NEW GENERATION HESI PATHOPHYSIOLOGY TEST BANK WITH
CORRECT ANSWERS | REAL EXAMS
1. After talking with the healthcare provider, a male client continues to have questions about the
results of a prostatic surface antigen (PSA) screening test and asks the nurse how the PSA levels
become elevated. The nurse should explain which pathophysiological mechanism?
A. As the prostate gland enlarges, its cells contribute more PSA in the circulating blood.
B. The PSA levels normally rise and fall, so multiple testing’s over time are necessary.
C. Low PSA levels indicate that the prostate gland is not functioning properly.
D. The PSA blood test is used to determine dosage for Viagra prescriptions.
Answer: A. As the prostate gland enlarges, its cells contribute more PSA in the circulating blood.
PSA is a glycoprotein found in prostatic epithelial cells, and elevations are used as a specific
tumor markers. Elevations in PSA are related to gland volume, i.e., benign prostatic hypertrophy,
prostatitis, and cancer of the prostate, indicating (tumor) cell load (A). PSA levels are also used
to monitor response to therapy. (B, C, and D) provide incorrect information.
2. A 26-year-old male client with Hodgkin's disease is scheduled to undergo radiation therapy.
The client expresses concern about the effect of radiation on his ability to have children. What
information should the nurse provide?
A. The radiation therapy causes the inability to have an erection.
B. Radiation therapy with chemotherapy causes temporary infertility.
C. Permanent sterility occurs in male clients who receive radiation.
D. The client should restrict sexual activity during radiotherapy.
Answer: C. Permanent sterility occurs in male clients who receive radiation.
Low sperm count and loss of motility are seen in males with Hodgkin's disease before any
therapy. Radiotherapy often results in permanent aspermia, or sterility (C). (A, B, and D) are
inaccurate.
3. The nurse hears short, high-pitched sounds just before the end of inspiration in the right and
left lower lobes when auscultating a client's lungs. How should this finding be recorded?
A. Inspiratory wheezes in both lungs.
B. Crackles in the right and left lower lobes.
C. Abnormal lung sounds in the bases of both lungs.
D. Pleural friction rub in the right and left lower lobes.
Answer: B. Crackles in the right and left lower lobes.
Fine crackles (B) are short, high-pitched sounds heard just before the end of inspiration that are
the result of rapid equalization of pressure when collapsed alveoli or terminal bronchioles
suddenly snap open. Wheezing (A) is a continuous high-pitched squeaking or musical sound
caused by rapid vibration of bronchial walls that are first evident on expiration and may be
audible. Although (C) describes an adventitious lung sound, this documentation is vague. (D) is a
creaking or grating sound from roughened, inflamed surfaces of the pleura rubbing together
heard during inspiration, expiration, and with no change during coughing.
4. A client is admitted to the Emergency Department with a tension pneumothorax. Which
assessment should the nurse expect to identify?
A. An absence of lung sounds on the affected side.
B. An inability to auscultate tracheal breath sounds.
C. A deviation of the trachea toward the side opposite the pneumothorax.
D. A shift of the point of maximal impulse to the left, with bounding pulses.
Answer: C. A deviation of the trachea toward the side opposite the pneumothorax.
Tension pneumothorax is caused by rapid accumulation of air in the pleural space, causing
severely high intrapleural pressure. This results in collapse of the lung, and the mediastinum
shifts toward the unaffected side, which is subsequently compressed (C). (A, B, and D) are not
demonstrated with a tension pneumothorax.
5. A client who is receiving a whole blood transfusion develops chills, fever, and a headache 30
minutes after the transfusion is started. The nurse should recognize these symptoms as
characteristic of what reaction?
A. A mild allergic reaction.
B. A febrile transfusion reaction.
C. An anaphylactic transfusion reaction.
D. An acute hemolytic transfusion reaction.
Answer: B. A febrile transfusion reaction.
Symptoms of a febrile reaction (B) include sudden chills, fever, headache, flushing and muscle
pain. An allergic reaction (A) is the response of histamine release which is characterized by
flushing, itching, and urticaria. An anaphylactic reaction (C) exhibits an exaggerated allergic
response that progresses to shock and possible cardiac arrest. An acute hemolytic reaction (D)
presents with fever and chills, but is hallmarked by the onset of low back pain, tachycardia,
tachypnea, vascular collapse, hemoglobinuria, dark urine, acute renal failure, shock, cardiac
arrest, and even death.
6. The nurse is analyzing the waveforms of a client's electrocardiogram. What finding indicates a
disturbance in electrical conduction in the ventricles?
A. T wave of 0.16 second.
B. PR interval of 0.18 second.
C. QT interval of 0.34 second.
D. QRS interval of 0.14 second.
Answer: D. QRS interval of 0.14 second.
The normal duration of the QRS is 0.04 to 0.12 second, so a prolonged QRS (D) indicates an
electrical anomaly in the ventricles. The T wave is normally 0.16 seconds (A). The PR interval
range is 0.12 to 0.20 second (B). The QT interval should be 0.31 to 0.38 second (C).
