Porth’s Pathophysiology, Concepts of Altered Health States- 9th Edition by Sheila Grossman-Carol Mattson Porth -Test Bank




Porth’s Pathophysiology, Concepts of Altered Health States- 9th Edition by Sheila Grossman-Carol Mattson Porth -Test Bank

Chapter 2- Concepts of Altered Health in Children


1. New parents were just told by their physician that their son is two standard deviations above the mean. The parents later asked the nurse what that means. The nurse will explain by stating,
  A) “If your child is one standard deviation from the norm that translates to mean, he will be taller than 50% of his peers.”
  B) “This is great news since it means you will have a larger baby than most.”
  C) “Being two standard deviations above the mean translates into that your child will likely be taller than 95% of children in the population.”
  D) “With the mean being average at 50%, two standard deviations means that your child will be at least 99.7% taller than his brother.”
  Ans: C
  The standard deviation determines how far a value varies or deviates from the mean. The points one standard deviation above or below the mean should include 68% of all values and two standard deviations 95% of all values. If a child’s height is within one standard deviation of the mean, he is as tall as 68% of children in the population.



2. A woman has recently determined that she is pregnant, and her clinician believes that the conception occurred around 8 weeks prior. Since the embryo is in the third stage of embryonic development, which of the following events and processes in growth and development would be expected to be taking place?
  A) Transition from a morula to a blastocyst
  B) Ossification of the skeleton and acceleration of body length growth
  C) Rapid eye movement and early support of respiration
  D) Formation of upper limbs and opening of the eyes
  Ans: D
  Limb formation and eye opening are associated with the third stage of the embryonic stage of development. The transition from a morula to a blastocyst occurs before the second week of gestation, while ossification of the skeleton and acceleration of body length growth do not take place until the early fetal period. Rapid eye movement and early pulmonary function emerge during the 26th through 29th weeks.



3. A midwife who is providing care for a woman during her first pregnancy is assessing for intrauterine growth retardation (IUGR) during an early prenatal checkup. Which of the following questions best addresses the risks for IUGR?
  A) “What does your typical diet look like over the course of a day?”
  B) “What is the highest level of education that you’ve finished?”
  C) “Are there many people in your life that you can count on for help and support?”
  D) “How would you describe your mood since you’ve been pregnant?”
  Ans: A
  Nutrition is a key aspect in the prevention of IUGR. Educational level, the presence or absence of support systems, and psychosocial health may all have ramifications that could affect fetal development, but they have a less direct bearing than maternal nutrition.



4. Which of the following assessment findings of a male infant 14 hours postpartum would be considered abnormal and would require further assessment and possible intervention?
  A) The baby’s first stool appears to contain blood.
  B) The child is unable to breathe through his mouth.
  C) The baby’s skin has a yellowish orange hue.
  D) The child’s suck is weak when placed at his mother’s breast.
  Ans: C
  While not an uncommon event in early postnatal life, jaundice requires further assessment and possibly intervention. Meconium often contains blood, and young infants are exclusive nose breathers. A child’s suck is frequently weak before it becomes established in the days to follow.



5. A nurse is performing a 5-minute Apgar score on a newborn female. Which of the following characteristics of the infant’s current condition would not be reflected in the child’s Apgar score?
  A) The baby’s heart rate is 122 beats/minute.
  B) The infant displays a startle reflex when the crib is accidentally kicked.
  C) The child’s temperature is 35.0°C (95°F) by axilla.
  D) The infant’s skin is pink in color.
  Ans: C
  While heart rate, color, and presence or absence of crying are all assessment criteria in the determination of an Apgar score, temperature is not a parameter that is measured.



6. The nursery has just admitted a new infant born 1 hour ago. While performing an assessment, the nurse suspects the infant may have hypoglycemia based on which of the following assessment data? Select all that apply.
  A) Heel stick glucose value of 50 mg/dL
  B) Infant having periods of apnea requiring physical stimulation
  C) Muscle twitching noted while lying in crib undisturbed by nurses
  D) Hyperactive reflexes noted especially when crying
  E) Poor suck reflex resulting in an inability to feed properly
  Ans: B, C, E
  In neonates, glucose levels stabilize to a value of 50 mg/dL or higher within the first 3 hours of life. Concentrations below 45 mg/dL should be considered abnormal. Signs and symptoms of neonatal hypoglycemia include cyanosis, apnea, hypothermia, hypotonia, poor feeding, lethargy, and seizures.



7. The first-time parents of an infant girl 2 days postpartum are distressed at the jaundiced appearance of her skin and are eager for both an explanation and treatment for the problem. Which of the following responses by their physician is most accurate?
  A) “Your daughter’s young liver is unable to get rid of the waste products from old red blood cells.”
  B) “Because your daughter’s kidneys are so small, they have a hard time getting rid of the wastes that are always accumulating in her blood.”
  C) “Nearly half of all infants have this problem, and while it is distressing to look at, it is largely harmless and will resolve in time.”
  D) “This is a sign that your baby needs more milk than she is currently getting, and increased breast-feeding will act to flush these pigments out of her system.”
  Ans: A
  Bilirubin is formed from the breakdown of hemoglobin in red blood cells. Normally about two thirds of the unconjugated bilirubin produced by a term newborn can be effectively cleared by the liver. However, the relative immaturity of the newborn liver and the shortened life span of the fetal red blood cells may predispose the term newborn to hyperbilirubinemia. Bilirubin clearance is not the domain of the kidneys, and treatment is often necessary. Jaundice can sometimes be addressed by increasing breast-feeding, but it is not a sign in and of itself of insufficient feeding.



8. Which of the following infants most likely requires medical intervention?
  A) A 2-day-old baby boy who has caput succedaneum
  B) An infant 4 hours postpartum who has visible coning of his head following vaginal delivery
  C) A girl 3 days postpartum with noticeable unilateral cephalhematoma
  D) A male infant whose vertex delivery resulted in a brachial plexus injury
  Ans: D
  While caput succedaneum, cephalhematoma, and head coning are all frequently able to resolve independently, a brachial plexus injury is likely to require treatment and rehabilitation.



9. A nurse who works in a neonatal intensive care unit is providing care for an infant born at 26 weeks’ gestation. Which of the following assessments would lead the nurse to suspect that the infant has developed respiratory distress syndrome (RDS)?
  A) The infant’s blood pressure and temperature are normal measurements as expected.
  B) Infant is grunting and has notable intercostal retractions with respirations.
  C) Infant has poor motor skills and limited limb range of motion.
  D) Infant has apnea lasting 5 to 10 seconds with a decrease in heart rate, which reverses with tactile stimulation.
  Ans: B
  While premature birth is associated with numerous potential health problems, including variations in vital signs, impaired motor function, and neurological deficits, the most common complications of prematurity involve respiratory function.



10. While assessing a premature infant born at 25 weeks’ gestation, the neonatal intensive care unit (NICU) nurse would suspect which diagnosis when the infant displays poor muscle tone, apnea, and a new onset of somnolence?
  A) Hydrocephalus
  B) Airway obstruction
  C) Intraventricular hemorrhage
  D) Sepsis
  Ans: C
  Prematurity is a risk for IVH. Clinical manifestations are determined by the level of involvement. The most common symptoms are poor muscle tone, lethargy, apnea, decreased hematocrit, and somnolence.



11. A premature infant who is receiving care in a neonatal intensive care unit (NICU) has just been identified as having necrotizing enterocolitis (NEC). Of the following clinical manifestations, identify those most likely to contribute to the diagnosis of NEC. Select all that apply.
  A) Feeding intolerance
  B) Inability to pass stool within the first 10 days of life
  C) Hard, taut abdomen with increasing distention
  D) Blood noted in stools
  E) Hypoactive bowel sounds on right lower quadrant
  Ans: A, C, D
  Immature immunity, shunting of circulation away from the GI tract, and infectious processes have all been implicated in the etiology of NEC. The classic initial symptoms are usually feeding intolerance, abdominal distention, and bloody stools shortly after the first week of life.



12. The neonatologist suspects an infant has developed sepsis with multiorgan system illness. The nurse caring for this infant will note which of the assessment findings support this diagnosis. Select all that apply.
  A) Decreasing BP with increase in heart rate indicative of shock
  B) Prolonged PT and PTT and decrease in platelet count
  C) Frequent voiding of a small amount of light-colored urine
  D) Bilateral warm feet but pedal pulses hard to palpate
  E) Positive Moro reflex when loud noise made at crib side
  Ans: A, B
  Premature infants’ health is severely impacted by early-onset infections and progressive multiorgan system illness. Infants with sepsis frequently present with respiratory failure, shock, meningitis, DIC, acute tubular necrosis, and symmetrical peripheral gangrene. Positive Moro reflex is normal for this infant.



13. The exasperated parents of a 4-month-old infant with colic have asked their health care provider what they can do to alleviate their child’s persistent crying. Based on their concerns, the nurse should educate/discuss with the parents which of the following?
  A) Encouraging them to walk away from the infant when they can no longer tolerate it
  B) Recommending them to reduce the amount of commercial formula and increase breast-feeding
  C) Discussing the use of prescribed antiflatulent medication that will help more than changing the formula
  D) Demonstrating how to use a soothing voice and slow rocking back and forth as a way to calm the infant
  Ans: D
  The lack of a single etiologic factor makes treatment of colic difficult. The incidence is similar with both breast-feeding and formula, and while antiflatulents are sometimes used, the problem is not always attributable to intestinal gas. Even though it is a common problem that does resolve with time, parents need support. Nonpharmacologic interventions include soothing voices, singing, swaddling, and slow rhythmic rocking.



