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1. Which of the fallowing arteries primarily feeds the heart's anterior wall?
1. circumflex artery
2. internal mammary artery
3. left anterior descending artery
4. right coronary artery
2. While auscultating a client's chest you hear a murmur at the second left intercostal space along the left sternal border. Which valve area is this?
1. aortic 3. pulmonic
2. mitral 4. tricuspid
3. What is the most common complication of a myocardial infarction (MI)?
1. cardiogenic shock 3. arrhythmias
2. heart failure 4. pericarditis
4. Which of the following Mood components is decreased in anemia?
1. erythrocytes 3. leukocytes
2. granulocytes 4. platelets
5. Which of the following are classic symptoms of thrombocytopenia?
1. weakness and fatigue 3. bruising and petechiae
2. dizziness and vomiting 4. light-headedness and nausea
6. Which of the following signs and symptoms would a client with tuberculosis (TB) have?
1. chest and lower-back pain
2. chills, fever, night sweats, and hemoptysis
3. fever of more than 104° F (40° C) and nausea
4. headache and photophobia
7. A 66-year-old client has marked dyspnea at rest, is thin, and uses accessory muscles to breathe. He's tachypneic, with a prolonged expiratory phase. He has no cough. He leans forward with his arms braced on his knees to support his chest and shoulders for breathing. This client has signs and symptoms of which of the following respiratory disorders?
1. acute respiratory distress syndrome (ARDS)
3. chronic bronchitis
8. Which of the following respiratory disorders is most common in the first 24 to 48 hours after surgery?
1. atelectasis 3. pneumonia
2. bronchitis 4. pneumothorax
9. A client with head trauma has a urine output of 300 ml/hour, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform immediately?
1. Evaluate urine specific gravity.
2. Anticipate treatment for renal failure.
3. Apply emollients to the skin to prevent breakdown.
4. Slow the I.V. infusion rate and notify the health care provider.
10. You should carefully watch a client who had a transsphenoidal hypophysectomy for hemorrhage, which may cause which of the following signs?
1. bloody drainage from his ears
2. frequent swallowing
3. guaiac-positive stools
11. Which of the following nursing interventions takes priority for the client having a tonic-clonic seizure?
1. maintaining a patent airway
2. timing the duration of the seizure
3. noting the origin of seizure activity
4. inserting a padded tongue blade to prevent him from biting his tongue
12. Which of the following signs and symptoms is an early sign of compartment syndrome?
1. heat 3. skin pallor
2. paresthesia 4. swelling
13. Which of the following signs and symptoms can occur with fat emboli?
1. tachypnea, tachycardia, shortness of breath, paresthesia
2. paresthesia, bradypnea, bradycardia, petechial rash on chest and neck
3. bradypnea, bradycardia, shortness of breath, petechial rash on chest and neck
4. tachypnea, tachycardia, shortness of breath, petechial rash on chest and neck
14. Which of the following types of diet is implicated in the development of diverticulosis?
1. low-fiber diet 3. high-protein diet
2. high-fiber diet 4. low-carbohydrate diet
15. The client with pancreatitis may exhibit Cullen's sign on physical examination. Which of the following symptoms best describes Cullen's sign?
1. jaundiced sciera
2. pain that occurs with movement
3. bluish discoloration of the left flank area
4. bluish discoloration of the periumbilical area
16. The client who's developing hepatic encephalopathy may exhibit which of the following signs and symptoms?
1. asterixis 3. increased energy
2. good concentration 4. talkativeness
17. Which of the following signs and symptoms indicate hyperglycemia?
1. polydipsia, polyuria, and weight loss
2. weight gain, tiredness, and bradycardia
3. irritability, diaphoresis, and tachycardia
4. diarrhea, abdominal pain, and weight loss
18. Which of the following potentially serious complications may occur when treating hypothyroidism?
1. acute hemolytic reaction 3. retinopathy
2. angina or cardiac arrhythmias 4. thrombocytopenia
1. 3. The left anterior descending artery is the primary source of blood for the heart's anterior wall. The circumflex artery supplies the lateral wall; the internal mammary artery (also known as the internal thoracic artery) supplies the anterior thoracic wall, mediastinal structures, and diaphragm; and the right coronary artery supplies the heart's inferior wall.
2. 3. Abnormalities of the pulmonic valve are auscultated at the second left intercostal space along the left sternal border. Aortic valve abnormalities are heard at the second intercostal space, to the right of the sternum. Mitral valve abnormalities are heard at the fifth intercostal space in the midclavicular line. Tricuspid valve abnormalities are heard at the third and fourth intercostal spaces along the sternal border.
3. 3. Arrhythmias caused by oxygen deprivation to the myocardium are the most common complication of an MI. Cardiogenic shock, another complication of MI, is defined as end-stage left ventricular dysfunction. The condition occurs in about 15% of clients with MI. Because the heart's pumping function is compromised by an MI, heart failure is the second most common complication. Pericarditis most commonly results from a bacterial or viral infection, although it may occur after MI.
