ATI RN
Pathophysiology Exam 1 Quizlet
1. A client has experienced a pontine stroke which has resulted in severe hemiparesis. What priority assessment should the nurse perform prior to allowing the client to eat or drink from the food tray?
- A. Evaluate the client's gag reflex.
- B. Assess the client's bowel sounds.
- C. Check the client's pupil reaction.
- D. Monitor the client's heart rate.
Correct answer: A
Rationale: The correct answer is to evaluate the client's gag reflex. When a client has experienced a stroke resulting in severe hemiparesis, assessing the gag reflex is crucial before allowing them to eat or drink. This assessment helps prevent aspiration, a serious complication that can occur due to impaired swallowing ability. Assessing bowel sounds (Choice B), pupil reaction (Choice C), or heart rate (Choice D) are important assessments but are not the priority in this situation where the risk of aspiration is higher.
2. A 45-year-old woman has been prescribed conjugated estrogens (Premarin) for the treatment of menopausal symptoms. What should the nurse include in the patient teaching?
- A. Increase fluid intake to prevent dehydration.
- B. Avoid smoking while taking this medication.
- C. Increase the intake of high-calcium foods.
- D. Take the medication at bedtime to prevent insomnia.
Correct answer: B
Rationale: The correct answer is to 'Avoid smoking while taking this medication' because patients taking conjugated estrogens should avoid smoking due to the increased risk of cardiovascular events. Increasing fluid intake to prevent dehydration is a good practice but not specifically related to conjugated estrogens. Increasing the intake of high-calcium foods may be beneficial for bone health but is not directly related to the medication. Taking the medication at bedtime to prevent insomnia is not a specific teaching point for conjugated estrogens.
3. A patient with a history of breast cancer is prescribed tamoxifen (Nolvadex). What critical information should the nurse include in the patient education?
- A. Tamoxifen may increase the risk of venous thromboembolism, so patients should be educated about the signs and symptoms of blood clots.
- B. Tamoxifen may cause weight gain, so patients should monitor their diet.
- C. Tamoxifen may decrease the risk of osteoporosis, so patients should ensure adequate calcium intake.
- D. Tamoxifen may cause hot flashes and other menopausal symptoms.
Correct answer: A
Rationale: Tamoxifen increases the risk of venous thromboembolism, so patients should be educated about the signs and symptoms of blood clots and the importance of seeking immediate medical attention if they occur.
4. A patient underwent an open cholecystectomy 4 days ago, and her incision is now in the proliferative phase of healing. The nurse knows that the next step in the process of wound healing is:
- A. Inflammation
- B. Maturation
- C. Remodeling
- D. Coagulation
Correct answer: C
Rationale: In the context of wound healing, after the proliferative phase comes the remodeling phase. During the remodeling phase, the wound gains strength as collagen fibers reorganize, and the scar matures. Inflammation is the initial phase of healing, where the body responds to injury with redness, swelling, and warmth. Maturation is the final stage where the scar tissue continues to undergo changes but is not the immediate next step after the proliferative phase. Coagulation is the process of blood clot formation and is not a phase in wound healing.
5. What is the cause of swelling during acute inflammation?
- A. Collagenase
- B. Fluid exudate
- C. Lymphocytic margination
- D. Anaerobic glycolysis
Correct answer: B
Rationale: Swelling during acute inflammation is primarily caused by the accumulation of fluid exudate in the affected tissues. This fluid exudate contains proteins and cells that leak from blood vessels due to increased vascular permeability. Collagenase (Choice A) is an enzyme that breaks down collagen and is not directly responsible for swelling. Lymphocytic margination (Choice C) is the process where white blood cells line up along the blood vessel walls, which does not directly cause swelling. Anaerobic glycolysis (Choice D) is a metabolic process that occurs in the absence of oxygen and is not related to the mechanism of swelling in acute inflammation.
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