14. During a prenatal education class, a participant has related a story about how her friend’s infant died of sudden infant death syndrome (SIDS). What can the educator tell the group about how they can prevent SIDS when they have their babies? Select all that apply.
  A) “The best sleeping position for your baby is on his back.”
  B) “Children are at particular risk of SIDS when they have a cold or flu, so these times require extra vigilance.”
  C) “Using drugs during pregnancy has been shown to be associated with SIDS after birth, which is one more reason for mothers to avoid them.”
  D) “It’s important if anyone in your home smokes to make sure they only do it outside.”
  E) “The exact cause of SIDS still isn’t known, so there’s little that you can do to prevent this tragic event.”
  Ans: A, C, D
  Prone or side-lying position, intrauterine drug exposure, and postnatal exposure to cigarette smoke are all associated with SIDS. Upper respiratory infections are not noted to present a particular risk, and though the exact etiology is not known, preventative measures do exist.



15. Due to rapid neural growth, a child can begin to control the bowel and bladder sphincters by what age?
  A) 12 months
  B) 18 months
  C) 2 years
  D) 4 years
  Ans: C
  The cephalocaudal proximodistal principle is followed as myelinization of the cortex, brain stem, and spinal cord is completed. The spinal cord is usually completely myelinated by 2 years of age. At that time, control of anal and urethral sphincters and motor skills of locomotion can be achieved.



16. What topic should health promotion initiatives emphasize if the target audience is parents of preschoolers and the goal is to minimize mortality?
  A) Handwashing as an infection control measure
  B) Injury prevention especially when the child is near water
  C) Identifying signs of child abuse and neglect
  D) The importance of good nutrition
  Ans: B
  Injuries are the leading cause of death in children aged 1 to 4. While handwashing does prevent many infections, these are not commonly fatal. Likewise, child abuse and poor nutrition are valid educational topics, but they do not relate as directly and frequently to childhood death as do injuries.



17. In the grocery store, a nurse overhears a teenage mother intentionally shaming and verbally reprimanding a child in public. The mother also grabbed the child’s stuffed animal and tore the limbs off. From what the nurse remembers about abuse, this would be classified as a form of
  A) physical abuse.
  B) emotional abuse.
  C) sexual abuse.
  D) neglect.
  Ans: B
  Emotional abuse or psychological maltreatment includes methods of verbal abuse, shaming, destruction of child’s personal property, harming or killing child’s pet, and bullying.



18. A 10-year-old boy has a body mass index that places him in the 96th percentile for his age and gender. While educating the parents about obesity, the nurse should emphasize that his weight may predispose him to the development of
  A) scoliosis.
  B) respiratory infections.
  C) gastrointestinal disorders.
  D) type 2 diabetes.
  Ans: D
  Adolescent obesity is associated with an increased risk of type 2 diabetes. He is less likely to face a heightened risk of scoliosis, respiratory infections, or GI disorders.



19. A 14-year-old boy has experienced a pronounced growth spurt over the last several months. While discussing this with his parents, the nurse educates what normal male growth patterns contain. Of the following, which are accurate statements to relay to the parents? Select all that apply.
  A) Most males will complete their growth spurt by age 16.
  B) It is not usual for their son to gain up to 30 kg in weight.
  C) With parathyroid hormone involvement, your son may be at risk for fractures.
  D) Expect the thorax to become broader and for the pelvis to remain narrow.
  E) Some children have stunted growth in their arms or legs.
  Ans: B, D
  In males, they may continue to gain height until 18 to 20 years of age and gain from 7 to 30 kg of weight. Parathyroid hormone does not have roles that relate to the adolescent growth spurt. In males, the thorax becomes broader and the pelvis remains narrow. In girls, the opposite occurs. Growth in the arms, legs, hands, feet, and neck is followed by increases in the hip and chest months later.



20. Which of the following statements made by parents of high schoolers would be a cause for the concern the child may be thinking about suicide?
  A) “My child seems to eat all the time. He tells me that all of his friends are eating a lot as well.”
  B) “My child seems to go shopping at the mall every day after school with her friends. I think they hang out at the mall.”
  C) “My child has never had problems in school until now. He is failing classes and getting in trouble.”
  D) “My child used to talk to me about anything. Now she spends most of her time in her room texting friends.”
  Ans: C
  Risk factors for suicide in adolescents include substance abuse, personal or family history of depression, anxiety disorders, problems at school, problems communicating with parents, having a friend who committed suicide, and family ownership of a handgun.



Chapter 16- Acquired Immunodeficiency Syndrome

1. While teaching about HIV/AIDS to a group of high school seniors, the school health nurse will begin by explaining the basic facts that will likely include which of the following information?
  A) Like all viruses, HIV is a  genetic material made from DNA with long molecules that carry genetic information.
  B) HIV is different from other viruses since it is a retrovirus that selectively attacks the body’s immune cells.
  C) There are two types of HIV, but the one that is endemic to the United States is HIV type 2.
  D) HIV type 1 for some reason rarely develops into full-blown AIDS.
  Ans: B
  HIV is a retrovirus that selectively attacks the CD4+ T lymphocytes, the immune cells responsible for orchestrating and coordinating the immune response to infection. It must change from RNA to DNA through a series of stages in order to get in a cell and begin replication. HIV type 2 is endemic in West Africa but is rarely seen in other parts of the world. People with HIV-2 tend not to develop AIDS.



2. As part of her prenatal education, a 29-year-old woman who is pregnant with her first child is receiving teaching from her primary care provider. Which of the following statements by the woman reflects an accurate understanding of HIV transmission?
  A) “I know my baby is safe from HIV while in the womb, but the delivery will place him or her at real risk.”
  B) “It’s discouraging to know that my breast milk can pass on HIV to my baby.”
  C) “I know it’s possible, but it’s comforting that the chances of my child contracting my HIV are actually very low.”
  D) “I’m relieved to learn that a caesarean delivery will protect my baby from being born HIV positive.”
  Ans: B
  Transmission from mother to infant is the most common way that children become infected with HIV. HIV may be transmitted from infected women to their offspring in utero, during labor and delivery, or through breast-feeding. Ninety percent of infected children acquired the virus from their mother. The risk of transmission of HIV from mother to infant is approximately 25%, with estimates ranging from 15% to 45%, depending on what country they live in.



3. A potential donor is angry at the personal nature of the questions about HIV risk factors that he is required to answer at a blood collection center and states that simple blood testing should suffice. How can the nurse at the center best respond?
  A) “There are some very uncommon subtypes of the HIV virus that are not detectable by current testing methods.”
  B) “There’s a chance that persons who are asymptomatic, but HIV positive can have their antibodies missed by serum testing.”
  C) “There’s a period shortly after someone is infected with HIV when blood tests might still be negative.”
  D) “Even though blood tests are completely accurate, the high stakes of blood donation and transfusion mean that double measures are appropriate.”
  Ans: C
  The time after infection and before seroconversion is known as the window period, during which HIV antibody screening may be negative. Potential donors are thus screened to identify potential risk factors. Undetectable subtypes of HIV do not exist, and individuals who are asymptomatic are still able to be accurately tested.



4. A 40-year-old male who has been HIV positive for 6 years is experiencing a new increase in his viral load along with a corresponding decrease in his CD4+ count. Which of the following aspects of his immune system is likely to remain most intact?
  A) Presentation of major histocompatibility molecules on body cells
  B) Orchestration of natural killer cells as part of cell-mediated immunity
  C) Activation of B lymphocytes
  D) Phagocytic function of monocytes and macrophages
  Ans: A
  The expression of MHC on various cells of the body is not noted to be directly influenced by HIV. However, infected CD4+ cells are compromised in their ability to guide the action of NK cells, to direct phagocytic function of macrophages, and to present antigens that activate B cells.



5. A 19-year-old intravenous drug user was exposed to the HIV 3 weeks ago and is experiencing a rapid proliferation in viral load. Which of the following statements best captures an aspect of the process of HIV replication that underlies this proliferation?
  A) Free HIV RNA is able to attach to the cell coat of CD4+ cells.
  B) The cytoplasm of CD4+ cells provides a protected environment for the replication of RNA by HIV.
  C) Expression of reverse transcriptase by CD4+ cells allows replication of HIV cells rather than new lymphocytes.
  D) HIV is able to change its RNA into DNA to allow for replication by CD4+ cells.
  Ans: D
  In order for the HIV to reproduce, it must change its RNA into DNA. It does this by using the reverse transcriptase enzyme. Reverse transcriptase makes a copy of the viral RNA and then in reverse makes another mirror-image copy. The result is double-stranded DNA that carries instructions for viral replication. HIV RNA does not directly attach to CD4+ cells, and RNA is not replicated by HIV itself in the CD4+ cytoplasm. Reverse transcriptase is not produced by CD4+ cells, and CD4+ cells do not directly produce new lymphocytes.



6. Utilizing the World Health Organization (WHO) framework of clinical categories for persons with acquired immunodeficiency syndrome (AIDS) over 15 years of age, a visitor to the United States goes to a city clinic complaining of diarrhea, weight loss of 20 lb, and feeling like he is running a temperature. These manifestations have been occurring for the past 5 weeks. The nurse would identify this patient to be in which clinical stage?
  A) Stage 1
  B) Stage 2
  C) Stage 3
  D) Stage 4
  Ans: C
  Clinical stage 3 includes unexplained chronic diarrhea for greater than 1 month, persistent oral candidiasis, oral hairy leukoplakia, TB, neutropenia, anemia, and thrombocytopenia.



