A client is suspected of having MI. A nurse assesses for elevations in which of the following isoenzyme values reported with the creatinine ohosphokinase (CPK) level?
Ans: CPK is a cellular enzyme that can be fractionated into three isoenzymes. The MB band reflects CPK from cardiac muscle. This is the level that elevates with MI. The MM band reflects CPK from skeletal muscle. The BB band reflects CPK from the brain. There is no MK band.
A 7-year old child is seen in a clinic, and the primary health care provider documents a diagnosis of primary nocturnal enuresis. The mother asks a nurse about the diagnosis. The nurse plans to respond, knowing that primary nocturnal enuresis
? does not respond to treatment
? is common and most children will outgrow the bedwetting problem without therapeutic intervention
? requires surgical intervention to improve the problem
? is caused by a psychiatric problem
Ans: Primary nocturnal enuresis occurs in a child who has never been dry at night for extended periods. The condition is common in children. And most children eventually will outgrow bed-wetting without therapeutic intervention. The child is not able to sense a full bladder and does not awaken to void. The child may have delayed maturation of the CNS. The condition is not caused by a psychiatric problem.
The immobile client is at risk for disuse osteoporosis. The nurse understands that which of the following substances plays an important role in the bone remodeling process?
? Thyroid hormone
? Vitamin C
? Vitamin A
Ans: Bone remodeling is the results of osteoblastic and osteoclastic activity based on the degree of stress that is placed on the degree of stress that is placed on the bone. The three substances that plat an important role in this process are parathyroid hormone (which regulates calcium levels and bone resorption), vitamin D (which is active in bone formation and calcium resorption from bone), and calcitonin (which inhibits osteoclastic bone resorption). The other substances listed do not play a role in this process.
A nurse understands that the excessive use of oral antacids containing bicarbonate can result in which acid-base disturbance?
? respiratory acidosis
? metabolic acidosis
? metabolic alkalosis
? respiratory alkalosis
Ans: Increases in base components occur as a result of oral or parenteral intake of bicarbonates, carbonates, acetates, citrates, or lactates. Excessive use of oral antacids containing bicarbonate can cause a metabolic alkalosis.
The mother of a 1-month-old infant is bottle-feeding her infant and asks the nurse about the stomach capacity of an infant. The nurse responds, knowing that the stomach capacity for a 1-month-old is about
? 30 to 90 ml
? 75 to 100 ml
? 10 to 20 ml
? 90 to 150 ml
Ans: The stomach capacity of a newborn infant is 10 to 20 ml; 30 to 60 ml for a 1-week-old infant; 75 to 100 ml for a 2 to 3-week-old infant; and 90 to 150 ml for a 1-month-old infant.
Morphine sulfate is prescribed for a client for acute pain control and will be administered through a patient-controlled analgesia device. The nurse plans care knowing that morphine sulfate rather than meperidine hydrochloride (Demerol) will be used for patient-controlled analgesia because
? Meperidine hydrochloride usually does not relieve acute pain
? Morphine sulfate will not cause any drowsiness
? Meperidine hydrochloride is reserved for short-term PCA because of its toxic effects and accumulation of the medication in the blood
? Morphine sulfate will not cause any respiratory depression
Ans: Meperidine hydrochloride is used for the relief of acute pain. However, the use of meperidine hydrochloride for PCA is reserved for short-term use, usually less than 48 to 72 hours, because its toxic metabolite, normeperidine, may accumulate in the blood and may cause drowsiness and respiratory depression, and the nurse monitors the client closely for these effects.
A client is experiencing a decrease in a blood pressure. The nurse anticipates that this will have which of the following primary effects on the client’s heart?
? increased contractility
? decreased heart rate
? decreased myocardial blood flow
? increased resistance to electrical stimulation
Ans: The primary effect of a decreased blood pressure is reduced blood flow to the myocardium, which in turn decreases the oxygenation to cardiac tissue. Cardiac tissue is likely to become more excitable or irritable in the presence of hypoxia. Correspondingly, the heart rate is likely to increase in response to this change, not decrease. The effects of tissue ischemia will lead to decreased contractility over time.
The instructor asks the nursing student about the physiology related to the cessation of ovulation that occurs during pregnancy. Which of the following responses, if made by the student, indicates an understanding of this physiological process?
? “Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are low.”
? “Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high.”
? “The low levels of estrogen and progesterone increase the release of the FSH and LH.”
? "The high levels of estrogen and progesterone promote the release of the FSH and LH.”
Ans: Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high, inhibiting the release of the FSH and LH that are necessary for ovulation.
The client has suffered a head injury affecting the occipital lobe of the brain. The nurse anticipates that the client may experience difficulty with
Ans: The occipital lobe is responsible for reception of vision and contains visual association areas. This area of the brain helps the individual visually to recognize and understand the surroundings. The other senses listed are not a function of the occipital lobe.
The nursing student is asked to describe the corpus of the uterus. Which of the following responses, if made by the student, indicates an understanding of the anatomy of the uterus?
? “The corpus is the upper part of the uterus.”
? “The corpus is the lower portion of the uterus.”
? “The corpus is the area where the vagina meets the uterus.”
? “The corpus is the area where the cervix meets the external os.”
Ans: The uterus has three divisions: the corpus, isthmus, and the cervix. The upper division is the corpus or the body of the uterus. The uppermost part of the uterine corpus, above the area where the fallopian tubes enter the uterus, is the fundus of the uterus
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