7. Several hours after surgical repair of an abdominal aortic aneurysm (AAA), the client
develops left flank pain. The nurse determines the client's urinary output is 20 ml/hr for the past
2 hours. The nurse should conclude that these findings support which complication?
A. Infection.
B. Hypovolemia.
C. Intestinal ischemia.
D. Renal artery embolization.
Answer: D. Renal artery embolization.
Postoperative complications of surgical repair of AAA are related to the location of resection,
graft, or stent placement along the abdominal aorta. Embolization of a fragment of thrombus or
plaque from the aorta into a renal artery (D) can compromise blood flow in one of the renal
arteries, resulting in renal ischemia that precipitates unilateral flank pain. Intraoperative blood
loss or rupture of the aorta anastomosis can cause acute renal failure related to hypovolemia (B),
which involves both kidneys and causing bilateral flank pain. (A and C) are not associated with
these symptoms.
8. A client with a markedly distended bladder is diagnosed with hydronephrosis and left
hydroureter after an IV pyelogram. The nurse catheterizes the client and obtains a residual urine
volume of 1650 ml. This finding supports which pathophysiological cause of the client's urinary
tract obstruction?
A. Obstruction at the urinary bladder neck.
B. Ureteral calculi obstruction.
C. Ureteropelvic junction stricture.
D. Partial post-renal obstruction due to ureteral stricture.
Answer: A. Obstruction at the urinary bladder neck.
Hydroureter (dilation of the renal pelvis), vesicoureteral reflux (backward movement of urine
from the lower to upper urinary tracts), and hydronephrosis (dilation or enlargement of the renal
pelvis and calyces) result from post-renal obstruction which can consequently result in chronic
pyelonephritis and renal atrophy. Ascending urinary reflux occurs when normal ureteral
peristaltic pressure is met with an increase in urinary pressure occurring during bladder filling if
the urinary bladder neck is obstructed (A). A large residual urine does not occur with (B, C, and
D) because the urine cannot get to the bladder.
9. The nurse is planning care for a client who has a right hemispheric stroke. Which nursing
diagnosis should the nurse include in the plan of care?
A. Impaired physical mobility related to right-sided hemiplegia.
B. Risk for injury related to denial of deficits and impulsiveness.
C. Impaired verbal communication related to speech-language deficits.
D. Ineffective coping related to depression and distress about disability.
Answer: B. Risk for injury related to denial of deficits and impulsiveness.
With right-brain damage, a client experience difficulty in judgment and spatial perception and is
more likely to be impulsive and move quickly, which placing the client at risk for falls (B).
Although clients with right and left hemisphere damage may experience impaired physical
mobility, the client with right brain damage will manifest physical impairments on the
contralateral side of the body, not the same side (A). The client with a left brain injury may
manifest right-sided hemiplegia with speech or language deficits (C). A client with left- brain
damage is more likely to be aware of the deficits and experience grief related to physical
impairment and depression
10. The nurse is teaching a client with maple syrup urine disease (MSUD), an autosomal
recessive disorder, about the inheritance pattern. Which information should the nurse provide?
A. This recessive disorder is carried only on the X chromosome.
B. Occurrences mainly affect males and heterozygous females.
C. Both genes of a pair must be abnormal for the disorder to occur.
D. One copy of the abnormal gene is required for this disorder.
Answer: C. Both genes of a pair must be abnormal for the disorder to occur.
Maple syrup urine disease (MSUD) is a type of autosomal recessive inheritance disorder in
which both genes of a pair must be abnormal for the disorder to be expressed (C). MSUD is not
an x-linked (A and B) dominant or recessive disorder or an autosomal dominant inheritance
disorder. Both genes of a pair, not (D), must be present.
11. A female client tells the nurse that she does not know which day of the month is best to do
breast self-exams (BSE). Which instruction should the nurse provide?
A. Midway between menstrual cycles.
B. One week before your period.
C. The first day of your period.
D. Five to seven days after menses cease.
Answer: D. Five to seven days after menses cease.
Due to the effect of cyclic ovarian changes on the breast, the best time for breast selfexamination (BSE) is 5 to 7 days after menstruation stops (D) because physiologic alterations in
breast size and activity reach their minimal level after menses. (A and B) can vary from month to
month and do not provide a consistent day of the month for the client to remember to do BSE.
(C) is commonly the day of the menstrual cycle that the breast are most affected by hormonal
influence.
12. A client reports unprotected sexual intercourse one week ago and is worried about HIV
exposure. An initial HIV antibody screen (ELISA) is obtained. The nurse teaches the client that
seroconversion to HIV positive relies on antibody production by B lymphocytes after exposure
to the virus. When should the nurse recommend the client return for repeat blood testing?