7. Which of the following patients would be considered to be in the latent period of HIV infection?
  A) A 16-year-old prostitute who has open sores on her labia that drain purulent secretions
  B) A 33-year-old heroin drug abuser who has numerous enlarged lymph nodes in his axilla and cervical neck region for the past 4 months
  C) A 45-year-old alcohol abuser who is complaining of excessive vomiting of blood that started 2 weeks ago
  D) A 24-year-old college student who has developed a chronic cough that will not go away, even after taking two courses of antibiotics.
  Ans: B
  In the latent period, which can last up to 10 years, the CD4+ count falls gradually to approximately 200 cells/µL. Some people experience swollen lymph nodes that are chronically swollen for more than 3 months in at least two locations, not including the groin. The lymph nodes may be sore or visible externally.



8. A person who has been diagnosed with HIV infection 12 years ago and still has a CD4+ cell count of 800 cells/µL and a low viral load is considered clinical to be a
  A) rapid progressor.
  B) typical progressor.
  C) slow progressor.
  D) long-term nonprogressor.
  Ans: D
  There is a subset of slow progressors: the long-term nonprogressors, who account for 1% of all HIV infections. These people have been infected for at least 8 years, are antiretroviral naive, have high CD4+ cell counts, and usually have very low viral loads. They are being investigated to determine how they maintain viral suppression of HIV.



9. A 39-year-old female with HIV infection has been characterized as a typical progressor by her care team and is experiencing an increase in her manifestations and health complaints as her CD4+ count declines. Which of the following health problems would her care team most likely attribute to a cause other than her HIV?
  A) Her recent diagnosis of bacterial pneumonia
  B) Her esophagitis that has been linked to herpes simplex infection
  C) Her decreased bone density and recent fractures
  D) Her increasing confusion and disorientation
  Ans: C
  While pneumonia, esophagitis, and cognitive deficits are all well-documented manifestations of HIV, changes in bone density are less likely to be a direct result of the virus.



10. A patient comes into a clinic complaining of cough, fever, and shortness of breath. The patient informs the health care provider that he is HIV positive. Upon physical exam, the family nurse practitioner (FNP) may note which of the following clinical manifestations of suspected Pneumocystis jiroveci pneumonia (PCP)? Select all that apply.
  A) Interstitial infiltrates on chest x-ray
  B) Respiratory rate of 32 with normal breath sounds
  C) Stridor when taking a deep breath
  D) Use of abdominal muscles to breathe while sitting on the exam table
  E) Night sweats that require clothing changes frequently throughout the night
  Ans: A, B
  PCP is a common presenting manifestation of AIDS or people with compromised immune systems. The symptoms include cough, fever, shortness of breath, and weight loss. Physical exam demonstrates only fever and tachypnea (elevated respiratory rate) and normal breath sounds. Chest x-ray shows interstitial infiltrates. Night sweats are usually associated with tuberculosis infection.



11. Members of an AIDS support group who have more advanced cases are sharing some of their recent health problems with a member who has just been diagnosed. Which of the member’s statements is most accurate?
  A) “One of the scariest things out there now is the huge increase in drug-resistant tuberculosis.”
  B) “The eradication of Pneumocystis jiroveci pneumonia (PCP) has helped extend the life expectancy of a lot of persons living with AIDS.”
  C) “Those of us with HIV are so much more prone to loss of vision and hearing.”
  D) “As people with HIV live longer, most of us are eventually succumbing to the cancers that are associated with HIV.”
  Ans: D
  There is an increased risk of AIDS-associated cancers as persons with age live longer. Drug resistance in tuberculosis is on the decline in recent years, and PCP has not been eradicated. Sensory loss is not a noted HIV-related manifestation.



12. A 48-year-old man who has been HIV positive for 6 years has just learned that he has been diagnosed with Kaposi sarcoma (KS). Which of the following facts most accurately conveys an aspect of his diagnosis?
  A) An opportunistic Epstein-Barr virus underlies the man’s KS.
  B) He is likely to have lesions on his skin, mouth, or GI tract.
  C) Intense pain was probably his first manifestation of KS.
  D) Heterosexual contact most likely underlies his HIV and subsequent KS.
  Ans: B
  The lesions of KS can be found on the skin and in the oral cavity, gastrointestinal tract, and the lungs. More than 50% of people with skin lesions also have gastrointestinal lesions. It is linked with a herpes virus and can often be painless, especially in early stages. Men who have sex with men are at a higher risk of developing KS.



13. Which of the following signs and diagnostic findings are recognized components of the metabolic and morphologic changes that occur with HIV infection accompanied with lipodystrophy? Select all that apply.
  A) Hyperlipidemia
  B) Insulin resistance
  C) Deficiencies of anterior pituitary hormones
  D) Increased abdominal girth
  E) Breast enlargement
  Ans: A, B, D, E
  Hyperlipidemia and insulin resistance are aspects of lipodystrophy, a phenomenon that also frequently includes breast enlargement and increased abdominal girth. Pituitary hormone deficiencies are not a noted component of HIV-related metabolic changes.



14. When counseling a male patient with suspected HIV, the nurse informs him that if the enzyme-linked immunosorbent assay (ELISA) comes back positive, then
  A) no further testing is required since this confirms HIV infection.
  B) a second test known as the Western blot assay will be ordered to confirm positive HIV status.
  C) he will be sent to an infectious disease physician for a tissue biopsy to confirm infection.
  D) if the second test, the Western blot, returns negative, he has not developed a case of full-blown AIDS.
  Ans: B
  If ELISA is positive, his blood sample is then sent for Western blot assay. If the Western blot is positive, diagnosis of HIV is confirmed. If the Western blot is negative, then the person is not infected with HIV.



15. A school nurse is teaching high school students about HIV and AIDS in the context of the school’s sexual health curriculum. Which of the students’ following statements would the nurse most likely want to correct or clarify?
  A) “They have to take a blood sample from you in order to test you for AIDS.”
  B) “Drugs for AIDS reduce the virus in your body, but they don’t get rid of it.”
  C) “Lots more heterosexual people get HIV these days than they used to.”
  D) “Condoms provide really good protection from AIDS.”
  Ans: A
  Oral tests now exist for preliminary diagnosis of HIV. Medications for AIDS do not cure the disease, and incidence is increasing among heterosexuals. Condoms provide effective protection from the virus.



16. Which of the following individuals would most likely be placed on highly active antiretroviral therapy (HAART) if he or she were not yet receiving the treatment? Select all that apply.
  A) A 35-year-old female sex trade worker who is HIV negative but who has a documented history of sharing needles for heroin use
  B) A 46-year-old male with long-standing HIV and a CD4+ count of 125 cells/mL
  C) A 16-year-old female who was diagnosed with HIV 2 days prior and is asymptomatic with normal CD4+ levels
  D) A 38-year-old woman who has a CD4+ count of 250 cells/mL and is keen to begin HAART
  E) Prophylactically to a health care worker who incurred a laceration from a scalpel used in surgery but has no abnormal lab results
  Ans: B, D
  All symptomatic patients should be treated with antiretroviral therapy. If the individual is asymptomatic, therapy is recommended for CD4+ cell counts less than or equal to 160/mL. For those who have a CD4+ cell count greater than 350 cells/mL, antiretroviral therapy is generally not recommended. For those whose CD4+ cell count is 160 to 350 cells/mL, then antiretroviral therapy should be considered, and a decision individualized to the patient should be made. HAART is not begun prophylactically in the absence of HIV.



17. A 37-year-old male with HIV who has recently become symptomatic has begun highly active antiretroviral therapy (HAART). Among the numerous medications that the man now regularly takes are several that inhibit the change of HIV RNA to DNA in a CD4+ cell. Which of the following classes of medications addresses this component of the HIV replication cycle?
  A) Entry inhibitors
  B) Protease inhibitors
  C) Integrase inhibitors
  D) Non-nucleoside reverse transcriptase inhibitors
  Ans: D
  Reverse transcriptase inhibitors inhibit HIV replication by acting on the enzyme reverse transcriptase. Non-nucleotide reverse transcriptase inhibitors block the copying of RNA into DNA. Entry inhibitors, protease inhibitors, and integrase inhibitors do not address this aspect of the HIV replication cycle.



18. All antiretroviral medications interfere with some stage of the HIV life cycle. What stage do protease inhibitors prevent?
  A) Cleavage of the polyprotein chain into the individual proteins that will be used to make new virus
  B) Addition of more nucleosides to the DNA chain
  C) Killing of the CD4+ T cell to release virions into the bloodstream
  D) Attachment of the virus to CD4+ cell receptors
  Ans: A
  By binding to the protease enzyme and inhibiting its function, protease inhibitors prevent cleavage of the polyprotein chain into individual proteins. Virions are still released into the body, but they are immature and noninfectious.



19. A 23-year-old HIV-positive woman in the United States with routinely low viral loads and robust CD4+ cell counts is planning to get pregnant. Which precaution would her care giver eliminate from her care?
  A) Offer her HAART that includes zidovudine
  B) Counsel her not to breast-feed
  C) Give her single-dose perinatal nevirapine
  D) Give the infant trimethoprim–sulfamethoxazole, starting at 4 to 6 weeks of age
  Ans: C
  Single-dose nevirapine is an appropriate alternative when zidovudine is not available. However, HAART-containing zidovudine is readily available in the United States. Avoiding breast-feeding will reduce the client’s chances of transmitting HIV to her infant. Because the risk of transmission is not zero, prophylaxis with trimethoprim–sulfamethoxazole will protect her infant from PCP until its serostatus is known.



