QB for 3 questions and above

As a consequence of a long-standing lung disease, a client is in a chronic state of hypoxia. Which of the following phenomena would the client's care team be most justified in anticipating?

Select all that apply.

A) Metabolic alkalosis

B) Increased erythropoietin production

C) Pulmonary vasodilation

D) Hyperventilation

E) Personality changes

B D E

Feedback: Increased production of erythropoietin, hyperventilation, and cognitive and personality changes are all associated with hypoxemia. Acidosis, not alkalosis, and vasoconstriction rather than vasodilation are likely to occur.

A patient who has been on a high-protein diet comes to the emergency department with respiratory symptoms. Upon analysis of arterial blood gases (ABGs), the patient is diagnosed with hypercapnia. The nurse will note the ABG results that confirm this diagnosis include: Select all that apply.

A) pH 7.31 (normal 7.35 to 7.45).

B) PO2 of 97%.

C) PCO2 of 58 mm Hg (normal 38 to 42).

D) Serum HCO3of -33 mEq/L (normal 22 to 28).

E) Serum K+ (potassium)of 3.6 mmol/L (normal 3.5 to 5.0).

A C D

Feedback: Hypercapnia affects a number of body functions, including acid–base balance and renal, neurological, and CV functions. Elevated levels of PCO2 (38 to 42) produce a decrease in pH (7.35 to 7.45) and respiratory acidosis. Compensatory mechanisms result in an increase in serum HCO3 (22 to 28). In this example, the PO2 level is within normal range. Serum K+ is not part of the ABG analysis.

A nurse is providing care for a patient who has been admitted with a newly diagnosed bilateral pleural effusion. Which of the following findings from the nurse's initial assessment of the patient is incongruent with the patient's diagnosis and would require further investigation?

A) The client complains of sharp pain exacerbated by deep inspiration.

B) The client's breath sounds are diminished on auscultation.

C) Pulse oximetry indicates that the client is hypoxemic.

D) The client complains of dyspnea and increased work of breathing.

A

Feedback: Pleural effusion is not normally associated with pain, and intense pain that is worsened by deep breathing would necessitate further investigation. Diminished breath sounds, hypoxemia, and dyspnea are common findings associated with pleural effusion.

A patient arrives in the ED after an automobile accident. Which of the following clinical manifestations lead the nurse to suspect a pneumothorax? Select all that apply.

A) Respiratory rate 34

B) Asymmetrical chest movements, especially on inspiration

C) Diminished breath sounds over the painful chest area

D) Pulse oximetry 98%

E) ABG pH level of 7.38

A B C

Feedback: Manifestations of pneumothorax include increase in respiratory rate, dyspnea, asymmetrical movements of the chest wall, especially during inspiration, hyperresonant sound on percussion, and decreased or absent breath sounds over the area of pneumothorax. The pulse oximetry reading is normal. ABG pH level of 7.38 is a normal finding.

A short, nonsmoking 44-year-old male presents to the emergency room with left-sided chest pain and a cough. He states that the pain started abruptly and worsens with deep breathing and coughing. He denies recent injury. Assessment includes shallow respirations with a rate of 36, normal breath sounds, and no cyanosis. Which condition is most likely causing his symptoms?

A) Myocardial infarction

B) Spontaneous pneumothorax

C) Pleuritis related to infection

D) Obstructive atelectasis

C

Feedback: Pleuritis, which frequently accompanies infections that cause cough, is unilateral, starts abruptly, and is worsened by coughing or deep breathing. The client's shallow, rapid breathing may be due to anxiety but also is a way of maintaining adequate air intake while avoiding deep breathing, which exacerbates the pain of pleuritis. His cough may be an indication of infection, especially as he is not a smoker. The pain of myocardial infarction is not worsened by deep breathing or coughing. Spontaneous pneumothorax would be very unlikely in a short, nonsmoking middle-aged man. Tachypnea might indicate obstructive atelectasis, but normal breath sounds and lack of cyanosis argue against it

A 51-year-old female client who is 2 days postoperative in a surgical unit of a hospital is at risk of developing atelectasis as a result of being largely immobile. Which of the following teaching points by her nurse is most appropriate?

A) "Being in bed increases the risk of fluid accumulating between your lungs and their lining, so it's important for you to change positions often."

B) "You should breathe deeply and cough to help your lungs expand as much as possible while you're in bed."

C) "Make sure that you stay hydrated and walk as soon as possible to avoid us having to insert a chest tube."

D) "I'll proscribe bronchodilator medications that will help open up your airways and allow more oxygen in."

B

Feedback: Atelectasis is characterized by incomplete lung expansion and can often be prevented by deep breathing and coughing. Pleural effusion, not atelectasis, is associated with fluid accumulation between the lungs and their lining, and neither chest tube insertion nor bronchodilators are common treatments for atelectasis.

Which of the following statements best captures the etiology of the acute response phase of extrinsic (atopic) asthma?

A) IgG production is heightened as a consequence of exposure to an allergen.

B) Airway remodeling results in airflow limitations.

C) Epithelial injury and edema occur along with changes in mucociliary function.

D) Chemical mediators are released from presensitized mast cells.

D

Feedback: The acute response phase of extrinsic asthma is characterized by the release of chemical mediators from mast cells that have been sensitized. Epithelial injury and edema, as well as airway remodeling, are not associated with the acute phase, and IgE, not IgG, is primarily involved in asthma.

The mother of a 7-year-old boy who has recently been diagnosed with childhood asthma has come to the education center to learn more about her son's condition. Which of the following teaching points is most justifiable?

A) "Research has shown that viruses may actually be a factor in many children's asthma."

B) "The most reliable indicator that your child is having an asthma attack is audible wheezing."

C) "Steroids that your child can inhale will likely be the first line of defense."

D) "Your son will likely need to limit or avoid exercise and sports."

A

Feedback: Viruses have been implicated as a contributing factor in childhood asthma. Wheezing may or may not be present in children, and inhaled corticosteroids are not common as an initial therapy. Current treatment guidelines do not advise the categorical avoidance of exercise

In the early morning, an African American woman brings her 5-year-old son to the emergency room. The boy is wheezing, is short of breath, and has a dry cough. The mother states that he has always been very healthy. He went to bed with only a slight cold and a runny nose but woke her with his coughing shortly after 4 AM. His symptoms worsened so dramatically that she brought him to the hospital. The care team would most likely suspect that he has

A) respiratory syncytial virus.

B) influenza.

C) asthma.

D) pneumonia.

C

Feedback: Although the child may have an infectious disease, his symptoms and the timing of them (both in terms of his age and the time of symptom onset) are classic for asthma. They are not as closely associated with RSV, influenza, or pneumonia.

Which of the following residents of a long-term care facility is most likely to be exhibiting the signs and symptoms of chronic obstructive pulmonary disease (COPD)?

A) A 79-year-old lifetime smoker who is complaining of shortness of breath and pain on deep inspiration

B) An 81-year-old smoker who has increased exercise intolerance, a fever, and increased white blood cells

C) An 81-year-old male who has a productive cough and recurrent respiratory infections

D) An 88-year-old female who experiences acute shortness of breath and airway constriction when exposed to tobacco smoke

C

Feedback: Productive cough and recurrent respiratory infections are associated with COPD, while pain, fever, and increased white cells are not common signs and symptoms of COPD. Acute shortness of breath and bronchoconstriction are associated with asthma

A COPD patient asks the nurse what medications are prescribed to help his breathing. The nurse, looking at the list of medications, will educate the patient about which of the following medications to help his COPD in the long term? Select all that apply.

A) Salmeterol (Serevent), a bronchodilator

B) Tiotropium (Spiriva), anticholinergic

C) Alprazolam (Xanax), a benzodiazepine

D) Sildenafil (Viagra), a vasodilator

E) Ketorolac (Toradol), an NSAID

A B

Feedback: Pharmacologic treatment of COPD includes the use of bronchodilators (Serevent) and anticholinergic drugs (Tiotropium). Benzodiazepines are used for anxiety, and sildenafil is a vasodilator commonly prescribed not only for erectile dysfunction but also for patients with pulmonary hypertension. Toradol (ketorolac) is an NSAID for pain and inflammation.