A. 6 to 18 months.
B. 1 to 12 months.
C. 1 to 18 weeks.
D. 6 to 12 weeks.
Answer: D. 6 to 12 weeks.
Although the HIV antigen is detectable approximately 2 weeks after exposure, seroconversion to
HIV positive may take up to 6 to 12 weeks (D) after exposure, so the client should return to
repeat the serum screen for the presence of HIV antibodies during that time frame. (A) will delay
treatment if the client tests positive. (B and C) may provide inaccurate results because the time
frame maybe too early to reevaluate the client.
13. A nurse is planning to teach self-care measures to a female client about prevention of yeast
infections. Which instructions should the nurse provide?
A. Use a douche preparation no more than once a month.
B. Increase daily intake of fibre and leafy green vegetables.
C. Select nylon underwear that is loose-fitting, white, and comfortable.
D. Avoid tight-fitting clothing and do not use bubble-bath or bath salts.
Answer: D. Avoid tight-fitting clothing and do not use bubble-bath or bath salts.
A common genital tract infection in females is candidiasis, which is an overgrowth of the normal
vaginal flora of Candida albicans that thrives in an environment that is warm and moist and is
perpetuated by tight-fitting clothing, underwear, or pantyhose made of non-absorbent materials.
The client should wear clothing that is loose fitting and absorbent, such as cotton underwear, and
avoid using bubble-bath or bath salts (D) which further irritate sensitive genital tissue. Douching
(A) is not recommended because it can irritate vaginal tissue, alter pH, and contribute to fungal
growth. While (B) encourages healthy, nutritional guidelines, it is not the focus of the teaching.
Cotton, not nylon undergarments (C), provide absorbancy and reduce moisture in the perineal
14. Which reaction should the nurse identify in a client who is responding to stimulation of the
sympathetic nervous system?
A. Pupil constriction.
B. Increased heart rate.
C. Bronchial constriction.
D. Decreased blood pressure.
Answer: B. Increased heart rate.
Any stressor that is perceived as threatening to homeostasis acts to stimulate the sympathetic
nervous system and manifests as a flight-or-fight response, which includes an increase in heart
rate (B). (A, C, and D) are responses of the parasympathetic nervous system.
15. A client with asthma receives a prescription for high blood pressure during a clinic visit.
Which prescription should the nurse anticipate the client to receive that is least likely to
exacerbate asthma?
A. Pindolol (Visken).
B. Carteolol (Ocupress).
C. Metoprolol tartrate (Lopressor).
D. Propranolol hydrochloride (Inderal).
Answer: C. Metoprolol tartrate (Lopressor).
The best antihypertensive agent for clients with asthma is metoprolol (Lopressor) (C), a beta2
blocking agent which is also cardio selective and less likely to cause bronchoconstriction.
Pindolol (A) is a beta2 blocker that can cause bronchoconstriction and increase asthmatic
symptoms. Although carteolol (B) is a beta blocking agent and an effective antihypertensive
agent used in managing angina, it can increase a client's risk for bronchoconstriction due to its
nonselective beta blocker action. Propranolol (D) also blocks the beta2 receptors in the lungs,
causing bronchoconstriction, and is not indicated in clients with asthma and other obstructive
pulmonary
16. The nurse is preparing to administer atropine, an anticholinergic, to a client who is scheduled
for a cholecystectomy. The client asks the nurse to explain the reason for the prescribed
medication. What response is best for the nurse to provide?
A. Provide a more rapid induction of anesthesia.
B. Decrease the risk of bradycardia during surgery.
C. Induce relaxation before induction of anesthesia.
D. Minimize the amount of analgesia needed postoperatively.
Answer: B. Decrease the risk of bradycardia during surgery.
Atropine may be prescribed preoperatively to increase the automaticity of the sinoatrial node and
prevent a dangerous reduction in heart rate (B) during surgical anesthesia. (A, C and D) do not
address the therapeutic action of atropine use perioperatively.
17. A deficiency of intrinsic factor should alert the nurse to assess a client's history for which
condition?
A. Emphysema.
B. Hemophilia.
C. Pernicious anemia.
D. Oxalic acid toxicity.
Answer: C. Pernicious anemia.
Pernicious anemia (A) is a type of anemia due to failure of absorption of cobalamin (Vit B12).
The most common cause is lack of intrinsic factor, a glucoprotein produced by the parietal cells
of the gastric lining. (A, C, and D) are incorrect.
18. The nurse is assessing an older client and determines that the client's left upper eyelid droops,
covering more of the iris than the right eyelid. Which description should the nurse use to
document this finding?
A. Ptosis on the left eyelid.
B. A nystagmus on the left.
C. Astigmatism on the right.
D. Exophthalmos on the right.
Answer: A. Ptosis on the left eyelid.
Ptosis is the term to describe an eyelid droop that covers a large portion of the iris (A), which
may result from oculomotor nerve or eyelid muscle disorder. (B) is characterized by rapid,
rhythmic movement of both eyes. (C) is a distortion of the lens of the eye, causing decreased
visual acuity. (D) is a term used to describe a protrusion of the eyeballs that occurs with
hyperthyroidism.