20. While volunteering in an HIV clinic in a big city, the nurse notices a new mom and her baby (a 6-month-old male) in the waiting room. Upon assessing the infant for possible HIV infection, the nurse will be assessing for which of the following clinical manifestations of HIV infection? Select all that apply.
  A) Weighing him to determine if he is gaining 1.5 to 2 lb/month
  B) Observing to see if he can roll over from back to stomach
  C) Lack of coordination to play with toys/stuffed animals
  D) History of repeated episodes of bacterial pneumonia and ear infections
  E) Listlessness and poor eye contact
  Ans: C, D, E
  Children differ as to their clinical presentation of HIV infection when compared to adults. Failure to thrive (gain weight/height), CNS abnormalities (listlessness), and developmental delays are the most prominent primary manifestation of HIV infection in children. Answers A and B are normal growth and developmental tasks of a 6-month-old.



Chapter 32- Disorders of Cardiac Function

1. In which of the following patient situations would a physician be most justified in preliminarily ruling out pericarditis as a contributing pathology to the patient’s health problems?
  A) A 61-year-old man whose ECG was characterized by widespread T-wave inversions on admission but whose T waves have recently normalized
  B) A 77-year-old with diminished S3 and S4 heart tones, irregular heart rate, and a history of atrial fibrillation
  C) A 56-year-old obese man who is complaining of chest pain that is exacerbated by deep inspiration and is radiating to his neck and scapular ridge
  D) A 60-year-old woman whose admission blood work indicates elevated white cells, erythrocyte sedimentation rate, and C-reactive protein levels
  Ans: B
  S3 and S4 irregularities and irregular heart rate are not noted symptoms of pericarditis. Widespread T-wave inversions that later normalize; chest pain radiating to the neck and scapula that is worse on inspiration; and high white cells, erythrocyte sedimentation rate, and C-reactive protein levels are all indicators of pericarditis.



2. Following cardiac surgery, the nurse suspects the patient may be developing a cardiac tamponade. Which of the following clinical manifestations would support this diagnosis? Select all that apply.
  A) Muffled heart tones
  B) Narrowed pulse pressure
  C) Low BP—84/60
  D) Heart rate 78
  E) Bounding femoral pulse
  Ans: A, B, C
  Cardiac tamponade results in increased intracardiac pressure, progressive limitation of ventricular diastolic filling, and decreased stroke volume and cardiac output. This accumulation of fluid results in tachycardia, elevated CVP, jugular vein distention, fall in systolic BP, narrowed pulse pressure, and signs of shock. Heart sounds may be muffled. A pulse rate of 78 is normal (not tachycardic). With pulsus paradoxus, the arterial pulse as palpated at the carotid or femoral artery becomes weakened (not bulging) or absent with inspiration.



3. Which of the following phenomena would be most likely to accompany increased myocardial oxygen demand (MVO2)?
  A) Inadequate ventricular end-diastolic pressure
  B) Use of calcium channel blocker medications
  C) Increased aortic pressure
  D) Ventricular atrophy
  Ans: C
  An increase in aortic pressure results in a rise in afterload, wall tension, and, ultimately, MVO2. Increased, not inadequate, ventricular end-diastolic pressure would cause an increase in MVO2, and medications such as calcium channel blockers would decrease MVO2. Hypertrophy of ventricles would occur in response to prolonged wall stress and consequent oxygen demand.



4. As part of the diagnostic workup for a male client with a complex history of cardiovascular disease, the care team has identified the need for a record of the electrical activity of his heart, insight into the metabolism of his myocardium, and physical measurements and imaging of his heart. Which of the following series of tests is most likely to provide the needed data for his diagnosis and care?
  A) Echocardiogram, PET scan, ECG
  B) Ambulatory ECG, cardiac MRI, echocardiogram
  C) Serum creatinine levels, chest auscultation, myocardial perfusion scintigraphy
  D) Cardiac catheterization, cardiac CT, exercise stress testing
  Ans: A
  An echocardiogram would provide an image of the client’s heart, while a PET scan reveals metabolic activity and an ECG the electrical activity. Answer B would lack data on the client’s myocardial metabolism; answer C would lack electrical and physical measurement information; answer D would lack electrical measurement of his heart.



5. Which of the following teaching points would be most appropriate for a group of older adults who are concerned about their cardiac health?
  A) “People with plaque in their arteries experience attacks of blood flow disruption at seemingly random times.”
  B) “The plaque that builds up in your heart vessels obstructs the normal flow of blood and can even break loose and lodge itself in a vessel.”
  C) “Infections of any sort are often a signal that plaque disruption is in danger of occurring.”
  D) “The impaired function of the lungs that accompanies pneumonia or chronic obstructive pulmonary disease is a precursor to plaque disruption.”
  Ans: B
  Stable plaque is associated with obstruction of blood flow, while unstable plaque may dislodge and result in thrombus formation. Plaque disruption is noted to correlate with sympathetic events and is not seemingly random; infections and respiratory problems are not noted to be associated with obstruction of blood flow, however.



6. Four patients were admitted to the emergency department with severe chest pain. All were given preliminary treatment with aspirin, morphine, oxygen, and nitrates and were monitored by ECG. Which patient most likely experienced myocardial infarction?
  A) A 33-year-old male whose pain started at 7 AM during moderate exercise and was relieved by nitrates; ECG was normal; cardiac markers remained stable.
  B) A 67-year-old female whose pain started at 2 AM while she was asleep and responded to nitrates; the ECG showed arrhythmias and ST-segment elevation; cardiac markers remained stable.
  C) An 80-year-old woman whose pain started at 6 AM shortly after awakening and was not relieved by nitrates or rest; the ECG showed ST-segment elevation with inverted T waves and abnormal Q waves; levels of cardiac markers subsequently rose.
  D) A 61-year-old man whose pain started at 9 AM during a short walk and responded to nitrates, but not to rest; ECG and cardiac markers remained stable, but anginal pattern worsened.
  Ans: C
  The chest pain of myocardial infarction does not respond to rest or to nitrates. Ischemic injury to the myocardium alters the ECG patterns, often elevating the ST segment and inverting T waves. Abnormal Q waves indicate necrosis. Cardiac markers are released in response to myocardial injury; rising levels indicate damage to the heart. The other patients have angina of varying severity.



7. Which of the following statements provides blood work results and rationale that would be most closely associated with acute coronary syndrome?
  A) Increased serum creatinine and troponin I as a result of enzyme release from damaged cells
  B) Increased serum potassium and decreased sodium as a result of myocardial cell lysis, release of normally intracellular potassium, and disruption of the sodium–potassium pump
  C) Elevated creatine kinase and troponin, both of which normally exist intracellularly rather than in circulation
  D) Low circulatory levels of myoglobin and creatine kinase as a result of the inflammatory response
  Ans: C
  Myocardial necrosis releases creatine kinase and troponins that normally exist intracellularly. Serum creatinine and potassium are not core markers of heart damage, and myoglobin and creatine kinase levels rise, not fall, with cardiac events.



8. A number of clients have presented to the emergency department in the last 32 hours with complaints that are preliminarily indicative of myocardial infarction. Which of the following clients is least likely to have an ST-segment myocardial infarction (STEMI)?
  A) A 70-year-old woman who is complaining of shortness of breath and vague chest discomfort
  B) A 66-year-old man who has presented with fatigue, nausea and vomiting, and cool, moist skin
  C) A 43-year-old man who woke up with substernal pain that is radiating to his neck and jaw
  D) A 71-year-old man who has moist skin, fever, and chest pain that is excruciating when he moves but relieved when at rest
  Ans: D
  STEMI pain is not normally relieved by rest, nor would fever be a common symptom. Shortness of breath, vague chest discomfort, fatigue, GI symptoms, and radiating substernal pain are all associated with STEMI.



9. Following a ST-segment myocardial infarction (STEMI), the nurse should be assessing the patient for which of the following complications? Select all that apply.
  A) Large amount of pink, frothy sputum and new onset of murmur
  B) Tachypnea with respiratory distress
  C) Frequent ventricular arrhythmia unrelieved with amiodarone drip
  D) Complaints of facial numbness and tingling
  E) Enhanced renal perfusion as seen as an increase in urine output
  Ans: A, B, C, D
  Following MI, many complications can occur: Answer choice A relates to pulmonary edema or papillary muscle rupture; answer choice B refers that acute respiratory distress could result from heart failure; answer choice C relates to life-threatening arrhythmias; answer choice D relates to acute stroke.



10. A 78-year-old man has been experiencing nocturnal chest pain over the last several months, and his family physician has diagnosed him with variant angina. Which of the following teaching points should the physician include in his explanation of the man’s new diagnosis?
  A) “I’ll be able to help track the course of your angina through regular blood work that we will schedule at a lab in the community.”
  B) “With some simple lifestyle modifications and taking your heparin regularly, we can realistically cure you of this.”
  C) “I’m going to start you on low-dose aspirin, and it will help greatly if you can lose weight and keep exercising.”
  D) “There are things you can do to reduce the chance that you will need a heart bypass, including limiting physical activity as much as possible.”
  Ans: C
  Aspirin, exercise, and weight loss are all identified treatments for angina. Angina does not normally necessitate blood work, heparin administration, or avoidance of activity.