A nurse is providing care for a client who has been admitted to a medical unit with a diagnosis of bronchiectasis. Which of the following signs and symptoms should the nurse expect to find during physical assessment of the client and the review of the client's history? Select all that apply.

A) Recurrent chest infections

B) Production of purulent sputum

C) A barrel chest

D) Low hemoglobin levels

E) Recent surgery

A B D

Feedback: Chest infections, copious production of purulent sputum, and anemia are all associated with bronchiectasis. A barrel chest is more commonly evident with emphysema, and recent surgery is not a noted factor.

A physician is providing care for a child who has a diagnosis of cystic fibrosis (CF). Place the following events in the etiology of CF in ascending chronological order. Use all the options.

A) Airway obstruction

B) Recurrent pulmonary infections

C) Impaired Cl- transport

D) Decreased water content of mucociliary blanket

E) Increased Na+ absorption

C E D A B

Feedback: CF is associated with impaired Cl– transport and a consequent increase in Na+ absorption. These result in a lowered water content of the mucociliary blanket making it more viscid. These changes to the mucociliary blanket cause airway obstruction and, ultimately, pulmonary infections

Which of the following clinical findings would be most closely associated with a client who has interstitial lung disease in comparison to chronic obstructive pulmonary disease (COPD)?

A) Audible wheezing on expiration

B) Reduced expiratory flow rates

C) Decreased tidal volume

D) Normal forced expiratory volume

C

Feedback: Because it takes less work to move air through the airways at an increased rate than it does to stretch a stiff lung to accommodate a larger tidal volume, interstitial lung disease is commonly associated with an increased respiratory rate but decreased tidal volume. Wheezing and decreased expiratory flow rate are more closely associated with COPD.

A patient is admitted for a relapse for sarcoidosis. Knowing this is usually caused by an inflammatory process, the nurse can anticipate administering

A) a bronchodilator.

B) a corticosteroid.

C) aspirin.

D) an albuterol inhaler

B

Feedback: Treatment is directed at interrupting the granulomatous inflammatory process that is characteristic of the disease and managing the associated complications. When treatment is indicated, corticosteroid drugs are used. Bronchodilators may be used if there is wheezing, but this is not a normal medication for this disease. Aspirin is a blood thinner. Albuterol is a short-term bronchodilator for acute asthma

Which of the following clients are displaying known risk factors for the development of pulmonary emboli? Select all that apply. A client who is:

A) immobilized following orthopedic surgery.

B) experiencing impaired Cl- and Na+ regulation.

C) taking amiodarone for the treatment of premature ventricular contractions.

D) a smoker and who takes oral contraceptives.

E) undergoing radiation therapy for the treatment of breast cancer.

A D

Feedback: Postsurgical immobility, smoking, and the use of oral contraceptives are all identified risk factors for the development of pulmonary emboli. Impaired Cl– and Na+ regulation are associated with cystic fibrosis, while amiodarone and radiation therapy are linked to interstitial lung diseases.

A patient with pulmonary hypertension may display which of the following clinical manifestations? Select all that apply.

A) Shortness of breath

B) Decreased exercise tolerance

C) Nasal flaring

D) Grunting on expiration

E) Swelling (edema) of the legs and feet

A B E

Feedback: Symptoms of PAH typically progress from shortness of breath and decreasing exercise tolerance to right heart failure, with marked peripheral edema and functional limitations. Other common symptoms include fatigue, angina, and syncope (fainting) or near-syncope. Nasal flaring and expiratory grunting are usually seen in infants experiencing respiratory distress.

Upon admission to the ICU, a patient with a history of cor pulmonale will likely be exhibiting which of the following clinical manifestations of right heart failure? Select all that apply.

A) Fine crackles throughout both lung fields

B) +4 pitting edema in lower extremities

C) Expectorating copious amounts of frothy, pink sputum

D) Jugular vein distension

E) Altered level of consciousness

B D E

Feedback: Signs of right-sided HF include venous congestion (jugular vein distension), peripheral edema (+4 pitting edema in feet), shortness of breath, and productive cough. Altered level of consciousness may occur as the result of carbon dioxide retention. Fine crackles in all lung fields and frothy, pink sputum are common in left-sided HF.

A 41-year-old male client has presented to the emergency department with an acute onset of increased respiratory rate and difficulty breathing. STAT chest x-ray indicates diffuse bilateral infiltrates of his lung tissue, and ECG displays no cardiac dysfunction. What is this client's most likely diagnosis?

A) Cor pulmonale

B) Acute lung injury

C) Pulmonary hypertension

D) Sarcoidosis

B

Feedback: Rapid onset of respiratory distress accompanied by diffuse bilateral infiltrates of lung tissue and an absence of cardiac changes are associated with acute lung injury/acute respiratory distress syndrome. These particular signs and symptoms are not as closely associated with cor pulmonale, pulmonary hypertension, or sarcoidosis.

While rock climbing, a 22-year-old male has endured a severe head injury. Which of the following statements best captures expected clinical manifestations and treatments for his immediate condition?

A) Oxygen therapy is likely to decrease his respiratory drive and produce an increase in PCO2.

B) Cheyne-Stokes breathing is likely but will respond to bronchodilators.

C) The client is unlikely to respond to supplementary oxygen therapy due to impaired diffusion.

D) Hypoventilation may exist, resulting in increased PCO2 and hypoxemia that may require mechanical ventilation

D

Feedback: Brain injuries and accompanying hypoventilation are often associated with increased PCO2 and by hypoxemia that responds to oxygen therapy. Persons with COPD are more vulnerable to diminished respiratory drive secondary to oxygen therapy, while Cheyne-Stokes breathing is not identified as a likely consequence of brain injury. Impaired alveolar diffusion is not an aspect of the client's injury

In which of the following patient situations would a physician be most justified in preliminarily ruling out pericarditis as a contributing pathology to the client'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 reporting 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.

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

1. Muffled heart tones

2. Narrowed pulse pressure

3. Low BP—84/60

4. Heart rate 78

5. Bounding femoral pulse

1,2,3

Feedback: 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.

Which of the following phenomena would be most likely to accompany increased myocardial oxygen demand (MVO2)?

1. Inadequate ventricular end-diastolic pressure

2. Use of calcium channel blocker medications

3. Increased aortic pressure

4. Ventricular atrophy

3

Feedback: 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.

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?

1. Echocardiogram, PET scan, ECG

2. Ambulatory ECG, cardiac MRI, echocardiogram

3. Serum creatinine levels, chest auscultation, myocardial perfusion scintigraphy

4. Cardiac catheterization, cardiac CT, exercise stress testing

1

Feedback: 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.

Which of the following teaching points would be most appropriate for a group of older adults who are concerned about their cardiac health?

1. “People with plaque in their arteries experience attacks of blood flow disruption at seemingly random times.”

2. “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.”

3. “Infections of any sort are often a signal that plaque disruption is in danger of occurring.”

4. “The impaired function of the lungs that accompanies pneumonia or chronic obstructive pulmonary disease is a precursor to plaque disruption.”

2

Feedback: 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.

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 client MOST likely experienced myocardial infarction?

A. A 33-year-old man 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 2am while she was asleep and which responded to nitrates; the ECG showed dysrhythmias and ST-segment elevation; cardiac markers remained stable.

C. An 80-year-old woman whose pain started at 6am shortly after awakening and was not relieved by nitrated 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 9am during a short walk and responded to nitrated, 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 clients have angina of varying severity.

Which of the following statements provides blood work results and rationale that would be most closely associated with acute coronary syndrome?

1. Increased serum creatinine and troponin I as a result of enzyme release from damaged cells

2. 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

3. Elevated creatine kinase and troponin, both of which normally exist intracellularly rather than in circulation

4. Low circulatory levels of myoglobin and creatine kinase as a result of the inflammatory response

3

Feedback: 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.

A number of clients have presented to the emergency department in the last 32 hours with reports that are preliminarily indicative of myocardial infarction. Which client is LEAST likely to have an ST-segment myocardial infarction (STEMI)?

A. A 70-year-old woman who is reporting 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.

Following a ST-segment myocardial infarction (STEMI), the nurse should be assessing the patient for which of the following complications? Select all that apply.