19. A client with aortic valve stenosis develops heart failure (HF). Which pathophysiological
finding occurs in the myocardial cells as a result of the increased cardiac workload?
A. Increase in size.
B. Decrease in length.
C. Increase in number.
D. Decrease in excitability.
Answer: A. Increase in size.
Hypertension and incompetent or stenotic heart valves cause an increase in the workload of the
heart by increasing afterload which requires an increase in the force of contraction to pump
blood out of the heart. Myocardial hypertrophy results because the cells increase in surface area
or size (A) by increasing the amount of contractile proteins, but the quantity (C) of fibers remain
constant. As myocardial hypertrophy progresses, the heart becomes ineffective as a pump
because the ventricular wall cannot develop enough tension to cause effective contraction (B),
which causes myocardial irritability (D) due to hypoxia.
20. The nurse is measuring blood pressure on all four extremities of a child with coarctation of
the aorta. Which blood pressure finding should the nurse expect to obtain?
A. Higher on the left side.
B. Higher on the right side.
C. Lower in the arms than in the legs.
D. Lower in the legs than in the arms.
Answer: D. Lower in the legs than in the arms.
In coarctation of the aorta, a congenital constriction is found at the aorta near the ductus
arteriosus region that lies past the left subclavian arteries, which perfuses the upper extremities.
The child should have higher blood pressures in the upper extremities than in the legs (D). (A, B,
and C) are not expected in coarctation.
21. What is the underlying pathophysiologic process between free radicals and destruction of a
cell membrane?
A. Inadequate mitochondrial ATP.
B. Enzyme release from lysosomes.
C. Defective chromosomes for protein.
D. Defective integral membrane proteins.
Answer: B. Enzyme release from lysosomes.
Oxidative damage to cells is thought to be a causative factor in disease and aging. If free radicals
bind to polyunsaturated fatty acids found in the lysosome membrane, the lysosome, nicknamed
"suicide bags", leaks its protein catalytic enzymes (B) intracellularly and the cell is destroyed.
Inadequate ATP production (A) and defective protein synthesis (C) lead to cell death either as the
result of defective chromosomes or production of defective integral proteins (D).
22. Which clinical finding should the nurse identify in a client who is admitted with cardiac
cirrhosis?
A. Jaundice.
B. Vomiting.
C. Peripheral edema.
D. Left upper quadrant pain.
Answer: C. Peripheral edema.
Four types of cirrhosis include alcoholic, post-necrotic, biliary, and cardiac cirrhosis, which is
associated with severe right-sided heart failure (HF), so peripheral edema (C) is most consistent
with right-sided HF. Although (A and B) can occur in all types of cirrhosis, the most defining
characteristic of cardiac cirrhosis is related to HF. Hepatic engorgement can occur in a client with
HF or cirrhosis and cause right upper quadrant pain, not left (D).
23. While the nurse obtains a male client's history, review of systems, and physical examination,
the client tells the nurse that his breast drains fluid secretions from the nipple. The nurse should
seek further evaluation of which endocrine gland function?
A. Posterior pituitary and testes.
B. Adrenal medulla and adrenal cortex.
C. Hypothalamus and anterior pituitary.
D. Parathyroid and islets of Langerhans.
Answer: C. Hypothalamus and anterior pituitary.
Breast fluid and milk production are induced by the presence of prolactin secreted from the
anterior pituitary gland, which is regulated by the hypothalamus' secretion of prolactin-inhibiting
hormone in both men and women. Further evaluation of the hypothalamus and the anterior
pituitary gland (C) should provide additional information about the secretions or lactation.
Evaluation of (A, B, or D) do not support a physiologic mechanism or pathology related to
mammary discharge.
24. The nurse is assessing the laboratory results for a client who is admitted with renal failure
and osteodystrophy. Which findings are consistent with this client's clinical picture?
A. Blood urea nitrogen 40 m and creatinine 1.0.
B. Cloudy, amber urine with sediment, specific gravity of 1.040.
C. Serum potassium of 5.5 mEq and total calcium of 6 mg/ dl.
D. Hemoglobin of 10 g and hypophosphatemia.
Answer: C. Serum potassium of 5.5 mEq and total calcium of 6 mg/dl.
In renal failure, normal serum electrolyte balance is altered because the kidneys fail to activate
vitamin D, calcium absorption is impaired, and serum calcium decreases, which stimulates the
release of PTH causing resorption of calcium and phosphate from the bone. A decreased tubular
excretion and a decreased glomerular filtration rate results in hypocalcemia, hyperphosphatemia,
and hyperkalemia (C). (A) is reflective of a non-renal cause, such as dehydration or liver
pathology. (B) is more indicative of infection. Renal failure causes anemia and
hyperphosphatemia, not (D).