11. The initial medical management for a symptomatic patient with obstructive hypertrophic cardiomyopathy (HCM) would be administering a medication to block the effects of catecholamines. The nurse will anticipate administering which of the following medications?
  A) Lisinopril, an ACE inhibitor
  B) Lasix, a diuretic
  C) Propranolol, a b-adrenergic blocker
  D) Lanoxin, an inotropic
  Ans: C
  b-Adrenergic blockers are generally the initial choice for persons with symptomatic HCM. Calcium channel blockers can also be used. ACE inhibitors, diuretics, or positive inotropics are not the first-line medications.



12. Which of the following ECG patterns would the nurse observe in a patient admitted for arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D)? Select all that apply.
  A) Atrial flutter
  B) Ventricular tachycardia with left bundle branch block pattern
  C) T-wave inversion in the right precordial leads
  D) Sinus arrhythmia with a first-degree AV block
  E) Development of a “U” wave following a normal T wave
  Ans: B, C
  The electrical (ECG) changes associated with ARVC/D include ventricular tachycardia with LBBB, T-wave inversion in the right precordial leads, and epsilon waves. Right ventricular BBB may also be present. Atrial flutter and sinus arrhythmia with a first-degree AV block are not characteristic of this form of cardiomyopathy.



13. A 31-year-old African American female who is in her 30th week of pregnancy has been diagnosed with peripartum cardiomyopathy. Which of the following statements best captures an aspect of peripartum cardiomyopathy?
  A) Her diagnosis might be attributable to a disordered immune response, nutritional factors, or infectious processes.
  B) Treatment is possible in postpartum women, but antepartum women are dependent on spontaneous resolution of the problem.
  C) Mortality exceeds 50%, and very few surviving women regain normal heart function.
  D) Symptomatology mimics that of stable angina and is diagnosed and treated similarly.
  Ans: A
  Immune responses, diet, and infections are all potential etiologies of peripartum cardiomyopathy. Treatment is complicated, but not impossible, in antepartum women due to possible teratogenic drug effects. About half of women suffer long-term effects on cardiac function, while signs and symptoms are similar to those of early heart failure.



14. An IV drug abuser walks into the ED telling the nurse that, “he is sick.” He looks feverish with flushed, moist skin; dehydrated with dry lips/mucous membranes; and fatigued. The assessment reveals a loud murmur. An echocardiogram was ordered that shows a large vegetation growing on his mitral valve. The patient is admitted to the ICU. The nurse will be assessing this patient for which possible life-threatening complications?
  A) Systemic emboli, especially to the brain
  B) Petechial hemorrhages under the skin and nail beds
  C) GI upset from the massive amount of antibiotics required to kill the bacteria
  D) Pancreas enlargement due to increased need for insulin secretion
  Ans: A
  Systemic emboli develop and break off the mitral valve and travel into the vascular system. There is a high probability that the emboli could lodge in the brain, kidneys, lower extremities, etc. Answer choice B refers that petechial hemorrhages are signs and symptoms of IE. GI upset is common following antibiotic therapy but is not usually life threatening. Stress can increase insulin needs but not associated with pancreas enlargement.



15. A 34-year-old man who is an intravenous drug user has presented to the emergency department with malaise, abdominal pain, and lethargy. The health care team wants to rule out endocarditis as a diagnosis. Staff of the department would most realistically anticipate which of the following sets of diagnostics?
  A) CT of the heart, chest x-ray, and ECG
  B) Echocardiogram, blood cultures, and temperature
  C) ECG, blood pressure, and stress test
  D) Cardiac catheterization, chest x-ray, electrolyte measurement, and white cell count
  Ans: B
  An echocardiogram would help visualize the heart, while blood cultures would confirm the presence or absence of microorganisms in circulation, and temperature would gauge the presence of infection. A chest x-ray, blood pressure measurement, and cardiac catheterization would be less likely to indicate infective endocarditis.



16. A 13-year-old boy has had a sore throat for at least a week and has been vomiting for 2 days. His glands are swollen, and he moves stiffly because his joints hurt. His parents, who believe in “natural remedies,” have been treating him with various herbal preparations without success and are now seeking antibiotic treatment. Throat cultures show infection with group A streptococci. This child is at high risk for
  A) myocarditis.
  B) mitral valve stenosis.
  C) infective endocarditis.
  D) vasculitis.
  Ans: B
  Group A streptococcal infection can be adequately treated with antibiotics, but this infection may have been present long enough to trigger an immune response—rheumatic fever—that will damage his heart valves, ultimately causing mitral valve stenosis. Group A streptococcal infection is not known to predispose to myocarditis, endocarditis, or vasculitis and aneurysm of coronary arteries.



17. On a routine physical exam visit, the physician mentions that he hears a new murmur. The patient gets worried and asks, “What does this mean?” The physician responds,
  A) “It would be caused by stress. Let’s keep our eye on it and see if it goes away with your next visit.”
  B) “This could be caused by an infection. Have you been feeling well the past few weeks?”
  C) “One of your heart valves is not opening properly. We need to do an echocardiogram to see which valve is having problem.”
  D) “This may make you a little more fatigued than usual. Let me know if you start getting dizzy or light-headed.”
  Ans: C
  Stenosis refers to a narrowing of the valve orifice and failure of the valve leaflets to open normally. Blood flow through a normal valve can increase by five to seven times the resting volume. Valvular disease is not caused by stress. The murmur can be caused not only by infection but also by stenosis or regurgitation of a valve leaflet. The valve problem is very severe if it is causing signs of decreased cardiac output.



18. A client has been diagnosed with mitral valve stenosis following his recovery from rheumatic fever. Which of the following teaching points would be most accurate to convey to the client?
  A) “The normal tissue that makes up the valve between the right sides of your heart has stiffened.”
  B) “Your mitral valve isn’t opening up enough for blood to flow into the part of your heart that sends blood into circulation.”
  C) “Your heart’s mitral valve isn’t closing properly so blood is flowing backward in your heart and eventually into your lungs.”
  D) “The valve between your left ventricle and left atria is infected and isn’t allowing enough blood through.”
  Ans: B
  Mitral valve stenosis represents the incomplete opening of the mitral valve during diastole with left atrial distention and impaired filling of the left ventricle. It does not exist in the right side of the heart, and the problem is associated primarily with improper ventricular filling and with pulmonary backflow only secondarily. Although it is often caused by infection, it is not an infectious process of the valve per se.



19. A 66-year-old client’s echocardiogram report reveals a hypertrophied left ventricle. The health care provider suspects the client has aortic stenosis. Which of the following clinical manifestations would be observed if this client has aortic stenosis? Select all that apply.
  A) Decrease in exercise tolerance
  B) Exertional dyspnea
  C) Palpitations
  D) Syncope
  E) Heartburn
  Ans: A, B, D
  Because of the slow onset of aortic valve stenosis, the heart is able to compensate by hypertrophying and may still maintain a normal chamber volume and ejection fraction. As the stenosis progresses, the patient will experience classic symptoms of angina, syncope, heart failure, and decrease in exercise tolerance or exertional dyspnea. Palpitations and heartburn are not usually noted with aortic stenosis.



20. Which of the following situations related to transition from fetal to perinatal circulation would be most likely to necessitate medical intervention?
  A) Pressure in pulmonary circulation and the right side of the infant’s heart fall markedly.
  B) Alveolar oxygen tension increases causing reversal of pulmonary vasoconstriction of the fetal arteries.
  C) Systemic vascular resistance and left ventricular pressure are both increasing.
  D) Pulmonary vascular resistance, related to muscle regression in the pulmonary arteries, rises over the course of the infant’s first week.
  Ans: D
  One of the hallmarks of the transition from placental circulation is a rapid and then steady decrease in pulmonary vascular resistance. Answers A, B, and C relate normal physiological processes.



21. A pediatric nurse is assessing a newborn diagnosed with persistent patency of the ductus arteriosus. Which of the following findings are associated with this heart defect? Select all that apply.
  A) Murmur heard at the second intercostal space, during both systole and diastole
  B) BP 84/30 classified as a wide pulse pressure
  C) Shortness of breath with activity such as kicking
  D) Stridor with inspiratory wheezes
  E) Bulging jugular neck veins
  Ans: A, B
  Persistent patency of the ductus arteriosus is defined as a duct that remains open for  greater than 3 months. A murmur is detected within days of birth. It is loudest at the second left intercostal space and is continuous through systole and diastole. A wide pulse pressure is common (BP 84/30). Most newborns have an elevated respiratory rate with exertional activity. Stridor is usually associated with bronchial infections or narrowing of the airways. Bulging jugular neck veins are associated with right-sided heart failure.



22. A nurse who works on a pediatric cardiology unit of a hospital is providing care for an infant with a diagnosis of tetralogy of Fallot. Which of the following pathophysiologic results should the nurse anticipate?
  A) There is a break in the normal wall between the right and left atria that results in compromised oxygenation.
  B) The aortic valve is stenotic, resulting in increased afterload.
  C) Blood outflow into the pulmonary circulation is restricted by pulmonic valve stenosis.
  D) The right ventricle is atrophic as a consequence of impaired myocardial blood supply.
  Ans: C
  Tetralogy of Fallot is marked by obstruction or narrowing of the pulmonary outflow channel, including pulmonic valve stenosis, a decrease in the size of the pulmonary trunk, or both. The characteristic septal defect is ventricular, not atrial. Aortic valve stenosis and right ventricular atrophy are not associated with the diagnosis.