1. Large amount of pink, frothy sputum and new onset of murmur

2. Tachypnea with respiratory distress

3. Frequent ventricular arrhythmia unrelieved with amiodarone drip

4. Complaints of facial numbness and tingling

5. Enhanced renal perfusion as seen as an increase in urine output

1,2,3,4

Feedback: 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.

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?

1. “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.”

2. “With some simple lifestyle modifications and taking your heparin regularly, we can realistically cure you of this.”

3. “I'm going to start you on low-dose aspirin, and it will help greatly if you can lose weight and keep exercising.”

4. “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.”

3

Feedback: Aspirin, exercise, and weight loss are all identified treatments for angina. Angina does not normally necessitate blood work, heparin administration, or avoidance of activity

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?

1. Lisinopril, an ACE inhibitor

2. Lasix, a diuretic

3. Propranolol, a B-adrenergic blocker

4. Lanoxin, an inotropic

3

Feedback: 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.

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.

1. Atrial flutter

2. Ventricular tachycardia with left bundle branch block pattern

3. T-wave inversion in the right precordial leads

4. Sinus arrhythmia with a first-degree AV block

5. Development of a “U” wave following a normal T wave

2,3

Feedback: 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.

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?

1. Her diagnosis might be attributable to a disordered immune response, nutritional factors, or infectious processes.

2. Treatment is possible in postpartum women, but antepartum women are dependent on spontaneous resolution of the problem.

3. Mortality exceeds 50%, and very few surviving women regain normal heart function.

4. Symptomatology mimics that of stable angina and is diagnosed and treated similarly.

1

Feedback: 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.

An IV drug abuser walks into the ED telling the nurse, "I am sick." The client 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 the client's mitral valve. The client is admitted to the ICU. The nurse will be assessing this client for which possible life-threatening complication?

A. Systemic emboli, especially to 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. Petechial hemorrhages are signs/symptoms of infective endocarditis (IE). GI upset is common following antibiotic therapy but is not usually life-threatening. Stress can increase insulin needs but is not associated with pancreas enlargement.

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?

1. CT of the heart, chest x-ray, and ECG

2. Echocardiogram, blood cultures, and temperature

3. ECG, blood pressure, and stress test

4. Cardiac catheterization, chest x-ray, electrolyte measurement, and white cell count

2

Feedback: 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.

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

1. myocarditis.

2. mitral valve stenosis.

3. infective endocarditis.

4. vasculitis

2

Feedback: 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.

On a routine physical exam visit, the physician mentions that he hears a new murmur. The client 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 problems."

D. "This may make you a little more fatigued than usual. Let me know if you start getting dizzy or lightheaded."

Ans: C

Stenosis refers to a narrowing of the of the valve orifice and failure of the valve leaflets to open normally. Blood flow through a normal valve can increase by 5-7 times the resting volume. Valvular disease is not caused by stress. The murmur can be caused by infection but also stenosis or regurgitation of a valve leaflet. The valve problem is very severe if it is causing signs of decrease cardiac output.

A client has been diagnosed with mitral valve stenosis following his recovery from rheumatic fever. Which teaching point 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 backwards 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. Though it is often caused by infection, it is not an infectious process of the valve per se.

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.

1. Decrease in exercise tolerance

2. Exertional dyspnea

3. Palpitations

4. Syncope

5. Heartburn

1,2,4

Feedback: 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.

Which of the following situations related to transition from fetal to perinatal circulation would be most likely to necessitate medical intervention?

1. Pressure in pulmonary circulation and the right side of the infant's heart fall markedly.

2. Alveolar oxygen tension increases causing reversal of pulmonary vasoconstriction of the fetal arteries.

3. Systemic vascular resistance and left ventricular pressure are both increasing.

4. Pulmonary vascular resistance, related to muscle regression in the pulmonary arteries, rises over the course of the infant's first week.

4

Feedback: 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.

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.

1. Murmur heard at the second intercostal space, during both systole and diastole

2. BP 84/30 classified as a wide pulse pressure

3. Shortness of breath with activity such as kicking

4. Stridor with inspiratory wheezes

5. Bulging jugular neck veins

1,2

Feedback: 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.

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 pathophysiologic result 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 outfflow 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.

A 66-year-old obese man with diagnoses of ischemic heart disease has been diagnosed with heart failure that his care team has characterized as attributable to systolic dysfunction. Which of the following assessment findings is inconsistent with his diagnosis?

1. His resting blood pressure is normally in the range of 150/90, and an echocardiogram indicates his ejection fraction is 30%.

2. His end-diastolic volume is higher than normal, and his resting heart rate is regular and 82 beats/minute.

3. He is presently volume overloaded following several days of intravenous fluid replacement.

4. Ventricular dilation and wall tension are significantly lower than normal.

4

Feedback: Systolic dysfunction is associated with increased ventricular dilation and wall tension. Hypertension, low ejection fraction, high preload, and volume overload are all commonly associated with systolic dysfunction.

A nurse will be providing care for a female client who has a diagnosis of heart failure that has been characterized as being primarily right-sided. Which statement BEST describes the presentation that the nurse should anticipate? The client:

A. has a distended bladder, facial edema, and difficulty breathing during nighttime hours.

B. complains of dyspnea and has adventitious breath sounds on auscultation.

C. has pitting edema to the ankles and feet bilaterally, decreased activity tolerance and occasional upper right quadrant pain.

D. has cyanotic lips and extremities, low urine output, and low blood pressure.

Ans: C

Right-sided failure is associated with peripheral edema, fatigues, and, on occasion, upper right quadrant pain. Abdominal distention can occur with right-side failure when the liver becomes engorged. Facial edema, pulmonary edema, peripheral cyanosis, low urine output and low blood pressure are less associated with right-sided failure. Left-sided failure is primarily associated with pulmonary signs/symptoms like dyspnea, pulmonary edema, frothy pink sputum, and respiratory congestion.

An 81-year-old male resident of a long-term care facility has a long-standing diagnosis of heart failure. Which of the following short-term and longer-term compensatory mechanisms are least likely to decrease the symptoms of his heart failure?

1. An increase in preload via the Frank-Starling mechanism

2. Sympathetic stimulation and increased serum levels of epinephrine and norepinephrine

3. Activation of the renin–angiotensin–aldosterone system and secretion of brain natriuretic peptide (BNP)

4. AV node pacemaking activity and vagal nerve suppression

4

Feedback: Reassignment of cardiac pacemaking activities and suppression of the vagal nerve are not noted compensatory actions related to heart failure. Increased preload and sympathetic stimulation, increased levels of epinephrine and norepinephrine, and activation of the renin–angiotensin–aldosterone system and secretion of brain natriuretic peptide (BNP) are all noted compensatory mechanisms.

The nurse working in the ICU knows that chronic elevation of left ventricular end-diastolic pressure will result in the patient displaying which of the following clinical manifestations?

1. Chest pain and intermittent ventricular tachycardia

2. Dyspnea and crackles in bilateral lung bases

3. Petechia and spontaneous bleeding

4. Muscle cramping and cyanosis in the feet

2

Feedback: Although it may preserve the resting cardiac output, the resulting chronic elevation of left ventricular end-diastolic pressure is transmitted to the atria and the pulmonary circulation, causing pulmonary congestion.

A 77-year-old client with a history of coronary artery disease and heart failure has arrived in the emergency room with rapid heart rate and feeling of "impending doom." Based on pathophysiologic principles, the nurse knows the rapid heart rate could:

A. Decrease renal perfusion and result in development of ascites.

B. be a result of catecholamines released from SNS, which could increased the myocardial oxygen demand.

C. desensitize the alpha-adrenergic receptors leading to increase in norepinephrine levels.

D. prolong the electrical firing from the SA node resulting in development of a heart block.

Ans: B

An increase in sympathetic activity by stimulation of the beta-adrenergic receptors of the heart leads to tachycardia, vasoconstriction, and dysrhythmias. Acutely, tachycardia significantly increased the workload of the heart, this increasing myocardial O2 demand and leading to cardiac ischemia, myocyte damage, and decreased contractility. Decrease renal perfusion would activate the RAAS system, increasing heart rate and BP further. Ventricular dysrhythmias are primarily seen at this stage of HF.