25. Which healthcare practice is most important for the nurse to teach a postmenopausal client?
A. Wear layers of clothes if experiencing hot flashes.
B. Use a water-soluble lubricant for vaginal dryness.
C. Consume adequate foods rich in calcium.
D. Participate in stimulating mental exercises.
Answer: C. Consume adequate foods rich in calcium.
Bone density loss associated with osteoporosis increases at a more rapid rate when estrogen
levels begin to fall, so the most important healthcare practice during menopause is ensuring an
adequate calcium (C) intake to help maintain bone density and prevent osteoporosis. Although
practices such as (A and B) may reduce some of the discomforts for a postmenopausal female,
calcium intake is more important than comfort measures. Although social and mental exercises
stimulate thought, there is no scientific evidence that mental exercises (D) prevent dementia or
common forgetfulness associated with reduced hormonal levels.
26. A middle-aged male client asks the nurse what findings from his digital rectal examination
(DRE) prompted the healthcare provider to prescribe a repeat serum prostatic surface antigen
(PSA) level. What information should the nurse provide?
A. A uniformly enlarged prostate is benign prostatic hypertrophy that occurs with aging.
B. The spongy or elastic texture of the prostate is normal and requires no further testing.
C. An infection is usually present when the prostate indents when a finger is pressed on it.
D. Stony, irregular nodules palpated on the prostate should be further evaluated.
Answer: D. Stony, irregular nodules palpated on the prostate should be further evaluated.
PSA levels are prescribed to screen for prostatic cancer which is often detected by DRE and
manifested as small, hard, or stony, irregularly-shaped nodules on the surface of the prostate (D).
Although PSA levels are prescribed for routine screening, the findings suggestive of BPH (A),
normal texture (B) or infection C) do not suggest cancer of the prostate, which requires further
evaluation.
27. Which condition is associated with an over secretion of renin?
A. Hypertension.
B. Diabetes mellitus.
C. Diabetes insipidus.
D. Alzheimer's disease.
Answer: A. Hypertension.
Renin is an enzyme synthesized and secreted by the juxtaglomerular cells of the kidney in
response to renal artery blood volume and pressure changes. Low renal perfusion stimulates the
release of renin, which is converted by angiotensinogen into angiotensin I, which causes the
secretion of aldosterone, resulting in renal reabsorption of sodium, water, and subsequently
increases blood pressure (A). (B, C, and D) are not directly related to renin over secretion.
28. What information should the nurse include in a teaching plan about the onset of menopause?
(Select all that apply).
A. Smoking.
B. Oophorectomy with hysterectomy
C. Early menarche.
D. Cardiac disease.
E. Genetic influence.
F. Chemotherapy exposure.
Answer: A. Smoking.
B. Oophorectomy with hysterectomy
C. Early menarche.
E. Genetic influence.
F. Chemotherapy exposure.
Correct responses are (A, B, C, E, and F). Menopausal symptoms are related to the cessation of
ovarian function. Factors influencing the onset of menopause include smoking (A), genetic
influences (E), early menarche (C), surgical removal (B), and exposure to chemotherapy agents
and radiation (F). Cardiovascular disease (D) is unrelated.
29. A client is brought to the Emergency Center after a snow-skiing accident. Which intervention
is most important for the nurse to implement?
A. Review the electrocardiogram tracing.
B. Obtain blood for coagulation studies.
C. Apply a warming blanket.
D. Provide heated PO fluids.
Answer: A. Review the electrocardiogram tracing.
Airway, breathing, and circulation are priorities in client assessment and treatment. Continuous
cardiac monitoring is indicated (A) because hypothermic clients have an increased risk for
dysrhythmias. Coagulations studies (A) and re-warming procedures (C and D) can be initiated
after a review of the ECG tracing (A).
30. Which client is at highest risk for chronic kidney disease (CKD) secondary to diabetes
mellitus (DM)?
A. Type 1 DM and a serum hemoglobin-A1c of 3.5%.
B. Type 1 DM and retinopathy and mild vision loss.
C. Type 2 DM and hypertension controlled by metoprolol.
D. Type 2 DM and a history of morbid obesity for 5 years.
Answer: B. Type 1 DM and retinopathy and mild vision loss.
Diabetic retinopathy and nephropathy are related to prolonged hyperglycemia and hypertension
which damage the microvasculature of the eyes and kidneys, so a client with Type 1 DM and
retinopathy is most likely to develop nephropathy (B) and CKD. (A) is demonstrating
compliance with therapy (H- A1c target level is no greater than 7%), which indicates tight
glucose control and reduces the risk for microvascular complications. The client with controlled
hypertension (C) is less likely to develop CKD, although metoprolol, a beta adrenergic receptor
antagonist, can mask the signs of hypoglycemia. A client with Type 2 DM is more likely at risk
for complications associated with chronic obesity (D).
31. A male client who has never smoked but has had COPD for the past 5 years is now being
assessed for cancer of the lung. The nurse knows that he is most likely to develop which type of
lung cancer?