Chapter 48- Mechanisms of Endocrine Control

1. Which of the following statements best captures an aspect of the role of hormones in the body?
  A) Some chemical substances can function as hormones or be integrated with the central and peripheral nervous systems.
  B) Hormones directly initiate many of the processes that contribute to homeostasis.
  C) Control of body processes is ensured by the fact that a single hormone can only exert one effect on one specific system or tissue.
  D) Each hormone that exists in the body is produced by only one specific endocrine gland.
  Ans: A
  Some chemicals, such as epinephrine, can both function as a hormone and be closely integrated with the central and peripheral nervous systems as well as the immune systems, leading to current terminology such as “neuroendocrine.” Hormones modulate, but do not initiate, changes in the body, and one hormone may exert multiple effects on multiple body systems. Hormones are produced by a variety of body tissues, not solely by endocrine glands.



2. An example of a single hormone that can exert effects in different tissues, erythropoietin, made in the kidney stimulates the bone marrow to produce
  A) platelets.
  B) natural killer cells.
  C) red blood cells.
  D) mast cells.
  Ans: C
  A characteristic of hormones is that a single hormone can exert various effects in different tissues. For example, erythropoietin, a traditional circulating hormone, is made in the kidney and stimulates erythropoiesis in the bone marrow.



3. A nurse who works in the office of an endocrinologist is orienting a new staff member. Which of the following teaching points is the nurse justified in including in the orientation? Select all that apply.
  A) “A bodily process can be the result of the combined effect of several different hormones from different sources.”
  B) “A single hormone can act not only on one process or organ but often on several different locations or processes.”
  C) “It’s common for production of hormones to be far removed from the tissue where they ultimately exert their effect.”
  D) “Sometimes hormones act locally on the area where they were produced, like in the case of paracrine and autocrine actions.”
  E) “The regulation in homeostasis requires that hormones be absent from the body when their effect is not needed.”
  Ans: A, B, C, D
  A single hormone can exert various effects in different tissues or, conversely, a single function can be regulated by several different hormones. Hormones act both distant from their source and more locally, as in the case of autocrine and paracrine actions. Hormones are normally present at all times.



4. When explaining about structural classifications to a group of students, the instructor discusses the peptides and proteins. They talk about small hormones and hormones as large and complex as growth hormone (GH), which has approximately how many amino acids involved?
  A) 50 amino acids
  B) 100 amino acids
  C) 150 amino acids
  D) 200 amino acids
  Ans: D
  Growth hormone is a very large and complex protein that has approximately 200 amino acids.



5. Which of the following hormones are derivatives of cholesterol?
  A) Epinephrine and norepinephrine
  B) Insulin and glucagon
  C) Aldosterone and testosterone
  D) Eicosanoids and retinoids
  Ans: C
  Steroids such as aldosterone and testosterone are a classification of hormones that are derived from cholesterol. Epinephrine and norepinephrine are both amino acids, while insulin and glucagon are classified among peptides, polypeptides, proteins, and glycoproteins. Eicosanoids and retinoids consist of fatty acid compounds.



6. A 51-year-old woman has been experiencing signs and symptoms of perimenopause and has sought help from her family physician. A deficiency in estrogen levels has been determined to be a contributing factor. Which of the following phenomena could potentially underlie the woman’s health problem?
  A) Sufficient synthesis of estrogen but inadequate vesicle-mediated release
  B) Inadequate synthesis in the rough endoplasmic reticulum of her ovarian cells
  C) Insufficient estrogen production within the smooth endoplasmic reticulum of the relevant cells
  D) A lack of prohormone precursors needed for estrogen synthesis and release
  Ans: C
  Steroids such as estrogen are produced in the smooth endoplasmic reticulum. Synthesis and release are not separate processes as in the case of peptide hormones, and prohormones are associated with peptide, polypeptide, and protein hormones.



7. Which of the following best describes the half-life of a highly protein-bound drug such as thyroxine (99% protein bound)? The half-life would be
  A) much longer to reduce the concentration of the hormone by one half.
  B) shorter because only a little of the hormone has to be used up to reduce the concentration.
  C) dependent on which drugs were in the blood system holding on to the hormone.
  D) dependent on the liver to carry the hormone to its designated target organ.
  Ans: A
  The half-life of a hormone—the time it takes for the body to reduce the concentration of the hormone by one half—is positively correlated with its percentage of protein binding. Thyroxine, which is more than 99% protein bound, has a half-life of 6 days, whereas aldosterone, 15% bound, has a half-life of only 25 minutes.



8. Since steroid hormones are bound to protein carriers for transport, this means
  A) they are water soluble and circulate freely in the blood.
  B) they are degraded by enzymes in the blood.
  C) they are inactive in the bound state.
  D) they will be converted into a useable form by enzymes in the blood.
  Ans: C
  Steroid hormones are bound to protein carriers for transport and are inactive in the bound state. Their activity depends on the availability of transport carriers.



9. Neurotransmitters like catecholamines (e.g., dopamine and epinephrine) have a reaction time of
  A) milliseconds.
  B) less than 10 minutes.
  C) 24 to 36 hours.
  D) 4 to 7 days.
  Ans: A
  The neurotransmitters, which control the opening of ion channels, have a reaction time of milliseconds.



10. A client with a history of an endocrine disorder exhibits signs and symptoms of hormone deficiency. Which of the following processes would the client’s care team most likely rule out first as a contributing factor?
  A) The client’s target cells lack sufficient receptors for the hormone in question.
  B) Hormone production is sufficient, but affinity on the part of the target cells is lacking.
  C) The process of down-regulation has resulted in decreased hormone sensitivity.
  D) Up-regulation has increased the sensitivity of the body to particular hormone levels.
  Ans: D
  Up-regulation is a response to low hormone levels in which the number of receptors increases. As such, it would not likely result in signs and symptoms of deficiency but is rather a compensatory mechanism that counters a deficiency. Insufficient numbers of receptors, low affinity, and down-regulation could all contribute to signs and symptoms of a hormone deficiency.



11. Which of the following statements best captures the essence of a second messenger in the mechanisms of the endocrine system?
  A) Second messengers act as the intracellular signal that responds to the presence of a hormone.
  B) Endocrine-producing cells must release both a hormone and a second messenger in order to exert a distant effect.
  C) Second messengers act to supplement hormone effects on cell receptors when the desired hormonal effect must be either increased.
  D) Second messengers provide an alternative pathway for endocrine effects on a cell that bypass the normal receptor pathways.
  Ans: A
  Second messengers interact with hormones that cannot cross the cell membrane, and they mediate the ultimate effect on the cell. They are not produced by the hormone-producing cell, and they are necessary to bring about hormonal effects, not simply for increasing the intensity of the effect. They are not an alternative mechanism of effect but rather a prerequisite for certain hormonal effects on body cells.



12. A client with a new diagnosis of an endocrine disorder is unclear how the body can control the levels of different hormones over time. Which of the following statements most accurately underlies the dominant regulation process of hormone levels in the body?
  A) A positive feedback cycle ensures that stable levels of hormones exist in the body over time.
  B) With input from various sensors, hormone production and release are adjusted based on existing hormone levels.
  C) The hypothalamus ensures that hormone levels correspond accurately to the diurnal cycle.
  D) The pituitary gland is genetically programmed to stimulate and inhibit hormone production and/or release based on the needs at different points in the life cycle.
  Ans: B
  Most hormone levels are controlled by way of a negative feedback cycle, in which low levels stimulate production and/or release. A positive feedback cycle would not achieve this effect. While some hormones are released on a diurnal schedule, the dominant form of hormone regulation in the body is that of negative feedback. Hormone release is not predetermined by the pituitary gland.



13. A 21-year-old female is suspected of having inadequate function of her hypothalamic–pituitary–thyroid system. Her care provider is planning to inject thyrotropin-releasing hormone (TRH) and then measure her levels of TSH. Which of the following diagnostic tests is being performed?
  A) Suppression test
  B) Radioimmunoassay (RIA) test
  C) Stimulation test
  D) Metabolite excretion test
  Ans: C
  A stimulation test involves the introduction of an element that stimulates the production of another factor or hormone followed by measurement of that hormone. This is not the case in a suppression test, RIA test, or metabolite excretion test.



14. Following a meal, a woman’s blood glucose level has increased. In addition, her pancreas has increased the amount of insulin produced and released. Which of the following phenomena has occurred?
  A) Increased hormone level according to a negative feedback mechanism
  B) Adjustment according to the level of the substance a hormone regulates
  C) Hormone production and release via the positive feedback cycle
  D) Hypothalamic–pituitary control of hormone levels
  Ans: B
  The level of some hormones is adjusted according to the amount of the substance that they control. In this case, insulin controls glucose levels and would increase in response to the increase in serum glucose that follows a meal. This differs from a negative feedback cycle in which a simple decrease in a hormone level stimulates production and/or release of that hormone. Positive feedback and hypothalamic–pituitary control are not evident in this situation.