A nurse educator in a geriatric medicine unit of a hospital is teaching a group of new graduates specific assessment criteria related to heart failure. Which of the following assessment criteria should the nurses prioritize in their practice?

1. Measurement of urine output and mental status assessment

2. Pupil response and counting the patient's apical heart rate

3. Palpation of pedal (foot) pulses and pain assessment

4. Activity tolerance and integumentary inspection

1

Feedback: Both increased and decreased urine output can be markers of heart failure, as can changes in mental status not attributable to other factors. While heart auscultation, pedal pulses, and activity tolerance are relevant parameters, integumentary inspection, pupil response, and pain assessment are less likely to be relevant assessment components.

Mr. V. has been admitted for exacerbation of his chronic heart failure (HF). When the nurse walks into his room, he is sitting on the edge of the bed, gasping for air, and his lips are dusty blue. Vital signs reveal heart rate of 112, respiratory rate of 36, and pulse oximeter reading of 81%. He starts coughing up frothy pink sputum. The priority intervention is to

1. have medical supply department bring up suction equipment.

2. apply oxygen via nasal cannula at 3 lpm.

3. page the respiratory therapist to come give him a breathing treatment.

4. call for emergency assistance utilizing hospital protocol.

4

Feedback: Mr. V. is experiencing acute pulmonary edema. This is a life-threatening condition. The person is seen sitting and gasping for air. The pulse is rapid, the skin is moist, and the lips/nail beds are cyanotic. Dyspnea and air hunger are accompanied by productive cough with frothy and often blood-tinged sputum (pink). The patient needs the emergency responder team (including ICU nurses, physicians, respiratory therapist, etc.) to intervene. Applying O2 by mask will not increase his oxygen level fast enough, and he is probably mouth breathing (gasping for air). Suction equipment may be needed, but getting a physician to give orders for diuretics and inotropic medications is the priority. Of course respiratory therapist will arrive with the emergency assistance team.

A female older adult client has presented with a new onset of shortness of breath, and the client's physician has ordered measurement of her brain natriuretic peptide (BNP) levels along with other diagnostic tests. What is the MOST accurate rationale for the physician's choice of bloodwork?

A. BNP is released as a compensatory mechanism during heart failure and measuring it can help differentiate the client's dyspnea from a respiratory pathology.

B. BNP is an indirect indicator of the effectiveness of the renin-angiotensin-aldosterone (RAA) system in compensating for heart failure.

C. BNP levels correlate with the client's risk of developing cognitive deficits secondary to heart failure and consequent brain hypoxia.

D. BNP becomes elevated in cases of cardiac asthma, Cheyne-Stokes respirations and acute pulmonary edema, and measurement can gauge the severity of pulmonary effects.

Ans: A

BNP is released to compensate for heart failure and elevated levels help confirm the diagnosis of heart failure as opposed to respiratory etiologies. It does not measure the effectiveness of the RAA system, the risk of cognitive deficits, or the specific severity of pulmonary symptoms of heart failure.

A nurse is administering morning mediations to a number of clients on a medical unit. Which medication regimen is MOST suggestive that the client has a diagnosis of heart failure?

A. Antihypertensive, diuretic, anti-platelet aggregator.

B. Diuretic, ACE inhibitor, beta-blocker.

C. Anticoagulant, antihypertensive, calcium supplement.

D. Beta-blocker, potassium supplement, anticoagulant.

Ans: B

Diuretics, ACE inhibitors, and beta-blockers are all commonly used in the treatment of heart failure. Anti-platelet aggregator, calcium and potassium supplements, and anticoagulants are less likely to relate directly to a diagnosis of heart failure.

Emergency medical technicians respond to a call to find an 80-year-old man who is showing signs and symptoms of severe shock. Which phenomenon is MOST likely taking place?

A. The man's alpha- and beta-adrenergic receptors have been activated, resulting in vasoconstriction and increased heart rate.

B. Hemolysis and blood pooling are taking place in the man's peripheral circulation.

C. Bronchoconstriction and hyperventilation are initiated as a compensatory mechanism.

D. Intracellular potassium and extracellular sodium levels are rising as a result of sodium-potassium pump failure.

Ans: A

Alpha- and beta-adrenergic receptor activation is a central response to all types of show. Hemolysis is not a noted accompaniment to shock. Bronchodilation, not bronchoconstriciton, often results from adrenergic stimulation. Sodium-potassium pump failure results in increased extracellular potassium and intracellular sodium.

Following coronary bypass graft (CABG) surgery for a massive myocardial infarction (MI) located on his left ventricle, the ICU nurses are assessing for clinical manifestations of cardiogenic shock. Which of the following assessment findings would confirm that the client may be in the early stages of cardiogenic shock? Select all that apply.

1. Decreasing mean arterial pressure (MAP)

2. Low BP reading of 86/60

3. Urine output of 15 mL last hour

4. Low pulmonary capillary wedge pressure (PCWP)

5. Periods of confusion

1,2,3,5

Feedback: Signs and symptoms of cardiogenic shock include indications of hypoperfusion with hypotension (BP 96/60), decrease in mean arterial pressure (MAP) due to poor stroke volume, and a narrow pulse pressure. Urine output decreases because of lower renal perfusion pressures. PCWP is usually elevated due to increased preload. Periods of confusion or altered cognition/consciousness may occur because of low cardiac output.

A 22-year-old male is experiencing hypovolemic shock following a fight in which his carotid artery was cut with a broken bottle. What immediate treatments are MOST likely to benefit the man?

A. Resolution of compensatory pulmonary edema and heart dysrhythmias.

B. Infusion of vasodilators of foster perfusion and inotropes to improve heart contractility.

C. Infusion of normal saline or Ringer's lactate to maintain the vascular space.

D. Administration of oxygen and epinephrine to promote perfusion.

Ans: C

Maintenance of vascular volume is the primary goal in the treatment of hypovolemic shock, and be achieved in the short term through intravenous administration of saline solution of Ringer's lactate. Resolution of pulmonary edema and heart dysrhythmias and infusion of vasodilators are associated with treatment of cardiogenic shock, while oxygen and epinephrine would address anaphylactic shock.

A 30-year-old woman presents at a hospital after fainting at a memorial service and she is diagnosed as being in neurogenic shock. Which signs/symptoms is she MOST likely to display?

A. Faster than normal heart rate

B. Pain

C. Dry and warm skin

D. Increased thirst

Ans: C

In contrast to hypovolemic shock, in which the heart rate is faster than normal and the skin is cold and clammy, a person in neurogenic shock is likely to have a slower than normal heart rate and dry, warm skin. Fainting due to emotional causes is a transient form of neurogenic shock, while increased thirst is an early sign of hypovolemic shock.

All of the following interventions are ordered stat. for a patient stung by a bee who is experiencing severe respiratory distress and faintness. Which priority intervention will the nurse administer first?

1. Epinephrine (Adrenalin)

2. Normal saline infusion

3. Dexamethasone (Decadron)

4. Diphenhydramine (Benadryl)

1

Feedback: Treatment includes immediate discontinuation of the inciting agent; close monitoring of CV and respiratory function; and maintenance of respiratory gas exchange, cardiac output, and tissue perfusion. Epinephrine is given in an anaphylactic reaction because it constricts blood vessels and relaxes the smooth muscle in the bronchioles.

A patient in the intensive care unit has a blood pressure of 87/39 mmHg and has warm, flushed skin accompanying his sudden decline in level of consciousness. The client also has arterial and venous dilation and a decrease in systemic vascular resistance. What is the client's MOST likely diagnosis?

A. hypovolemic shock

B. septic shock

C. neurogenic shock

D. obstructive shock

Ans: B

Low blood pressure accompanied by warm, flushed skin and cognitive changes is indicative of septic shock, as is vessel dilation and decreased vascular resistance.

A client has many residual health problems related to compromised circulation following recovery from septic shock. The nurse knows that which of the following complications listed below are a result of being diagnosed with septic shock and therefore should be assessed frequently? Select all that apply.

