Nursing III Exam III
Chapter 65
The nurse is caring for a client who has sustained multiple injuries from a motor
vehicle accident. The nurse realizes that the client will have a release of stress
hormones that are useful for all of the following EXCEPT:
Preventing ingestion of food
The nurse is planning care for a client diagnosed with acute respiratory distress
syndrome (ARDS)? Which of the following is not included in the management of
this disorder?
Promoting urine output
The nurse, caring for a client diagnosed with shock, realizes that the stage in
which the body attempts to remedy the problem by initiating the homeostatic
mechanism would be?
Compensatory stage
A client experiences a bee sting, complains of difficulty breathing, and shows sign
of hypoxia and hypotension. The nurse realizes these are signs of anaphylactic
shock, and she should do which of the following first?
Give epinephrine intravenously or via endotracheal tube
A client is diagnosed with failure of the left ventricle to provide adequate delivery
of oxygen to the body tissues due to a weakened forward pumping function of the
heart. The nurse realizes this client is experiencing:
cardiogenic shock
To assess if the renal system in a client diagnosed with multisystem failure is
functioning properly, the nurse would expect to see urine output of:
30 mL per hour
The nurse realizes that a client, diagnosed with neurogenic shock, is at risk for
developing: deep vein thrombosis
A client is diagnosed with septic shock. The nurse realizes that the major cause of
this type of shock is:
gram-negative bacteria
A client is diagnosed with cardiogenic shock. The nurse should plan interventions
to address which of the following potential complications of this disorder?
Myocardial infarction
The nurse is concerned that a client will develop neurogenic shock when which of
the following is assessed?
Spinal cord injury at T1
, The nurse is planning care for a client diagnosed with disseminated intravascular
coagulation. Which of the following should be included in this plan of care?
Avoid intramuscular injections
A firefighter is brought to the emergency department with complaints of headache,
weakness, shortness of breath, cough, and chest pain. During the assessment of this
client, the nurse realizes the client should be evaluated for:
Cyanide poisoning
The nurse is assessing a client for the acute phase of the inflammatory immune
response. Which of the following are considered cardinal signs of this response?
(Select all that apply.) Rubor
Tumo
r
Dolor
Calor
The nurse is determining if a client is experiencing chronic inflammation. Which of
the following are indications for this type of inflammation? (Select all that apply.)
Chronic elevation of white blood
cells Low-grade fever
Pain
Scar formation
The nurse is assessing a client for systemic inflammatory response syndrome (SIRS).
Which of the following disease processes are associated with this syndrome? (Select
all that apply.) Infection
Pancreatit
is
Ischemia
Trauma
Massive transfusions
A client is experiencing symptoms associated with distributive shock. What types of
shock are included in this category? (Select all that apply.)
Neurogeni
c
Anaphylact
ic Septic
The nurse is caring for a client experiencing hypovolemic shock. Which of the
following interventions would be appropriate for this client? (Select all that
apply.)
Monitor intravenous fluid
replacement Monitor vital signs
Assess for manifestations of fluid overload
Chapter 65
The nurse is caring for a client who has sustained multiple injuries from a motor
vehicle accident. The nurse realizes that the client will have a release of stress
hormones that are useful for all of the following EXCEPT:
Preventing ingestion of food
The nurse is planning care for a client diagnosed with acute respiratory distress
syndrome (ARDS)? Which of the following is not included in the management of
this disorder?
Promoting urine output
The nurse, caring for a client diagnosed with shock, realizes that the stage in
which the body attempts to remedy the problem by initiating the homeostatic
mechanism would be?
Compensatory stage
A client experiences a bee sting, complains of difficulty breathing, and shows sign
of hypoxia and hypotension. The nurse realizes these are signs of anaphylactic
shock, and she should do which of the following first?
Give epinephrine intravenously or via endotracheal tube
A client is diagnosed with failure of the left ventricle to provide adequate delivery
of oxygen to the body tissues due to a weakened forward pumping function of the
heart. The nurse realizes this client is experiencing:
cardiogenic shock
To assess if the renal system in a client diagnosed with multisystem failure is
functioning properly, the nurse would expect to see urine output of:
30 mL per hour
The nurse realizes that a client, diagnosed with neurogenic shock, is at risk for
developing: deep vein thrombosis
A client is diagnosed with septic shock. The nurse realizes that the major cause of
this type of shock is:
gram-negative bacteria
A client is diagnosed with cardiogenic shock. The nurse should plan interventions
to address which of the following potential complications of this disorder?
Myocardial infarction
The nurse is concerned that a client will develop neurogenic shock when which of
the following is assessed?
Spinal cord injury at T1
, The nurse is planning care for a client diagnosed with disseminated intravascular
coagulation. Which of the following should be included in this plan of care?
Avoid intramuscular injections
A firefighter is brought to the emergency department with complaints of headache,
weakness, shortness of breath, cough, and chest pain. During the assessment of this
client, the nurse realizes the client should be evaluated for:
Cyanide poisoning
The nurse is assessing a client for the acute phase of the inflammatory immune
response. Which of the following are considered cardinal signs of this response?
(Select all that apply.) Rubor
Tumo
r
Dolor
Calor
The nurse is determining if a client is experiencing chronic inflammation. Which of
the following are indications for this type of inflammation? (Select all that apply.)
Chronic elevation of white blood
cells Low-grade fever
Pain
Scar formation
The nurse is assessing a client for systemic inflammatory response syndrome (SIRS).
Which of the following disease processes are associated with this syndrome? (Select
all that apply.) Infection
Pancreatit
is
Ischemia
Trauma
Massive transfusions
A client is experiencing symptoms associated with distributive shock. What types of
shock are included in this category? (Select all that apply.)
Neurogeni
c
Anaphylact
ic Septic
The nurse is caring for a client experiencing hypovolemic shock. Which of the
following interventions would be appropriate for this client? (Select all that
apply.)
Monitor intravenous fluid
replacement Monitor vital signs
Assess for manifestations of fluid overload
