NU 160 Final Spring 2025

Correct Answers:

A. Pregnancy

B. Obesity

 C.Atrial fibrillation

Explanation:

 Pulmonary embolism (PE) occurs when a blood clot travels to the lungs, often originating in the deep veins of the legs. Risk factors include anything that promotes blood stasis, vessel injury, or hypercoagulability. Pregnancy increases clotting factors and pressure on veins, obesity contributes to decreased mobility and vascular strain, and atrial fibrillation can lead to thrombus formation in the heart that can embolize to the lungs.

Why Other Options are Wrong:

D. Marathon running:

 Although strenuous exercise has risks, marathon running improves circulation and cardiovascular health, lowering the risk for venous thromboembolism. It is not a risk factor for PE.

E. Young age:

 Youth is generally a protective factor. Older adults, especially those with comorbidities or reduced mobility, are at greater risk for PE. Young individuals without other risk factors rarely develop PE.

Correct Answer C: Monitor for any changes in the color of your stool such as dark or black-colored stool.

Explanation:

 Dark or black-colored stools, also known as melena, can be a sign of gastrointestinal bleeding, which is a common complication of peptic ulcers. The blood from the ulcer can travel through the gastrointestinal tract and appear black or tarry when excreted in the stool. It is important for the nurse to instruct the client to monitor for these signs as they may require prompt medical attention to prevent further complications.

Why "C" is correct:

 C. "Monitor for any changes in the color of your stool such as dark or black-colored stool."

 This instruction is crucial because black or tarry stools indicate the presence of digested blood, which could be a sign of active bleeding from the ulcer. Early identification of this symptom can help prevent more severe complications, such as hypovolemic shock or the need for blood transfusions.

Why the Other Options Are Incorrect:

A. Monitor for any increase or unintentional weight gain.

 Weight gain is not typically associated with peptic ulcers, and it is not a common symptom to monitor in this context. In fact, weight loss might occur in severe cases due to difficulty eating or nausea. Therefore, weight gain is not a relevant symptom for monitoring in clients with peptic ulcers.

B. Monitor for the appearance of ecchymosis on the sides of your abdomen/pelvic areas.

 Ecchymosis (bruising) is not a typical sign of a peptic ulcer. While bleeding from an ulcer may occur, it typically presents with symptoms like dark stools, abdominal pain, and vomiting blood. Ecchymosis may be a sign of other medical conditions or trauma, but it is not directly related to peptic ulcers.

D. Monitor for any changes in the color of your urine such as maroon or red-colored urine.

 Red or maroon-colored urine may suggest urinary tract issues, such as a urinary tract infection, kidney stones, or hematuria. This is not directly related to peptic ulcers. The focus for the client with a peptic ulcer should be on signs of gastrointestinal bleeding, such as black or tarry stools, rather than changes in urine color.

Correct Answer A: Mental status changes

Explanation:

 Mental status changes, such as confusion or decreased alertness, are a hallmark of severe DKA due to the effects of hyperglycemia and metabolic acidosis on the brain. Elevated ketone levels and dehydration can lead to cerebral edema and altered consciousness. This is a critical finding that suggests worsening DKA and requires urgent intervention.

Why Other Options are Wrong:

B. Dizziness:

 While dizziness may occur in many conditions, it is non-specific and not one of the key diagnostic signs of DKA. It may be present in dehydration, but mental status changes take clinical priority and are more definitive in DKA assessment.

C. Nervousness:

 This symptom is more commonly associated with hypoglycemia, not DKA. Clients with low blood sugar often feel jittery or anxious, which contrasts with the mental dulling or confusion of hyperglycemic crises like DKA.

D. Cool, clammy skin:

 This is a sign of hypoglycemia, not hyperglycemia. DKA is more often associated with dry, warm skin due to dehydration. Cool and clammy skin would not be expected in this hyperglycemic state.

Correct Answer C: Light blue colored eyes

Explanation:

Individuals with light-colored eyes, such as blue or gray, are at higher risk for age-related macular degeneration (AMD). Lighter eyes have less melanin, which may provide less natural protection from UV and blue light damage to the retina and macula.

Why Other Options are Wrong:

A. Overexposure to UV light

 While UV exposure may play a role in general eye health issues, its link to AMD is less direct compared to genetic and pigmentation factors. Protective eyewear is still advised, but this is not the primary risk factor.

B. Exposure to environmental toxins

 This is more commonly associated with cancer or systemic illness and has not been clearly linked as a direct cause of AMD.

D. Previous traumatic eye injury

 Trauma can cause other conditions such as retinal detachment or cataracts, but not AMD, which is a progressive and age-related retinal condition.

Correct Answer B: A client who does not get much sleep

Explanation:

Chronic sleep deprivation has been shown to significantly impair glucose metabolism and insulin sensitivity, which are key contributors to the development of type 2 diabetes. Lack of sleep leads to increased cortisol levels, insulin resistance, and weight gain—all risk factors for type 2 diabetes.