15. Which of the following statements best captures the relationship between the hypothalamus and the pituitary gland as it relates to endocrine function?
  A) The hypothalamus directly measures the levels of most hormones throughout the body and inhibits or stimulates the pituitary accordingly.
  B) The pituitary gland coordinates and dictates the release of hormones from the hypothalamus that act on their intended target cells.
  C) The pituitary gland and hypothalamus have two-way communication that mediates the signals from neuronal inputs.
  D) The hypothalamus receives input from numerous sources throughout the body and directs the pituitary to then control many target glands and cells.
  Ans: D
  The hypothalamus can be viewed as a bridge by which signals from multiple systems are relayed to the pituitary gland. The hypothalamus collects data from sources throughout the body rather than directly measuring levels, and communication normally flows from the hypothalamus to the pituitary.



16. A 38-year-old woman takes clomiphene, an infertility drug that works by competing with, and thereby blocking, cellular receptors for estrogen. Which of the following statements is most likely to be true of this client?
  A) Receptors for all other steroid hormones will also be blocked.
  B) Up-regulation will increase the number of estrogen receptors on each target cell.
  C) Estrogen will continue to pass freely through the cellular membranes.
  D) Laboratory tests will reveal an increase in cyclic adenosine monophosphate (cAMP) levels.
  Ans: C
  Because estrogen is a steroid hormone, its receptors in target cells are located inside the cell membrane, and their blockage does not affect the movement of the hormone into and out of the cell. Receptors are specific for each hormone, so no hormones other than estrogen will be blocked. Up-regulation occurs when hormone levels are decreased, and in this case, the estrogen level will increase. Second messengers, such as cAMP, are only activated by peptide hormones and catecholamines.



17. During the follicular stage of menstruation, increased estradiol production causes an increase in FSH production. This increase in FSH production by the anterior pituitary gland will have what effect on the follicle?
  A) The follicle will continue to grow until it can no longer stay in its membrane.
  B) The follicle will die, which results in a fall of FSH.
  C) The follicle will continue to grow and produce estradiol.
  D) The follicle will secrete additional hormones to attract swimming sperm.
  Ans: B
  In positive feedback control, rising levels of a hormone cause another gland to release a hormone that is stimulating to the first. Increased estradiol production during the follicular stage of the menstrual cycle causes increased FSH production by the anterior pituitary gland. This stimulates further increases in estradiol levels until the demise of the follicle.



18. A middle-aged woman has acromegaly as a result of a pituitary adenoma that was found and removed when she was a teenager. The physician is suspecting that the tumor has returned and has ordered a diagnostic work-up. A glucose load is ordered. If the tumor has returned, the nurse would expect which of the following results?
  A) The glucoses load will suppress GH level.
  B) The growth hormone level will not be suppressed following glucose load.
  C) The glucose load will raise her serum glucose level to the point of requiring insulin.
  D) There will be no change in the serum growth hormone level following the glucose load.
  Ans: B
  When a GH-secreting tumor is suspected, the GH response to a glucose load is measured as part of the diagnostic workup. Normally, a glucose load would suppress GH levels. However, in adults with GH-secreting tumors (acromegaly), GH levels are not suppressed (and paradoxically increase in 50% of cases) to a glucose load.



19. A patient exhibiting problems with his or her thyroid has been scheduled for a radioactive scan. From the following list of patients, what would the nurse question as to whether this would be a safe procedure for this patient?
  A) An adult patient having an episode of wheezing from allergies
  B) A young female patient who has been trying to get pregnant
  C) A middle-aged male patient with uncontrolled type 2 diabetes mellitus
  D) An elderly patient who has a history of aortic stenosis
  Ans: B
  Radioactive iodine therapy is contraindicated in pregnant women because 131I crosses the placenta and can adversely affect the fetal thyroid gland. The other clients would have no contraindication to the substance.



20. A 48-year-old woman has been found to have nodules on her thyroid that must be biopsied to determine whether or not they are malignant. Which of the following imaging techniques will be most helpful to the surgeon in visualization of the nodes for fine needle aspiration?
  A) Ultrasound
  B) Magnetic resonance imaging
  C) Radioactive scanning using radioiodine
  D) Radioactive scanning using sestamibi
  Ans: A
  Thyroid ultrasound is recommended for managing thyroid nodules and can aid in visualization of the nodule for biopsy (fine needle aspiration [FNA]), which is necessary to help distinguish benign from malignant etiology. Magnetic resonance imaging is the preferred choice for pituitary and hypothalamic imaging. Isotopic imaging includes radioactive scanning of the thyroid (e.g., using radioiodine), parathyroids (e.g., using sestamibi), and adrenals (e.g., using metaiodobenzylguanidine [MIBG] to detect pheochromocytoma).



Chapter 60- Structure and Function of the Skin

1. After falling off his bicycle, an 8-year-old boy has a large abrasion on his posterior thigh that has removed the epidermis in the region but left the dermis largely intact. Which of the following changes in integumentary system would be expected in the area of his wound?
  A) Profuse bleeding from removal of his epidermis
  B) Fewer Merkel and Langerhans cells in the region
  C) Exposure of the underlying subcutaneous tissue
  D) Removal of hair follicle roots from the area of the wound bed
  Ans: B
  Merkel cells and Langerhans cells are components of the epidermis. Bleeding may be minimal since the epidermis is avascular. Subcutaneous tissue is below the dermis and would not be directly exposed, and hair follicle roots exist at a deeper level than the epidermis.



2. Which of the following statements best conveys an aspect of the process of keratinization?
  A) Keratin cells synthesized in the dermis migrate to the surface over 20 to 30 days.
  B) Mitosis that begins with the cells of the stratum granulosum results in a continual supply of new keratinocytes.
  C) The stratum germinativum continuously produces new keratinocytes to replace losses.
  D) The basal cells of the epidermis migrate to the skin surface at a rate that matches superficial losses of skin cells.
  Ans: C
  The stratum germinativum, or stratum basale, consists of a single layer of basal cells that are attached to the basal lamina. The basal cells, which are columnar, undergo mitosis to produce new keratinocytes that move toward the skin surface to replace cells lost during normal skin shedding. Keratinization does not originate in the dermis or stratum granulosum, and the basal cells of the epidermis do not migrate to the surface.



3. A nurse is teaching a client about the role that skin plays in forming a barrier to environmental agents and microorganisms. The nurse would recognize that which of the following types of cells/junctions are involved in the communication and regulation of the immune response and the secretions of cytokines?
  A) Gap junctions
  B) Desmosomes
  C) Adherens junctions
  D) Keratinocytes
  Ans: D
  Keratinocytes are now known to be active secretory cells that play an important role in the immunobiology of the skin by communicating and regulating cells of the immune response and secreting cytokines and inflammatory mediators. Gap junctions allow ions and molecules to pass between skin cells, and adherens junctions provide a mechanical connection between cells. Desmosomes are localized patches or plaques that hold two cells tightly together by proteins called cadherins. They are terminal end points on the cell walls of keratinocytes.



4. While studying the skin in a science class, a student asks why all people have a pinkish color to their lips/mucous membranes. The instructor would respond by citing which of the following responses?
  A) Melanocytes are the pigment-synthesizing cells.
  B) Pheomelanin is the yellow to red pigment particularly concentrated in the lips and nipples of humans.
  C) Tyrosinase is responsible for all-colored cell production.
  D) A person with tiny melanocytes will have more concentrated pigment resulting in darker color.
  Ans: B
  Pheomelanin, the yellow to red pigment, is found in all humans. It is particularly concentrated in the lips, nipples, glans penis, and vagina. Melanocytes are pigment-synthesizing cells that are scattered in the basal layer and are responsible for skin color (not mucous membranes). Tyrosinase converts the amino acid tyrosine to a precursor of melanin. If one has a lack of tyrosinase, the end result will be albinism. In dark-skinned people, larger melanin-containing melanosomes are produced and transferred individually to the keratinocyte.



5. A 40-year-old male client has a congenital syndrome that affects the function of the Langerhans cells of his epidermis. The man’s care provider would expect which of the following manifestations of his condition?
  A) Increased susceptibility to infection
  B) High permeability of his epidermis to environmental materials
  C) Lighter skin tone than other individuals of the same ethnicity
  D) Frequent separation between the dermal and epidermal layer of his skin
  Ans: A
  Langerhans cells are the immunologic cells responsible for recognizing foreign antigens harmful to the body, and they play an important role in defending the body against foreign antigens. A lack of Langerhans cells would not manifest in increased permeability of the skin, unexpected coloration, or separation between layers.



6. Clinical investigation of a 40-year-old female client with diverse dermatological signs and symptoms has focused on the woman’s basement membrane. Which of the following skin functions would a clinician most likely attribute to a region of the integument other than the basement membrane?
  A) Lack of sensory nerve impulse conduction
  B) Formation of blisters on various skin surfaces
  C) Lack of adhesion between the dermis and epidermis
  D) Large immunoglobulin deposits
  Ans: A
  While the basement membrane plays roles in adhering between skin layers and is a common site of immunoglobulin deposition and blister formation, it is not a major site of afferent nerve endings and consequent sensory transmission.



7. A person with severe lymphedema is asking the nurse where specifically are the lymph vessels located in the skin layers. The nurse would respond,
  A) “Basement membrane.”
  B) “Merkel cell layer.”
  C) “Subcutaneous tissue layer.”
  D) “Papillary dermis layer.”
  Ans: D
  Dermal papillae contain capillaries, end arterioles, and venules that nourish the epidermal layers of the skin. This layer of the dermis is richly vascularized. Lymph vessels and nerve tissue also are found in this layer. The basement membrane is a layer of intercellular and extracellular matrices that serves as an interface between the dermis and the epidermis. Merkel cells are connected to afferent nerve terminals, forming a Merkel disk. They are believed to be neuroendocrine cells. Subcutaneous tissue consists of fat cells and connective tissues that lend support to the vascular and neural structures.