1. Profound dyspnea due to acute respiratory distress syndrome

2. Atelectasis resulting in injury to endothelial lining of pulmonary vessels, which allows fluid/plasma to build up in alveolar spaces

3. Formation of plaque within vessels supplying blood to the heart causing muscle damage and chest pain

4. Acute renal failure due to decreased/impaired renal perfusion as a result of low BP

5. Flushed skin and pounding headache that coincides with each heart beat

1,2,4

Feedback: ARDS, atelectasis, and acute renal failure are all noted consequences of shock that might be, respectively, treated by dialysis, an ostomy, or platelet transfusion. Plaque formation to heart vessels is not directly related to any of the identified consequences of shock. Pounding headache that coincides with each heart beat may occur with migraine headaches.

A 3-year-old child with right-sided heart failure has been admitted for worsening of the condition. Which assessment would be considered one of the earliest signs of systemic venous congestion in this toddler?

A. breathlessness with activity

B. excessive crying

C. enlargement of liver

D. increased urine output

Ans: C

With RV function impaired, systemic venous congestion develops. Hepatomegaly due to liver congestion often is one of the first signs of systemic venous congestion in infants and children.

A pediatrician is teaching a group of medical student about some of the particularities of heart failure in children as compared with older adults. Which statement by the physician BEST captures an aspect of these difference?

A. "You'll find that, in pediatric clients, pulmonary edema is more often interstitial rather than alveolar, so you often won't hear crackles."

B. "Because of their higher relative blood volume, jugular venous distention is a better assessment technique for suspected heart failure in young clients."

C. "Signs and symptoms in children may sometimes mimic those of shock, with a low blood pressure and high heart rate."

D. "Fever is a sign of heart failure in children that you are unlikely to see in older adults."

Ans: A

The pulmonary edema that accompanies heart failure is more often interstitial rather than alveolar in children. Jugular venous distention is difficult to gauge in children. Low blood pressure and fever are not noted signs of heart failure in children.

Which of the following changes associated with aging contributes to heart failure development in older adults? Select all that apply

1. Increased incidence of mitral stenosis

2. Sludge buildup in the kidneys

3. Elevated diastolic BP

4. Increased vascular stiffness

5. Inflammation in the joints due to arthritis

3,4

Feedback: Changes with aging contribute to the development of HF in older adults. First is reduced responsiveness to -adrenergic stimulation. Second is increased vascular stiffness that contributes to ventricular hypertrophy. Third, the heart itself becomes less compliant with age. Fourth relates to altered myocardial metabolism at the level of the mitochondria. Older adults usually develop aortic stenosis and mitral regurgitation. Kidney stones do not contribute to HF. Increase in diastolic pressure compromises LV filling leading to increases in pressures predisposing to HF. Arthritis is not associated with heart failure.

Knowing the high incidence and prevalence of heart failure among the elderly, the manager of a long-term care home has organized a workshop on the identification of early signs and symptoms of heart failure. Which of the following teaching points is most accurate?

1. “Displays of aggression, confusion, and restlessness when the resident has no history of such behavior can be a sign of heart failure.”

2. “Heart failure will often first show up with persistent coughing and lung crackles.”

3. “Residents in early heart failure will often be flushed and have warm skin and a fever.”

4. “Complaints of chest pain are actually more often related to heart failure than to myocardial infarction.”

1

Feedback: Cognitive changes can often accompany heart failure in the elderly. Pulmonary edema is a later sign, and they are less likely to display coughing, chest pain of flushed skin, and fever

During a period of extreme excess fluid volume, a renal dialysis patient may be administered which type of IV solution to shrink the swollen cells by pulling water out of the cell?

A) 0.9% sodium chloride

B) 5% dextrose and water

C) 3% sodium chloride

D) Lactated Ringer solution

C

Feedback: When cells are placed in a hypotonic solution, which has a lower effective osmolality than the ICF, they swell as water moves into the cell, and when they are placed in a hypertonic solution, which has a greater effective osmolality than the ICF, they shrink as water is pulled out of the cell.

A 34-year-old male client has diagnoses of liver failure, ascites, and hepatic encephalopathy secondary to alcohol abuse. The client's family is questioning the care team as to why his abdomen is so large even though he is undernourished and emaciated. Which of the following statements most accurately underlies the explanation that a member of the care team would provide the family?

A) An inordinate amount of interstitial fluid is accumulating his abdomen.

B) The transcellular component of the intracellular fluid compartment contains far more fluid than normal.

C) Normally small transcellular fluid compartment, or third space, is becoming enlarged.

D) Gravity-dependent plasma is accumulating in his peritoneal cavity

C

Feedback: Ascites is characterized by an accumulation of fluid in the transcellular component of the ECF, not ICF. The fluid is not categorized as belonging to the plasma component of the ECF.

Which of the following individuals would be considered to be at risk for the development of edema? Select all that apply.

A) An 81-year-old man with right-sided heart failure and hypothyroidism

B) A 60-year-old obese female with a diagnosis of poorly controlled diabetes mellitus

C) A 34-year-old industrial worker who has suffered extensive burns in a job-related accident

D) A 77-year-old woman who has an active gastrointestinal bleed and consequent anemia

E) A 22-year-old female with hypoalbuminemia secondary to malnutrition and anorexia nervosa

A, C, E

Feedback: Right-sided heart failure, burns, and low levels of plasma proteins are all associated with the development of edema. Diabetes and GI bleeds are not identified as contributors to edema

Recognizing the prevalence and incidence of dehydration among older adults, a care aide at a long-term care facility is in the habit of encouraging residents to drink even though they may not feel thirsty at the time. Which of the following facts underlies the care aide's advice?

A) Older adults often experience a decrease in the sensation of thirst, even when serum sodium levels are high.

B) The metabolic needs for both fluid and sodium in older adults differ from those of younger individuals.

C) Regulation and maintenance of effective circulating volume by the kidneys is less effective in the elderly.

D) The renin–angiotensin–aldosterone system (RAAS) is less able to facilitate sodium clearance in older adults.

A

Feedback: The elderly are prone to hypodipsia even when osmolality and serum sodium levels are elevated, a fact that is compounded by sensory and/or neurological deficits. Hypodipsia in the elderly is not related to differing metabolic needs, ineffective kidney function, or compromise of the RAAS.

The nurse is providing teaching to a student nurse about how antidiuretic hormone (ADH) plays a central role in the reabsorption of water by the kidneys. The nursing student is correct to place the following components of the homeostatic action of ADH in the correct sequence. Use all the options.

A) Stored ADH is released into circulation.

B) ADH is transported along a neural pathway to the posterior pituitary gland.

C) Aquaporins are inserted into tubular cell membranes.

D) ADH is synthesized by cells in the supraoptic and paraventricular nuclei of the hypothalamus.

E) Serum osmolality increases.

D, B, E, A, C

Feedback: ADH is produced in the hypothalamus, sequestered in the pituitary, and is released in response to increased serum osmolality. Its influence on tubular cells is exerted by way of the insertion of aquaporins in the tubular membrane.

A patient arrives in the ED very hypovolemic related to excretion of “at least 3 gallon jugs of urine in the past 24 hours.” He describes the urine as being clear-like water. The physician suspects diabetes insipidus. The nurse should be prepared to administer which of the following medications?

A) Desmopressin acetate (DDAVP)

B) Benadryl, an anticholinergic

C) Calcium gluconate

D) Prednisone

A

Feedback: Diabetes insipidus is caused by a deficiency of or a decreased response to ADH. The preferred drug for treating chronic DI is desmopressin acetate (DDAVP).

A patient has been diagnosed with a brain tumor that cannot be removed surgically. During each office visit, the nurse will be assessing the patient for syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following assessments would alert the clinic nurse that the patient may be developing this complication?

A) Complaints that his urine output is decreased, no edema noted in ankles, and increasing headache

B) Elevated blood glucose levels, dry mucous membranes, and severe projectile vomiting

C) Fever, diarrhea, and nausea

D) Muscle cramps, pins and needle sensation around the mouth/lips, and unexplained bruising

A

Feedback: SIADH manifests as a dilutional hyponatremia. Decrease urine output, absence of edema, and headaches are signs of this. Answer choice B relates to s/s of diabetes insipidus; answer choice C is indicative of common flu s/s; answer choice D is relates to s/s of hypocalcemia.