A. Adenocarcinoma.
B. Oat-cell carcinoma.
C. Malignant melanoma.
D. Squamous-cell carcinoma.
Answer: A. Adenocarcinoma.
Adenocarcinoma is the only lung cancer not related to cigarette smoking (A). It has been found
to be directly related to lung scarring and fibrosis from preexisting pulmonary disease such as TB
or COPD. Both (B and D) are malignant lung cancers related to cigarette smoking. (C) is a skin
cancer and is related to exposure to sunlight, not to lung problems.
32. The nurse reviews the complete blood count (CBC) findings of an adolescent with acute
myelogenous leukemia (AML). The hemoglobin is 13.8 g/dl, hematocrit is 36.7%, white blood
cell count is 8,200 mm3, and platelet count is 115,000 mm3. Based on these findings, what is the
priority nursing diagnosis for this client's plan of care?
A. Impaired gas exchange.
B. Risk for infection.
C. Risk for injury.
D. Risk for activity intolerance.
Answer: C. Risk for injury.
A client with AML is at risk for anemia, neutropenia, and thrombocytopenia. These CBC
findings indicate that the platelet count is low (normal 250,000 to 400,000 mm3), which places
this client at an increased risk for injury (C), usually manifested as bruising or bleeding. There is
no evidence of impaired gas exchange (A) due to respiratory compromise, risk of infection (B)
due to neutropenia, or risk for activity intolerance (D) secondary to anemia and fatigue.
33. The parents of a child with hemophilia A ask the nurse about their probability of having
another child with hemophilia A. Which information is the basis for the nurse's response? (Select
all that apply.)
A. Autosomal dominance occurs with this disorder.
B. Sons of female carriers have a 50% chance of inheriting hemophilia.
C. Men with hemophilia have sons who also manifest the disease.
D. The disease occurs in daughters of men with hemophilia.
E. Hemophilia is an X-linked recessive disorder.
Answer: B. Sons of female carriers have a 50% chance of inheriting hemophilia.
E. Hemophilia is an X-linked recessive disorder.
Correct choices are (B and E). Hemophilia is an inherited disease that manifests in male children
whose mother is a carrier. With each pregnancy there is a 50% chance that a male child will
inherit the defective gene and manifest hemophilia A (B), which is an X-linked recessive
disorder (E). (A) is descriptive of a rare type of hemophilia, known as von Willebrand's disease.
Hemophilia is inherited by male offspring of female carriers (C). Daughters (D) do not manifest
the disease, but have a 50% chance of being a carrier.
34. The nurse is caring for a client who had an excision of a malignant pituitary tumor. Which
findings should the nurse document that indicate the client is developing syndrome of
inappropriate antidiuretic hormone (SIADH)?
A. Hypernatremia and periorbial edema.
B. Muscle spasticity and hypertension.
C. Weight gain with low serum sodium.
D. Increased urinary output and thirst.
Answer: C. Weight gain with low serum sodium.
SIADH most frequently occurs when cancer cells manufacture and release ADH, which is
manifested by water retention causing weight gain and hyponatremia (C). Other manifestations
include oliguria, weakness, not (A, B, and D), anorexia, nausea, vomiting, personality changes,
seizures, decrease in reflexes, and coma.
35. A man who was recently diagnosed with Huntington's disease asks the nurse if his adolescent
son should be tested for the disease. What response is best for the nurse to provide?
A. Autosomal dominant disorders, such as Huntington's, cannot be inherited from the parent.
B. Testing is needed because there is a 50 percent risk of passing the gene to each offspring.
C. Genetic counseling should be obtained prior to undertaking any genetic testing procedure.
D. Positive genetic testing may contribute to insurance discrimination that denies coverage.
Answer: C. Genetic counseling should be obtained prior to undertaking any genetic testing
procedure.
Genetic counseling provides clients and families with facts to assist them in making informed
decisions before any genetic testing procedure is undertaken. It also ensures that the client has
voluntarily opted for the testing and not coerced and is also able to weigh the risks and benefits
of knowing the result.
36. A mother is crying as she holds and rocks her child with tetanus who is having muscular
spasms and crying. After administering diazepam (Valium) to the child, what action should the
nurse implement?
A. Lay the child down and ask the mother to stay near the child in the crib.
B. Encourage the mother to take a break and leave the room to stop crying.
C. Keep all light sources off and close the window blinds to the room.
D. Use calm, reassurance and understanding to comfort the mother.
Answer: A. Lay the child down and ask the mother to stay near the child in the crib.
Controlling environmental stimulation such as noise, light, or tactile stimuli helps reduce CNS
irritability related to acute tetanus. The mother should be instructed to minimize handling of the
child during episodes of muscle spasticity and to stay calmly near the child (A). The mother's
presence with the child provides security and support, so (B) is not indicated. Reducing external
stimuli (C) may have some effect in reducing the child's distress, but light tends to be less
irritating than vibratory or auditory stimuli and is essential for careful observation. Although a
calm, reassuring manner and sympathetic understanding (D) can help reduce the mother's
anxiety, the most comforting
37. Which rationale best supports an older client's risk of complications related to a
dysrhythmia?