8. Which of the following components of immune function is absent in the dermis?
  A) Macrophages
  B) T cells
  C) Lymph nodes
  D) Mast cells
  Ans: C
  While macrophages, T cells, fibroblasts, and mast cells are all present in the dermis, lymph nodes are not noted to be present in this layer.



9. The skin is richly supplied with arteriovenous anastomoses in which blood flows directly between an artery and a vein, bypassing the capillary circulation. What is the primary significance of these structures?
  A) They regulate body temperature.
  B) They process sensory information.
  C) They control the formation of “goose bumps”
  D) They combat skin infections.
  Ans: A
  Anastomoses are important for temperature regulation. They can open up, letting blood flow through the skin vessels when there is a need to dissipate body heat, or close off, conserving body heat if the environmental temperature is cold. Although goose bumps are a reaction to cold, they are actually caused by the contraction of the arrector pili muscles.



10. A 51-year-old woman who was born congenitally blind and deaf is able to distinguish individuals by light touch of the individual’s face. Which of the following components of the woman’s skin innervation likely contributes the most to this ability?
  A) Ruffini corpuscles
  B) Meissner corpuscles
  C) Pacinian corpuscles
  D) Nociceptors
  Ans: B
  Meissner corpuscles are rapidly adapting nerve endings located on the palmar surfaces of the fingers and hands; as such, they would be likely to be involved in fine distinction using the fingers. Ruffini corpuscles are located in the subcutaneous tissue of hairy and glabrous skin, while pacinian corpuscles detect gross pressure and vibration. Nociceptors detect painful stimuli.



11. A frustrated 26-year-old female has sought a referral to a dermatologist in an effort to resolve her sweating and body odor that persists despite good hygiene. Which of the following facts would underlie the explanation that her physician provides about her problem?
  A) Sebaceous secretions vary in both quantity and constituency between individuals.
  B) Excess production by eccrine sweat glands, combined with bacteria, produces a characteristic odor in moist areas of the body.
  C) Apocrine sweat glands produce a substance that is more oily than sweat from other sources.
  D) Occlusion of sebaceous glands in the axillae and groin results in proliferation of microorganisms.
  Ans: C
  Body odor is the result of apocrine sweat gland secretions combining with bacteria to produce a characteristic odor. Neither eccrine sweat glands nor sebaceous glands are primarily involved.



12. Which of the following structures would likely be present in a hair follicle in a man’s groin but not in a follicle on his face?
  A) Arrector pili muscle
  B) Sebaceous gland
  C) Apocrine gland
  D) Hair papilla
  Ans: C
  Apocrine glands are only found in hair follicles in the underarms and groin. All hair follicles contain an arrector pili muscle, sebaceous gland, and blood supply in the form of the hair papilla.



13. While working in an allergy clinic, the nurse notices that many patients come in with all types of skin reactions. The nurse working in this area knows that which cells play a role in the development of allergic skin condition?
  A) Langerhans cells
  B) Merkel cells
  C) Spherical melanosomes
  D) Keratin
  Ans: A
  Langerhans cells, the antigen-presenting cells of the epidermal skin, not only protect against harmful pathogens but also play an important role in the development of allergic skin conditions. Merkel cells play a role in the neuroendocrine cell function such as neurotransmission for autonomic nerves. Spherical melanosomes are found in people with light skin. Red hair has spherical melanosomes. Keratin is a protein that forms the surface of the skin and is also the structural protein of the hair and nails.



14. A man’s primary care physician has characterized his skin lesion as being a temporary eruption but has cautioned him against repeated rubbing or scratching as to avoid lichenization. What is the most likely categorization of the man’s skin lesion?
  A) A blister
  B) A corn
  C) A callus
  D) A rash
  Ans: D
  A rash is a temporary eruption of the skin that can result in excoriation or lichenization if rubbed or scratched excessively. Corns, calluses, and blisters are not noted to share these characteristics.



15. A child comes in to show his parents (who are nurses) a blister on his foot from “breaking in” a new pair of shoes. The child wants to “pop the blister” to get all the fluid out of it, so it would not hurt so much when he puts on shoes/socks. The parents know that breaking the skin of the blister will put him at risk for
  A) fluid volume deficit.
  B) further edema due to loss of proteins.
  C) secondary infection.
  D) activity intolerance.
  Ans: C
  A blister is a vesicle or fluid-filled papule. They can have a mechanical origin caused by friction from repeated rubbing on a single area of skin. Friction blisters most commonly occur on the palmar and plantar surfaces of the hands and feet where the skin is constantly exposed to mechanical trauma. Breaking the skin of a blister to remove the fluid is inadvisable because of the risk of secondary infection. Fluid volume deficit is highly unlikely with only one blister on the foot. The fluid in the blister is composed of proteins but unlikely to cause a shift in fluids due to only having one blister. The child can continue to be active but usually need a dressing/bandage placed over the blister for comfort.



16. Following exposure to poison oak while camping, a 20-year-old male is experiencing pruritus as a consequence of his immune response to irritants in the plant. What physiological process best accounts for his complaint?
  A) His body is communicating a low-level pain response as a protective measure.
  B) Free nerve endings are initiating an itch-specific signal to the somatosensory cortex.
  C) Local irritation of Langerhans cells is sending signals by way of myelinated type C nerve fibers.
  D) Ruffini corpuscles are transmitting the message of pruritus to the cerebral cortex.
  Ans: B
  It is generally agreed that itch is a sensation that originates in free nerve endings in the skin, is carried by small myelinated type C nerve fibers to the dorsal horn of the spinal cord, and is then transmitted to the somatosensory cortex via the spinothalamic tract. Itching is no longer considered to be a low-level pain response. Ruffini corpuscles and Langerhans cells are not noted to play a role in pruritus.



17. A boy has arrived home after experiencing his first outdoor camping trip with his Boy Scout troupe. Upon arrival at home, he is very uncomfortable and scratching at a rash. It appears that he contacted poison ivy and that it has spread to many areas on his body. The nurse in the clinic will likely prescribe which of the following treatment measures for this child? Select all that apply.
  A) Prescription for corticosteroids.
  B) Cool showers especially right before bedtime.
  C) Over-the-counter antihistamines.
  D) Occlusive ointments with high petroleum content.
  Ans: A, B, C
  Most treatment measures for pruritus are nonspecific. Rubbing using the entire hand helps prevent scratching. Because vasodilation tends to increase itching, cold applications may provide relief. Cool showers before bed may be helpful. Topical corticosteroids may be helpful in some cases. However, systemic antihistamines and corticosteroids may be indicated for people with severe pruritus. Occlusive dressings are thick creams that contain petroleum and can act as a barrier to prevent water loss from the skin. They usually are prescribed for dry skin.



18. An 81-year-old woman has noted a gradual decrease in the moisture of her skin over many years. Which phenomena associated with the aging process are known to contribute to her xerosis? Select all that apply.
  A) Separation of the basement membrane from adjacent dermal and epidermal layers
  B) Changing composition of sebaceous gland secretions
  C) Flattening of the dermal rete ridges
  D) Decreased moisture secretions from sweat glands
  E) Decrease in skin capillaries
  Ans: B, C, D, E
  The effects of aging on skin dryness include a change in the composition of sebaceous gland secretions and a decrease in the secretion of moisture from the sweat glands. Aging is also accompanied by a decrease in skin capillaries and flattening of the dermal rete ridges resulting in less surface area for exchange of fluids between the dermis, epidermis, and skin surface. Separation of the basement membrane is not noted to be a normal accompaniment to aging.



19. When trying to explain the advantages of using an emollient over other products to a patient suffering from dry skin, the nurse will emphasize emollients
  A) can replenish the oils on the skin surface because they contain fatty acids.
  B) will draw water out from the deeper skin layers.
  C) provide moisture-proof material to the skin by providing a thick creamy layer as a barrier.
  D) will contain some form of numbing agent like lidocaine to help with the itching.
  Ans: A
  Emollients are fatty acid–containing lotions that replenish the oils on the skin surface but usually do not leave a residue on the skin. Humectants are the additives in lotions that draw out the water from the deeper skin layers and hold it on the skin surface. However, the water that is drawn to the skin is transepidermal water, not atmospheric water. Thus, continued evaporation from the skin can actually exacerbate dryness. Occlusive are thick creams that contain petroleum to act as a barrier. Lotions or cream additives include steroids or mild anesthetics, such as camphor, menthol, lidocaine, or benzocaine. These agents work by suppressing itching while moisturizing the skin.



20. Which of the following facts accounts for the variation in skin tone that exists between individuals?
  A) Someone with dark skin has more melanocytes in his or her skin layers.
  B) Darker-skinned individuals have melanosomes that produce melanin faster.
  C) Dark skin is associated with spherical melanosomes, which produce and “package” pigment differently.
  D) Greater numbers of keratinocytes result in darker skin tone.
  Ans: B
  The amount of melanin in the keratinocytes determines a person’s skin color. Dark-skinned and light-skinned people have the same amount of melanocytes. However, in dark-skinned people, larger melanosomes are produced and transferred to the keratinocyte individually. In light-skinned people, a number of smaller melanosomes are packaged together in a membrane and then transferred to the keratinocyte. The way the melanosomes are packaged is responsible for the pigmentation in darker-skinned persons. Darker-skinned people do not have more melanocytes than light-skinned people, but the production and packaging of pigment is different.





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