Why Other Options are Wrong:

A. A client who has an autoimmune disorder:

 Autoimmune disorders are more commonly associated with type 1 diabetes mellitus, not type 2. Type 1 diabetes involves autoimmune destruction of pancreatic beta cells, while type 2 is linked to insulin resistance.

C. A 40-year-old client with hypoglycemia:

 Hypoglycemia is a symptom, not a risk factor for diabetes. In fact, individuals with frequent hypoglycemia are often treated for other endocrine or metabolic issues—not considered at high risk for developing type 2 diabetes.

D. A 26-year-old female client who has never given birth:

 Being nulliparous (never having given birth) does not correlate with increased risk for type 2 diabetes. Gestational diabetes during pregnancy increases risk, but not having been pregnant is not itself a risk factor.

Correct Answer D: A hiatal hernia might increase your risk for GERD.

Explanation:

 A hiatal hernia occurs when a portion of the stomach protrudes through the diaphragm into the chest cavity. This displacement can weaken the lower esophageal sphincter, allowing stomach acid to move up into the esophagus. This significantly increases the risk of gastroesophageal reflux disease (GERD), which is the most common complication associated with hiatal hernias.

Why Other Options are Wrong:

A. A hiatal hernia might increase your risk for stomach cancer.

 There is no direct link between hiatal hernias and stomach cancer. While GERD can increase the risk of esophageal changes like Barrett's esophagus, this is not the same as stomach cancer.

B. A hiatal hernia might increase your risk for intestinal cancer.

 Hiatal hernias do not affect the intestines. They are specifically related to the upper gastrointestinal tract, particularly the stomach and esophagus, not the small or large intestine.

C. A hiatal hernia might increase your risk for lung disease.

 While large hiatal hernias can cause respiratory symptoms like shortness of breath, especially when the stomach pushes against the lungs, this is not the same as increasing the risk of lung disease. There is no established correlation between hiatal hernias and chronic lung conditions.

Correct Answer A: Shortness of breath

Explanation:

 Thoracic spine osteoporosis can lead to vertebral compression fractures, resulting in kyphosis (forward curvature of the upper spine). Severe kyphosis can impair lung expansion, leading to restrictive breathing patterns and shortness of breath—especially in older adults with reduced pulmonary reserve.

Why Other Options are Wrong:

B. Chronic pain:

 While chronic back pain is a symptom of osteoporosis, shortness of breath is more directly linked to thoracic spine involvement, which compromises respiratory mechanics.

C. Limited range of motion in arms:

 This is not a typical symptom of thoracic osteoporosis. It might occur in shoulder injuries or neurological conditions but not directly from spinal bone loss.

D. Stiff joints, especially first thing in the morning:

 This is more typical of rheumatoid arthritis or other inflammatory joint disorders, not osteoporosis. Osteoporosis is often painless until a fracture occurs.

Correct Answer D: Encourage the client to sit in the chair for all meals.

Explanation:

 Sitting in a chair promotes mobility, improves circulation, helps prevent pressure injuries, enhances digestion, and supports respiratory function. Encouraging clients to be out of bed for meals is a proactive nursing intervention that helps counteract the effects of immobility, such as muscle atrophy, constipation, and pulmonary complications.

Why Other Options are Wrong:

A. Have the client remain in bed for self-care activities:

This promotes immobility, which is the opposite of the intended goal. It increases the risk of complications such as pressure ulcers, thromboembolism, constipation, and deconditioning. The goal is to promote movement and independence when possible.

B. Elevate the head of the bed to 30° to 45° for medication administration:

While this is a good practice for preventing aspiration during medication administration, it does not significantly impact overall immobility-related risks like skin breakdown or muscle atrophy. It's a single-task intervention, not a holistic mobility strategy.

C. Instruct the client to wear a hospital gown every day, even when out of bed:

This action has no effect on preventing complications of immobility. It is related more to hospital routine or hygiene than to clinical outcomes. What matters is the client’s mobility and physical activity, not their attire.

Correct Answers:

A. Surgical intervention for fistulas

B. Biologic medications

C. Immunosuppressants

D. Anti-inflammatory medications

Explanation:

 Crohn’s disease is a chronic inflammatory bowel disease that can affect any part of the GI tract. Treatment focuses on reducing inflammation, managing symptoms, and preventing complications.

A. Surgical intervention for fistulas: Fistulas are a common complication of Crohn’s and may require surgical correction.

B. Biologic medications: TNF inhibitors (e.g., infliximab) are used to reduce inflammation and induce remission.

C. Immunosuppressants: Medications such as azathioprine help reduce immune system activity.

D. Anti-inflammatory medications: Agents like mesalamine are used to reduce inflammation in the intestines.

Why Other Options are Wrong:

E. High-fiber diet:

 Not typically recommended during active flares, as it can irritate the bowel. A low-residue diet is often preferred during exacerbations.

F. Antidepressants:

 Not a primary treatment for Crohn’s. While they may help with psychological symptoms, they are not part of the standard therapeutic regimen.