A. An older client usually lives alone and cannot summon help when symptoms appear.
B. An older clients is more likely to eat high-fat diets which predisposes to heart disease.
C. Cardiac symptoms, such as confusion, are more difficult to recognize in an older client.
D. An older client is intolerant of decreased cardiac output which may cause dizziness and falls.
Answer: D. An older client is intolerant of decreased cardiac output which may cause dizziness
and falls.
In an older client, cardiac output is decreased and a loss of contractility and elasticity reduces
systemic and cerebral blood flow, so dysrhythmias, such as bradycardia or tachycardia is poorly
tolerated, and increases the client's risk for syncope, falls, transient ischemic attacks, and
possibly dementia. (B and C) are generalized statements that are not applicable to most
individuals in the population. Although many older persons do live alone, inability to summon
help (A) cannot be assumed.
38. Muscular Dystrophy is characterized by which pathophysiological condition?
A. Stressed induced tremor and trembling.
B. Cardiac damage.
C. Seizure activity.
D. Skeletal muscle degeneration.
Answer: D. Skeletal muscle degeneration.
Skeletal muscle degeneration (D) is a classic symptom of Muscular Dystrophy. Tremors and
trembling (A) of hands, particularly when stressed, are symptoms of Parkinson's. Cardiac
damage (B) and seizures (C) are not exclusive to Muscular Dystrophy.
39. The nurse is assessing a client with a ruptured small bowel and determines that the client has
a temperature of 102.8° F. Which assessment finding provides the earliest indication that the
client is experiencing septic shock?
A. Bilateral crackles.
B. Hyperpnea.
C. Mucus production.
D. Weak peripheral pulses.
Answer: B. Hyperpnea.
The interrelated pathophysiologic changes associated with the hypermetabolic state of sepsis and
septic shock produce a pathologic imbalance between cellular oxygen demand, supply, and
consumption. Hyperpnea (B), an increased depth of respirations, is an early manifestation of
sepsis. (A, C, and D) are signs of advanced shock.
40. Which signs and symptoms are associated with arterial insufficiency?
A. Pallor, intermittent claudication.
B. Pedal edema, brown pigmentation.
C. Blanched skin, lower extremity ulcers.
D. Peripheral neuropathy, cold extremities.
Answer: A. Pallor, intermittent claudication.
Pallor and intermittent claudication (A) are signs related to stage II of peripheral vascular
disease, which results in arterial insufficiency. (B) are signs related to venous insufficiency. (C)
are not specific to arterial disease. Although (D) may be related to complications of diabetes
mellitus resulting in poor circulation, arterial insufficiency causes impaired perfusion resulting in
hypoxic pain or intermittent claudication.
41. The severity of diabetic retinopathy is directly related to which condition?
A. Poor blood glucose control.
B. Neurological effects of diabetes.
C. Susceptibility to infection.
D. Uncontrolled hypertension.
Answer: A. Poor blood glucose control.
Poor glucose control (A) worsens diabetic retinopathy, whereas tight glucose control can lessen
its severity. (B, C, and D) do not affect the severity of diabetic retinopathy.
42. A client with a fractured right radius reports severe, diffuse pain that has not responded to the
prescribed analgesics. The pain is greater with passive movement of the limb than with active
movement by the client. The nurse recognizes that the client is most likely exhibiting symptoms
of which condition?
A. Acute compartment syndrome.
B. Fat embolism syndrome.
C. Venous thromboembolism.
D. Aseptic ischemic necrosis.
Answer: A. Acute compartment syndrome.
These signs are specific indications of Acute Compartment Syndrome (A), and should be treated
as an emergency situation. The signs do not indicate (B, C, or D).
43. When observing a client for symptoms of a large bowel obstruction, the nurse should assess
for which finding?
A. Distention of the lower abdomen.
B. Nausea with profuse vomiting.
C. Upper abdominal discomfort.
D. Fluid and electrolyte imbalances.
Answer: A. Distention of the lower abdomen.
Among findings characteristic of a large bowel obstruction is the distention of the lower
abdomen (A). (B, C, and D) are findings associated with small bowel obstruction.
44. The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone
(SIADH), which is manifested by which symptoms?
A. Loss of thirst, weight gain.
B. Dependent edema, fever.
C. Polydipsia, polyuria.
D. Hypernatremia, tachypnea.
Answer: A. Loss of thirst, weight gain.
