A client has experienced a pontine stroke which has resulted in severe hemiparesis. What priority assessment should the nurse perform prior to allowing the client to eat or drink from the food tray?

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Pathophysiology Exam 1 Quizlet Questions

Question 1 of 5

A client has experienced a pontine stroke which has resulted in severe hemiparesis. What priority assessment should the nurse perform prior to allowing the client to eat or drink from the food tray?

Correct Answer: A

Rationale: The correct answer is to evaluate the client's gag reflex. When a client has experienced a stroke resulting in severe hemiparesis, assessing the gag reflex is crucial before allowing them to eat or drink. This assessment helps prevent aspiration, a serious complication that can occur due to impaired swallowing ability. Assessing bowel sounds (Choice B), pupil reaction (Choice C), or heart rate (Choice D) are important assessments but are not the priority in this situation where the risk of aspiration is higher.

Question 2 of 5

During an assessment of a male client suspected of having a disorder of motor function, which finding would suggest a possible upper motor neuron (UMN) lesion?

Correct Answer: B

Rationale: Hyperreflexia, or exaggerated reflexes, is a common sign of an upper motor neuron (UMN) lesion. An UMN lesion indicates damage to the central nervous system pathways that control movement. Hypotonia (choice A) refers to reduced muscle tone, which is more indicative of lower motor neuron lesions. Muscle atrophy (choice C) suggests long-standing denervation or disuse of muscles. Fasciculations (choice D) are involuntary muscle contractions that can be seen in lower motor neuron lesions, like in amyotrophic lateral sclerosis (ALS), rather than UMN lesions.

Question 3 of 5

A patient underwent an open cholecystectomy 4 days ago, and her incision is now in the proliferative phase of healing. The nurse knows that the next step in the process of wound healing is:

Correct Answer: C

Rationale: In the context of wound healing, after the proliferative phase comes the remodeling phase. During the remodeling phase, the wound gains strength as collagen fibers reorganize, and the scar matures. Inflammation is the initial phase of healing, where the body responds to injury with redness, swelling, and warmth. Maturation is the final stage where the scar tissue continues to undergo changes but is not the immediate next step after the proliferative phase. Coagulation is the process of blood clot formation and is not a phase in wound healing.

Question 4 of 5

An experiment is designed to determine specific cell types involved in cell-mediated immune response. The experimenter is interested in finding cells that attack cells that have specific antigens. Which cells should be isolated?

Correct Answer: B

Rationale: Cytotoxic T cells are the key players in cell-mediated immunity as they directly attack cells displaying specific antigens. Lymphokine-producing cells (Choice A) are involved in cytokine production, while Helper T cells (Choice C) assist in activating other immune cells. Macrophages (Choice D) are phagocytic cells that engulf and digest pathogens, but they are not the primary cells responsible for directly attacking cells with specific antigens in cell-mediated immunity.

Question 5 of 5

What is the expected outcome of administering a granulocyte colony-stimulating factor (G-CSF)?

Correct Answer: B

Rationale: The correct answer is B: Decreased number of infections. Granulocyte colony-stimulating factor (G-CSF) is a medication used to stimulate the production of white blood cells, specifically granulocytes, in the body. By increasing the number of white blood cells, G-CSF helps in boosting the immune system, leading to a decreased number of infections. Choice A is incorrect as G-CSF does not cause a reduction in red blood cell count. Choice C is incorrect as G-CSF primarily affects white blood cells and is not directly related to fatigue or energy levels. Choice D is incorrect as G-CSF does increase the white blood cell count but does not usually elevate it to 20,000 mm3.

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