4. 1. Anemia is defined as a decreased number of erythrocytes (red blood cells). Leukopenia is a decreased number of leukocytes (white blood cells), thrombocytopenia is a decreased number of platelets, and granulocytopenia is a decreased number of granulocytes (a type of white blood cell).
5. 3. Platelets are necessary for clot formation, so bruising and petechiae are signs of a decreased number of platelets (thrombocytopenia). Weakness and fatigue are signs of anemia. Dizziness and vomiting are not usual signs of thrombocytopenia; neither are light-headedness and nausea.
6. 2. Typical signs and symptoms of TB are chills, fever, night sweats, and hemoptysis. Chest pain may be present from coughing, but it isn't usual. Clients with TB typically have low-grade fever under 102° F (38.9° C). Headache and photophobia aren't usual TB symptoms; neither are lower-back pain or nausea.
7. 4. These are classic signs and symptoms of emphysema. They aren't consistent with ARDS, asthma, or chronic bronchitis.
8. 1. Atelectasis can develop from obstructed or hypoventilated alveoli, as well as from inhalation of concentrated oxygen or anesthetic agents. Postoperative pain makes clients reluctant to take deep breaths or change position, which places them at risk for atelectasis. The other respiratory disorders rarely develop in the first 24 to 48 hours after surgery.
9. 1. Urine output of 300 ml/hour may indicate diabetes insipidus, which is most commonly caused by the pituitary gland's failure to produce antidiuretic hormone. This may occur with increased intracranial pressure and head trauma; the nurse evaluates for low urine specific gravity, increased serum osmolarity, and dehydration. The evidence doesn't indicate that the client is experiencing renal failure. Providing an emollient to prevent skin breakdown is important but needn't be performed immediately. Slowing the I.V. infusion rate would contribute to dehydration when polyuria is present.
10. 2. Frequent swallowing after this surgery may indicate fluid or blood leaking from the sinuses into the oropharynx. Blood or fluid draining from the ear may indicate a basilar skull fracture. Guaiac-positive stools indicate gastrointestinal bleeding. Hematuria may result from cystitis or other urologie complications.
11.1. The priority during and after a seizure is to maintain a patent airway. Timing the seizure activity and noting the origin of motor dysfunction are done, but not first. Nothing should be placed in the client's mouth during a seizure because his teeth may be broken or dislodged or his tongue pushed back, further obstructing his airway.
12. 2. Paresthesia is the earliest symptom of compartment syndrome. Heat and swelling also occur, but after paresthesia. Skin pallor isn't a sign of compartment syndrome.
13. 4. Signs and symptoms of fat emboli include tachypnea, tachycardia, shortness of breath, and a petechial rash on the chest and neck. The fat globules enter the venous circulation and travel to the lung, obstructing pulmonary circulation. Bradycardia, bradypnea, and paresthesia aren't usual symptoms.
14. 1. Low-fiber diets have been implicated in the development of diverticula because these diets decrease fecal bulk, increase fecal transmit time, raise intracolonic pressures, and make elimination of stool more difficult. A high-fiber diet helps prevent diverticulosis. A high-protein or low-carbohydrate diet has no effect on the development of diverticulosis.
15. 4. Cullen's sign is bluish discoloration of the periumbilical area from severe hemorrhagic pancreatitis. Jaundiced sciera occurs with hepatitis. Pain with movement is a common finding with peritonitis. Turner's sign is the bluish discoloration of the flanks, which can be present in hemorrhagic pancreatitis.
16. 1. Asterixis, also known as liver flap, is commonly present in clients with hepatic encephalopathy. It can be easily elicited by applying a blood pressure cuff to the arm and noting if the flapping is present when the cuff is released. Lack of concentration, fatigue, and introversion are also symptoms of encephalopathy.
17. 1. Signs and symptoms of hyperglycemia include polydipsia, polyuria, and weight loss. Weight gain, tiredness, and bradycardia are symptoms of hypothyroidism. Irritability, diaphoresis, and tachycardia are symptoms of hypoglycemia. Symptoms of Crohn's disease include diarrhea, abdominal pain, and weight loss.
18. 2. Precipitation of angina or cardiac arrhythmias is a potentially serious complication of hypothyroidism treatment, especially in clients who are elderly or have underlying heart disease. Acute hemolytic reaction is a complication of blood transfusions. Retinopathy usually is a complication of diabetes mellitus. Thrombocytopenia, defined as a platelet count of less than 150,000/mcl, doesn't result from treating hypothyroidism.
Source: NCLEX-RN Questions & Answers Made Incredibly Easy!, 2nd edition, Lippincott Williams & Wilkins, 2003.
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