SIADH occurs when the posterior pituitary gland releases too much ADH, causing water
retention, a urine output of less than 20 ml/hour, and dilutional hyponatremia. Other indications
of SIADH are loss of thirst, weight gain (A), irritability, muscle weakness, and decreased level of
consciousness. (B) is not associated with SIADH. (C) is a finding associated with diabetes
insipidus (a water metabolism problem caused by an ADH deficiency), not SIADH. The increase
in plasma volume causes an increase in the glomerular filtration rate that inhibits the release of
rennin and aldosterone, which results in an increased sodium loss in urine, leading to greater
hyponatremia, not (D).
45. The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone
(SIADH). This condition is most often related to which predisposing condition?
A. Small cell lung cancer.
B. Active tuberculosis infection.
C. Hodgkinâ’s lymphoma.
D. Tricyclic antidepressant therapy.
Answer: A. Small cell lung cancer.
Cancer is the most common cause of the syndrome of inappropriate antidiuretic hormone
(SIADH), with small cell lung cancer (A) being the most common cancer that increases ADH,
which causes dilutional hyponatremia and fluid retention. (B, C, and D) are also possible causes,
but secondary to CNS trauma or disease.
46. The nurse is assessing a postmenopausal woman who is complaining of urinary urgency and
frequency and stress incontinence. She also reports difficulty in emptying her bladder. These
complaints are most likely due to which condition?
A. Cystocele.
B. Bladder infection.
C. Pyelonephritis.
D. Irritable bladder.
Answer: A. Cystocele.
This constellation of signs in a postmenopausal woman are characteristic of a cystocele (A).
These symptoms are not characteristic of (B, C, or D).
47. Which pathophysiological response supports a client's vomiting experience?
A. Sensory input of noxious stimuli relayed to the cognitive centers is associated with disgust
and illicits vomiting.
B. Response of stimulation of the posterior oropharynx results in reverse peristalsis of the
gastrointestinal tract.
C. Spasmodic reflex of respiratory and gastric movements results from stimulation of the
chemoreceptor trigger zone.
D. Increased gastric and colonic pressures move gastrointestinal contents to the orifice of least
resistance.
Answer: C. Spasmodic reflex of respiratory and gastric movements results from stimulation of
the chemoreceptor trigger zone.
Vomiting is a reflex of spasmodic respiratory movements against the glottis causing the forceful
expulsion of the contents of the stomach through the mouth. Stimulation of the emetic center
results from afferent vagal and sympathetic nerve pathways that activate the chemoreceptor
trigger zone (CTZ) (C). (A) is a learned response and influences nausea, but does not explain the
mechanical physiology. Although self-induced vomiting responds to tactile stimulation of the
posterior oropharynx (B), the physiological mechanism of vomiting coordinates actions required
to empty the gastric contents. (D) may occur, but does not explain reflex vomiting.
48. A client's family asks why their mother with heart failure needs a pulmonary artery (PA)
catheter now that she is in the intensive care unit (ICU). What information should the nurse
include in the explanation to the family?
A. A central monitoring system reduces the risk of complications undetected by observation.
B. A pulmonary artery catheter measures central pressures for monitoring fluid replacement.
C. Pulmonary artery catheters allow for early detection of lung problems.
D. The healthcare provider should explain the many reasons for its use.
Answer: B. A pulmonary artery catheter measures central pressures for monitoring fluid
replacement.
Pulmonary artery catheters are used to measure central pressures and fluid balance (B). Even
though all clients in the ICU require close monitoring, they do not all need a PA catheter (A). PA
lines do not detect pulmonary problems (C). (D) avoids the family's question.
49. What histologic finding in an affected area of the body would suggest the presence of chronic
inflammation?
A. Predominance of neutrophils.
B. Absence of fibroblasts and proteases.
C. Decrease in degradation products.
D. Increase in monocytes and macrophages.
Answer: D. Increase in monocytes and macrophages.
A predominance of monocytes and macrophages in an inflamed area indicates the start of a
chronic infection (D). Macrophages are responsible for "cleaning up" the healing wound through
phagocytic and debridement actions, and monocytes assist in the healing of the wound after
neutrophils have entered the area. (A) arrives during the acute stage of inflammation rather than
at the later, chronic stage. (B) accumulates at the scene of a chronic infection. (C) increases due
to the accumulation of dead neutrophils at the site.
50. Physical examination of a comatose client reveals decorticate posturing. Which statement is
accurate regarding this client's status based upon this finding?
A. A cerebral infectious process is causing the posturing.
B. Severe dysfunction of the cerebral cortex has occurred.
C. There is a probable dysfunction of the midbrain.
D. The client is exhibiting signs of a brain tumor.
Answer: B. Severe dysfunction of the cerebral cortex has occurred.
Decorticate posturing (adduction of arms at shoulders, flexion of arms on chest with wrists
flexed and hands fisted and extension and adduction of extremities) is seen with severe
dysfunction of the cerebral cortex (B). (A) is characteristic of meningitis. (C) is characterized by
decerebrate posturing (rigid extension and pronation of arms and legs). A client with (D) may
exhibit decorticate posturing, depending on the position of the tumor and the condition of the
client.
