevention and treatment of pressure ulcers, the most important intervention is to prevent pressure and ischemia.

This can be accomplished by frequently repositioning the client. Prophylactic antibiotics are not commonly used, and dressings are not normally required unless skin breakdown is evident.

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19. Dysplastic nevi are precursors of malignant melanoma that are: A) Larger than other nevi B) Oval epidermal nests C) Dermal cords of cells D) Brown, rounded papules Ans: A Feedback: Dysplastic nevi, a precursor of malignant melanoma, are larger than other nevi (often >5 mm in diameter), have a flat, slightly raised plaque and pebbly surface, or a target-like lesion with a darker, raised center and irregular border. Nevocellular nevi are tan to deep brown, uniformly pigmented, small papules with well-defined and rounded borders that grow in nests or clusters along the dermal–epidermal junction. Eventually, most junctional nevi grow into the surrounding dermis as nests or cords of cells.

20. A client has just received the diagnosis of malignant melanoma, stage 3B. He asks the nurse what this means. The nurse should respond relaying which of the following information? Select all that apply.

A) Malignant melanoma is a very rapid growing, aggressive cancer.

B) This cancer usually extends wide and deep but rarely metastasize.

C) This cancer is mainly contained to the head and neck area.

D) Your cancer has grown into the deep tissues and quite likely into lymph nodes (stage 3B).

Ans: A, D Feedback: Although melanoma represents a small subset of skin cancers, it is the most deadly. It is a rapidly progressing, metastatic form of cancer. Malignant melanomas differ in size and shape. Usually, they are slightly raised and black or brown. Borders are irregular and surfaces are uneven. Most appear to arise from preexisting nevi or new mole-like growths. There may be surrounding erythema, inflammation, and tenderness. Because most melanomas initially metastasize to regional lymph nodes, additional information may be obtained through lymph node biopsy. Consistent with other cancerous tumors, melanoma is commonly staged using the TNM (tumor, lymph node, and metastasis) staging system. Basal cell cancer usually extends wide and deep but rarely metastasizes and are most frequently seen on the head and neck, most often occurring on skin that has hair.

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21. The nurse caring for a client with a malignant melanoma should prepare the client for which of the following treatments? Select all that apply.

A) Cosmetic surgery to remove the mole without leaving a scar B) Immediate radiation therapy to shrink the tumors C) Surgical excision with lymph node biopsy D) Biologic therapy with interferon alfa-2B Ans: C, D Feedback: Treatment of melanoma is usually surgical excision, the extent of which is determined by the thickness of the lesion, invasion into the deeper skin layers, and spread to the regional lymph nodes. Current capability allows for mapping lymph flow to a regional lymph node that receives lymphatic drainage from tumor sites on the skin. This lymph node, which is called the sentinel lymph node, is then sampled for biopsy. If tumor cells have spread from the primary tumor to the regional lymph nodes, the sentinel node will be the first node in which tumor cells appear. Therefore, sentinel node biopsy can be used to test for the presence of melanoma cells and determine if radical lymph node dissection is necessary. Interferon alfa-2b is a biologic therapy available for adjuvant treatment of melanoma.

22. A woman has just delivered a child with a hemangioma on his right cheek area. The mother clutches the nurse and asks, “What is that thing on his face?” The nurse will respond with which of the following facts? Select all that apply.

A) “This is usually called a strawberry 'birth mark' and pretty common in newborns.”

B) “These hemangiomas may grow larger early on followed by a period where the growth is reversed.”

C) “Most of these hemangiomas will remain with the infant for the rest of his life.

However, they are not cancerous.”

D) “If this birth mark develops ulceration, we will need to keep a close eye on it to prevent any infections.”

E) “We will keep a close watch on your infant's vision since they can develop malformation of the eye that could develop into glaucoma.”

Ans: A, B, D Feedback: Hemangiomas of infancy (formerly called strawberry hemangiomas) are small, red lesions that are noticed shortly after birth. Hemangiomas of infancy are generally benign vascular tumors produced by proliferation of endothelial cells. They are seen in approximately 10% of children in the first year of life. Hemangiomas of infancy typically undergo an early period of proliferation during which they enlarge, followed by a period of slow involution during which the growth is reversed until complete resolution. A small percentage of hemangiomas develop complications. Ulceration, the most frequent complication, can be painful and carries the risk of infection, hemorrhage, and scarring. Port-wine stains usually are confined to the skin but may be associated with vascular malformations of the eye, resulting primarily in glaucoma.

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23. A 5-year-old girl has been presented for care by her father due to her recent development of macules on her trunk, extremities, and mucous membranes. The child is mildly febrile, but her primary symptom is extreme pruritus. What disorder of the skin should the clinician who is assessing the child first suspect?

A) Varicella B) Lichen planus C) Rosacea D) Impetigo.

Ans: A Feedback: Varicella (chickenpox) begins with a macular stage that is characterized by the development of macules over the trunk, spreading to the limbs, buccal mucosa, scalp, axillae, upper respiratory tract, and conjunctiva. Mild to extreme pruritus accompanies the lesions, and clients are often mildly febrile. Impetigo manifests vesicles or pustules that are primarily on the face. Rosacea and lichen planus are chronic skin disorders of older persons.

24. Which of the following changes are normal in the elderly population? Select all that apply.

A) The dermis and epidermis thin as one ages.

B) An increase in the amount of subcutaneous tissue.

C) A thickening of blood vessels.

D) Increased amount of padding on the buttocks.

E) Skin may become dry, rough, and scaly.

Ans: A, C, E Feedback: Normal skin changes associated with aging are seen on areas of the body that have not been exposed to the sun. They include thinning of the dermis and the epidermis, diminution in subcutaneous tissue, and a decrease and thickening of blood vessels.

These result in less padding and thinner skin, with color and elasticity changes.

Although the reason is poorly understood, the skin in most elderly persons older than 70 years of age becomes dry, rough, scaly, and itchy.

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25. Which one of the following skin disorders seen in elderly persons is considered a premalignant lesion?

A) Cherry angiomas B) Actinic keratosis C) Solar lentigines D) Telangiectases Ans: B Feedback: Actinic keratoses are the most common premalignant skin lesions that develop on sun-exposed areas. Solar lentigines are tan to brown, benign spots on sun-exposed areas.

They are commonly referred to as liver spots. Senile angiomas (cherry angiomas) are smooth, cherry-red or purple, dome-shaped papules, usually found on the trunk.

Telangiectases are single dilated blood vessels, capillaries, or terminal arteries that appear on areas exposed to sun or harsh weather, such as the cheeks and the nose.

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