A 77-year-old female hospital patient has contracted Clostridium difficile during her stay and is experiencing severe diarrhea. Which of the following statements best conveys a risk that this woman faces?

A) She is susceptible to isotonic fluid volume deficit.

B) She is prone to isotonic fluid volume excess.

C) She could develop third-spacing edema as a result of plasma protein losses.

D) She is at risk of compensatory fluid volume overload secondary to gastrointestinal water and electrolyte losses.

A

Feedback: This woman is at risk of isotonic fluid volume deficit and sodium imbalances as a result of her diarrhea. She is not likely to develop fluid volume excess or third spacing as consequences of diarrhea.

You are volunteering in the medical tent of a road race on a hot, humid day. A runner who has collapsed on the road is brought in with the following symptoms: sunken eyes, a body temperature of 100°F, and a complaint of dizziness while sitting to have his blood pressure taken (which subsides upon his lying down). These are signs of a fluid volume deficit. Which of the following treatments should be carried out first?

A) Offer water by mouth.

B) Begin cooling of his body by ice packs.

C) Give him a transfusion of FFP.

D) Give him an electrolyte solution by mouth.

D

Feedback: Fluid volume deficit results in postural hypotension (dizziness while upright) due to decreased blood volume. Sunken eyes and elevated temperature also point to a fluid volume deficit. The most important action to take is to replace fluid; however, pure water would be a mistake, since without accompanying electrolytes such as sodium, hyponatremia (water retention and a decrease in serum osmolality) could result. Thus, an oral electrolyte solution is recommended; in more severe cases, an IV would be appropriate

A client is brought to the emergency department with complaints of shortness of breath. Assessment reveals a full, bounding pulse, severe edema, and audible crackles in lower lung fields bilaterally. What is the client's most likely diagnosis?

A) Hyponatremia

B) Fluid volume excess

C) Electrolyte imbalance: hypocalcemia

D) Hyperkalemia

B

Feedback: Peripheral and pulmonary edema as well as a bounding pulse and dyspnea are indicators of fluid volume overload.

A 26-year-old male patient with a diagnosis of schizophrenia has been admitted with suspected hyponatremia after consuming copious quantities of tap water. Given this diagnosis, what clinical manifestations and lab results should the nurse anticipate the patient will exhibit?

A) High urine specific gravity, tachycardia, and a weak, thready pulse

B) Low blood pressure, dry mouth, and increased urine osmolality

C) Increased hematocrit and blood urea nitrogen and seizures

D) Muscle weakness, lethargy, and headaches.

D

Feedback: Weakness, lethargy, and nausea are noted manifestations of hyponatremia. High urine specific gravity, tachycardia, and a weak, thread pulse are associated with hypernatremia, while low blood pressure, fever, and increased urine osmolality are manifestations of fluid volume deficit. Increased hematocrit and blood urea nitrogen and seizures are also associated with hypernatremia.

An ECG technician is performing an ECG on a hospital patient who has developed hypokalemia secondary to diuretic use. Which of the following manifestations of the client's health problem will the technician anticipate on the ECG?

A) Irregular heart rate and a peaked T wave

B) A low T wave and an absent P wave

C) A prominent U wave and a flattened T wave

D) A narrow QRS complex and an absent U wave

C

Feedback: ECG changes associated with hypokalemia include a prominent U wave and a flattening of the T wave. Atrial fibrillation, a low P wave, and the absence of a U wave are not associated with hypokalemia.

A nurse in a medical unit has noted that a client’s potassium level is elevated at 6.1 mEq/L. The nurse has notified the physician, removed the banana from the client’s lunch tray, and is performing a focused assessment. When questioned by the client for the rationale for these actions, which of the following explanations is most appropriate?

A) “Your potassium level is high, and so I need you let me know if you feel numbness, tingling, or weakness.”

B) “Your potassium levels in the blood are higher than they should be, which brings a risk of changes in the brain function.”

C) “I'll need to monitor you today for signs of high potassium; tell me if you feel as if your heart is beating quickly or irregularly.”

D) “The amount of potassium in your blood is too high, but this can be resolved by changing the intravenous fluid you are receiving.”

A

Feedback: Paresthesia and muscle weakness are manifestations of hyperkalemia. Tachycardia and dysrhythmias are more commonly associated with hypokalemia, and the greatest risks associated with potassium imbalances are cardiac rather than neurological. Hyperkalemia is not normally resolved by correction using IV fluid.

A renal failure patient with severe hyperkalemia (K+ level 7.2 mEq/L) has just been admitted to the nursing unit. Given the severity of this situation, the nurse should be prepared to administer which intravenous infusion stat?

A) Lactated Ringer solution at 150 mL/hour to maintain blood glucose levels

B) Regular insulin infusion, rate dependent on lab values

C) Infusion of Solu-Medrol to decrease irritation to the intravascular system

D) Dilaudid via patient-controlled device (PCA) to control pain

B

Feedback: The administration of sodium bicarbonate, b-adrenergic agonists, or insulin distributes potassium into the ICF compartment and rapidly decreases the ECF concentration. Lactated Ringer solution, steroids, or narcotics will not help to lower potassium levels.

Vitamin D is integral to the regulation of calcium and phosphate levels. Put the following steps in the action of vitamin D into the correct sequence. Use all the options.

A) Vitamin D is present in the skin or intestine.

B) Vitamin D is concentrated in the liver.

C) Absorption of calcium from the intestine increases.

D) Vitamin D is transported to the kidneys.

E) Calcitriol is produced.

A, B, D, E, C

Feedback: Vitamin D is either synthesized in the skin by ultraviolet exposure or obtained from the intestines following ingestion. It is then concentrated in the liver and transported to the kidneys

A 52-year-old patient has just passed a kidney stone and has high levels of calcium in her urine. Blood tests show high levels of calcium in her blood as well. What subsequent lab results would be most likely to distinguish between primary hyperparathyroidism and hypercalcemia of malignancy?

A) Parathyroid hormone level

B) Bone scan

C) Plasma phosphate levels

D) Serum magnesium level

A

Feedback: Hyperparathyroidism, in which parathyroid hormone is secreted in excess, may be caused by a parathyroid adenoma. Since parathyroid hormone mobilizes calcium from bone and promotes its transfer to the extracellular fluid, excess calcium is excreted in the urine (promoting the development of kidney stones) and is evident in the plasma. In primary hyperparathyroidism, antibody binding assays of intact PTH would reveal either normal or elevated parathyroid hormone in the face of hypercalcemia, whereas in hypercalcemia of malignancy, levels of intact PTH are suppressed.

An 81-year-old female has a long-standing diagnosis of hypocalcemia secondary to kidney disease. She will be moving into an assisted living facility shortly. Which of the following clinical manifestations would the nursing staff at the facility likely observe in this patient?

A) Loss of appetite and complaints of nausea

B) Muscular spasms and complaints of tingling in the hands/feet

C) High fluid intake and copious amounts of dilute urine output

D) Lethargy and change in level of consciousness

B

Feedback: Muscular spasms and cramping are common manifestations of low serum calcium. Polydipsia, polyuria, anorexia, lethargy, and stupor are associated with hypercalcemia.

A terminally ill cancer patient with metastasis to the bone has been admitted with elevated calcium levels (hypercalcemic crisis). The patient is very lethargic and exhibiting muscle flaccidity. The nurse should be prepared to administer (Select all that apply.)

A) pamidronate, a bisphosphonate.

B) intravenous drip of insulin.

C) furosemide, a loop diuretic.

D) gallium nitrate, a gallium salt of nitric acid.

E) prednisone, a corticosteroid.

A, D, E

Feedback: The bisphosphonates (e.g.,pamidronate, zoledronate), which act mainly by inhibiting osteoclastic activity, provide a significant reduction in calcium levels with relatively few side effects. Calcitonin also inhibits osteoclastic activity. Gallium nitrate is highly effective in the treatment of severe hypercalcemia associated with malignancy. Prednisone, a corticosteroid, inhibits bone resorption.

A 56-year-old female hospital patient with a history of alcohol abuse is receiving intravenous (IV) phosphate replacement. Which of the following health problems will this IV therapy most likely resolve?

A) The client has an accumulation of fluid in her peritoneal cavity.

B) The client is acidotic and has impaired platelet function.

C) The client has an irregular heart rate and a thread pulse.

D) The client has abdominal spasms and hyperactive reflexes.

B

Feedback: Phosphate is necessary for the normal function of platelets and the excretion of hydrogen ions that contribute to acidosis. Phosphate replacement would be unlikely to resolve ascites and cardiac anomalies, while abdominal spasms and hyperactive reflexes are more likely consequences of low calcium levels.

A patient who has had a prolonged period of nasogastric (NG) suctioning following colon surgery is experiencing electrolyte imbalances. The magnesium level is low (1.2 mg/dL). Knowing that magnesium deficiency occurs in conjunction with low calcium levels, the nurse should assess the patient for which of the following clinical manifestations of hypocalcaemia? Select all that apply.

A) Personality changes

B) Hyperactive reflexes

C) Increase in ventricular arrhythmias

D) Increase in bouts of atrial fibrillation

E) Symptomatic hypotension

A, B, C

Feedback: Hypocalcaemia may be evidenced by personality changes and neuromuscular irritability along with tremors, choreiform movements, and positive Chvostek or Trousseau signs. Cardiovascular manifestations include tachycardia, hypertension, and ventricular dysrhythmias.

A nurse on a neurology unit is assessing a female brain-injured client. The client is unresponsive to speech, and her pupils are dilated and do not react to light. She is breathing regularly, but her respiratory rate is 45 breaths/minute. In response to a noxious stimulus, her arms and legs extend rigidly. What is her level of impairment?

A) Delirium

B) Coma

C) Brain death

D) Vegetative state

B

Feedback: The continuum of loss of consciousness is marked by the degree of client's responsiveness to stimuli, in addition to the preservation of brain stem reflexes. Since this client still exhibits a pain response (the extended arms and legs indicate decerebrate posturing), even though her pupils are not responsive to light, she has sustained sufficient brain function that she fails to qualify as being brain dead or in a vegetative state.

Following a motor vehicle accident 3 months prior, a 20-year-old female who has been in a coma since her accident has now had her condition declared a persistent vegetative state. How can her care providers most accurately explain an aspect of her situation to her parents?

A) “Your daughter has lost all her cognitive functions as well as all her basic reflexes.”

B) “Though she still goes through a cycle of sleeping and waking, her condition is unlikely to change.”

C) “If you or the care team notices any spontaneous eye opening, then we will change our treatment plan.”

D) “Your daughter's condition is an unfortunate combination with total loss of consciousness but continuation of all other normal brain functions.”

B

Feedback: A continuation of the sleep–wake cycle can exist in a persistent vegetative state. Reflexes often remain, as does spontaneous eye opening. Aspects of brain function beyond those governing consciousness are affected.

Which of the following individuals would most likely experience global ischemia to his or her brain?

A) A male client who has just had an ischemic stroke confirmed by CT of his head

B) A woman who has been admitted to the emergency department with a suspected intracranial bleed

C) A man who has entered cardiogenic shock following a severe myocardial infarction

D) A woman who is being brought to hospital by ambulance following suspected carbon monoxide poisoning related to a faulty portable heater

C

Feedback: Global ischemia is associated with a cessation of blood flow to the entire brain, as often occurs during cardiac arrest or myocardial infarction. Ischemic stroke and intracranial bleeding are likely to cause focal ischemia; carbon monoxide toxicity is associated with hypoxia.

Which of the following diagnostic findings is likely to result in the most serious brain insult?

A) Mean arterial pressure (MAP) that equals intracranial pressure (ICP)

B) Moderate decrease in brain tissue volume secondary to a brain tumor removal

C) Increased ICP accompanied by hyperventilation

D) High intracellular concentration of glutamate

A

Feedback: When the pressure in the cranial cavity approaches or exceeds the MAP, tissue perfusion becomes inadequate; cellular hypoxia results; and neuronal death may occur. Displacement of CSF and blood can partially compensate for decreased brain tissue volume. Hyperventilation partially mitigates, rather than exacerbates, increase in ICP. Glutamate is normally in far higher concentrations intracellularly than extracellularly.

Following a car accident of a male teenager who did not have his seatbelt on, he arrived in the emergency department with a traumatic brain injury. He has severe cerebral edema following emergent craniotomy. Throughout the night, the nurse has been monitoring and reporting changes in his assessment. Which of the following assessments correspond to a supratentorial herniation that has progressed to include midbrain involvement? Select all that apply.

A) Clouding of consciousness

B) Decorticate posturing with painful stimulation

C) Pupils fixed at approximately 5 mm in diameter

D) Respiration rate of 40 breaths/minute

E) Decerebrate posturing following painful stimulation of the sternum

C, D, E

Feedback: With midbrain involvement, pupils are fixed and midsized (5 mm in diameter), and reflex adduction of the eyes is impaired; pain elicits decerebrate posturing; and respirations change from Cheyne-Stokes respiration to neurogenic hyperventilation. Cloudiness of consciousness occurs in early diencephalic stages. Decorticate posturing with pain occurs in the diencephalic stage.

A patient in the intensive care unit who has a brain tumor has experienced a sharp decline. The care team suspects that water and protein have crossed the blood–brain barrier and been transferred from the vascular space into the client's interstitial space. Which of the following diagnoses best captures this pathophysiology?

A) Focal hypoxia

B) Cytotoxic edema

C) Hydrocephalus

D) Vasogenic edema

D

Feedback: Vasogenic edema occurs with conditions that impair the function of the blood–brain barrier and allow transfer of water and protein from the vascular into the interstitial space. It occurs in conditions such as tumors, prolonged ischemia, hemorrhage, brain injury, and infectious processes. Focal hypoxia is associated with localized delivery of blood with inadequate oxygen, and cytotoxic edema is an absolute increase in intracellular fluid. Hydrocephalus is an abnormal increase in CSF volume in any part or all of the ventricular system.

A baseball player was hit in the head with a bat during practice. In the emergency department, the physician tells the family that he has a “coup” injury. How will the nurse explain this to the family so they can understand?

A) “It's like squeezing an orange so tight that the juice runs out of the top.”

B) “Your son has a huge laceration inside his brain where the bat hit his skull.”

C) “Your son has a contusion of the brain at the site where the bat hit his head.”

D) “When the bat hit his head, his neck jerked backward causing injury to the spine.”

C

Feedback: A direct contusion of the brain at the site of external force is referred to as a coup injury. Contrecoup injury (answer choice D) is the rebound injury on the opposite side of the brain. Answer choice B relates to lacerations that are usually not caused by a direct blow to the head. However, depending on how hard the head was hit with a bat, a hematoma could form as the brain strikes the rough surface of the cranial vault.

Following an injury where a child hit his head from a fall, the CT scan reveals a contusion that the doctor classifies as a moderate brain injury. Which of the following manifestations will the nurse more than likely assess on this child that support this diagnosis? Select all that apply.

A) Coma with total paralysis

B) Periods of unconsciousness

C) Aphasia at times

D) Nuchal rigidity

E) Weakness or slight paralysis affecting one side of the body

B, C, E

Feedback: Moderate brain injury is characterized by a period of unconsciousness and may be associated with focal manifestations such as hemiparesis (weakness or slight paralysis affecting one side of the body), aphasia, and cranial nerve palsy. Coma with total paralysis is seen in severe brain injury. Nuchal rigidity is a classic sign of meningitis.

Following a collision while mountain biking, the diagnostic workup of a 22-year-old male has indicated the presence of an acute subdural hematoma. Which of the following pathophysiological processes most likely underlies his diagnosis?

A) Blood has accumulated between the man's dura and subarachnoid space.

B) Vessels have burst between the client's skull and his dura.

C) A traumatic lesion in the frontal or temporal lobe has resulted in increased ICP.

D) Blood has displaced CSF in the ventricles as a consequence of his coup–contrecoup injury.

A

Feedback: A subdural hematoma develops in the area between the dura and the arachnoid space, while epidural hematomas exist between the skull and dura. Intracerebral hematomas are located most often in the frontal or temporal lobe, and the ventricles are not directly involved in a subdural hematoma.

A 20-year-old has been admitted to a rehabilitation center after hospital treatment for an ischemic stroke. Which of the following aspects of the client's history would be considered to have contributed to his stroke? Select all that apply. The client

A) is an African American male.

B) takes iron supplements for the treatment of chronic anemia.

C) blood pressure has historically been in the range of 150s/90s.

D) was diagnosed with type 2 diabetes 8 years ago.

E) takes corticosteroids for the treatment of rheumatoid arthritis.

A, C, D

Feedback: African American race, male gender, hypertension, and diabetes are all well-documented risk factors for stroke. Anemia, autoimmune disorders like rheumatoid arthritis, and the use of corticosteroids are not noted to predispose to stroke.

A nurse at a long-term care facility provides care for an 85-year-old man who has had recent transient ischemic attacks (TIAs). Which of the following statements best identifies future complications associated with TIAs? TIAs

A) are an accumulation of small deficits that may eventually equal the effects of a full CVA.

B) are a relatively benign sign that necessitates monitoring but not treatment.

C) resolve rapidly but may place the client at an increased risk for stroke.

D) are caused by small bleeds that can be a warning sign of an impending stroke.

C

Feedback: TIAs can be considered a warning sign for future strokes. They are not hemorrhagic in nature, and their effects are not normally cumulative. They may require treatment medically or surgically.

Which of the following clients' signs and symptoms would allow a clinician to be most justified in ruling out stroke as a cause? An adult

A) has had a gradual onset of weakness, headache, and visual disturbances over the last 2 days.

B) has experienced a sudden loss of balance and slurred speech.

C) has vomited and complained of a severe headache.

D) states that his left arm and leg are numb, and gait is consequently unsteady.

A

Feedback: A cardinal trait of the manifestations of stroke is that the onset is sudden, and a gradual onset of symptoms over 2 days would suggest an alternative etiology. Ataxia, slurred speech, and unilateral numbness are associated with stroke, with sudden vomiting and headache being particularly indicative of a hemorrhagic CVA.

The nurse knows that which of the following treatment plans listed below is most likely to be prescribed after a computed tomography (CT) scan of the head reveals a new-onset aneurysmal subarachnoid hemorrhage?

A) Stat administration of tissue plasminogen activator (tPA)

B) Administration of a diuretic such as mannitol to reduce cerebral edema and ICP

C) Monitoring in the ICU for signs and symptoms of cerebral insult

D) Craniotomy and clipping of the affected vessel

D

Feedback: Surgery for treatment of aneurysmal subarachnoid hemorrhage involves craniotomy and inserting a specially designed silver clip that is tightened around the neck of the aneurysm. Administration of tPA would exacerbate bleeding, and a diuretic would not address the issue of bleeding. Monitoring alone would be an insufficient response given the severity of the problem.

A college student has been experiencing frequent headaches that he describes as throbbing and complaining of difficulty concentrating while studying. Upon cerebral angiography, he is found to have an arteriovenous malformation. Which of the following pathophysiological concepts is likely responsible for his symptoms?

A) Increased tissue perfusion at the site of the malformation

B) Hydrocephalus and protein in the cerebral spinal fluid

C) High pressure and local hemorrhage of the venous system

D) Localized ischemia with areas of necrosis noted on CT angiography

C

Feedback: In arteriovenous malformations, a tangle of arteries and veins acts as a bypass between the cerebral arterial and venous circulation, in place of the normal capillary bed. However, the capillaries are necessary to attenuate the high arterial blood pressure before this volume drains to the venous system. As a result, the venous channels experience high pressure, making them to hemorrhage and rupture more likely; the lack of perfusion of surrounding tissue causes neurologic deficits such as learning disorders. Headaches are severe, and people with the disorder may describe them as throbbing (synchronous with their heartbeat). Increased tissue perfusion means that more oxygenated blood is brought to the area, which is not the case. The elevated arterial and venous pressures divert blood away from the surrounding tissue, impairing tissue perfusion. Answer choice B is incorrect since arteriovenous malformation is associated with blood vessels and not the fluid within the ventricles of the brain. Answer choice D is incorrect in that there is blood flow to the area. Ischemia is associated with decreased arterial flow resulting in death to brain tissue.

A 9-year-old boy has been brought to the emergency department by his father who is concerned by his son's recent fever, stiff neck, pain, and nausea. Examination reveals a petechial rash. Which of the following assessment questions by the emergency room physician is most appropriate?

A) “Is your son currently taking any medications?”

B) “Has your son had any sinus or ear infections in the last little while?”

C) “Does your son have a history of cancer?”

D) “Was your son born with any problems that affect his bone marrow or blood?”

B

Feedback: The most common symptoms of acute bacterial meningitis are fever and chills; headache; stiff neck; back, abdominal, and extremity pains; and nausea and vomiting. Risk factors associated with contracting meningitis include otitis media and sinusitis or mastoiditis. Particular medications, a history of neoplasm, and hematopoietic problems would be unlikely to relate directly to his symptoms of meningitis.

A teenager, exposed to West Nile virus a few weeks ago while camping with friends, is admitted with headache, fever, and nuchal rigidity. The teenager is also displaying some lethargy and disorientation. The nurse knows which of the following medical diagnoses listed below may be associated with these clinical manifestations?

A) Rocky Mountain spotted fever

B) Lyme disease

C) Encephalitis

D) Spinal infection

C

Feedback: Encephalitis represents a generalized infection of the parenchyma of the brain or spinal cord. A virus, such as West Nile virus, usually causes encephalitis although it may be caused by bacteria, fungi, and other organisms. Encephalitis is characterized by fever, headache, and nuchal rigidity. However, more often, people also experience neurologic disturbances, such as lethargy, disorientation, seizures, focal paralysis, delirium, and coma. Rocky Mountain spotted fever (answer choice A) is a tick-borne disease caused by the bacterium Rickettsia rickettsii and usually begins with a sudden onset of fever and headache. A rash may occur 2 to 5 days after fever onset. Lyme disease (answer choice B) is also a tick-borne disease. Typical symptoms include fever, headache, fatigue, and a characteristic skin rash called erythema migrans. As the disease progresses, the patient develops bouts of severe joint pain and swelling of the joint. Neurological problems may occur for weeks, months, or even years after the infection and may include inflammation of the membranes surrounding the brain (meningitis). Spinal infections (answer choice D) can be thought of as a spectrum of diseases comprising spondylitis, discitis, spondylodiscitis, pyogenic facet arthropathy, and meningitis.

A 20-year-old has been diagnosed with an astrocytic brain tumor located in the brain stem. Which of the following statements by the oncologist treating the client is most accurate?

A) “Your prognosis will depend on whether we can surgically resect your tumor.”

B) “Our treatment plan will depend on whether your tumor is malignant or benign.”

C) “This is likely a result of a combination of heredity and lifestyle.”

D) “The major risk that you face is metastases to your lungs, liver, or bones.”

A

Feedback: The prognosis of people with pilocytic astrocytomas is influenced primarily by their location. The prognosis is usually better for people with surgically resectable tumors, such as those located in the cerebellar cortex, than for people with less accessible tumors, such as those involving the hypothalamus or brain stem. Because of infiltration of brain tissue that prevents total resection, surgery rarely cures brain tumors. The binary of malignant and benign is not used to characterize brain tumors, and the etiology and substantive risk factors are largely unknown. Brain tumors rarely metastasize outside the CNS.

A brain tumor causing clinical manifestations of headache, nausea, projectile vomiting, and mental changes is likely located in which parts of the brain? Select all that apply.

A) Intra-axially

B) Extra-axially

C) Brain stem

D) Temporal lobe

E) Frontal lobe

A, B, E

Feedback: Tumors within the intracranial (intra-axially) cavity are fixed and cause s/s of increased ICP like headache, nausea, vomiting, mental changes, papilledema, visual disturbances, and alterations in sensory and motor function. Outside the brain tissue (extra-axially), but within the cranium, tumors may reach large sizes without producing s/s. After they reach a sufficient size, s/s of increased ICP appear. Temporal lobe tumors often produce seizures as their first symptom. Brain stem tumors commonly produce upper/lower motor neuron s/s such as weakness of facial muscles and ocular palsies. Frontal lobe tumors also grow to a large size and cause s/s of increased ICP.