a client has experienced a pontine stroke which has resulted in severe hemiparesis what priority assessment should the nurse perform prior to allowing

ATI RN

Pathophysiology Exam 1 Quizlet

1. 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?

A. Evaluate the client's gag reflex.
B. Assess the client's bowel sounds.
C. Check the client's pupil reaction.
D. Monitor the client's heart rate.

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.

2. Which immunoglobulin is the first to appear in response to a new antigen?

A. IgA
B. IgG
C. IgE
D. IgM

Correct answer: D

Rationale: The correct answer is IgM. IgM is the first immunoglobulin to appear in response to a new antigen. It is produced initially during the primary immune response. IgA is mainly found in mucosal areas and secretions. IgG is produced in a secondary immune response and is the most abundant immunoglobulin in the bloodstream. IgE is involved in allergic reactions and parasitic infections, not the initial response to a new antigen.

3. What causes hepatic encephalopathy?

A. A brain infection
B. Increased ammonia levels in the bloodstream
C. Decreased albumin blood levels
D. Untreated chronic bronchitis

Correct answer: B

Rationale: Hepatic encephalopathy is caused by increased ammonia levels in the bloodstream. Ammonia, a byproduct of protein metabolism normally processed by the liver, accumulates in the bloodstream when the liver is unable to function properly. This excess ammonia affects brain function, leading to symptoms of hepatic encephalopathy. Choices A, C, and D are incorrect because they do not directly relate to the pathophysiology of hepatic encephalopathy.

4. What is the main function of the mitochondria in a cell?

A. To produce energy in the form of ATP
B. To synthesize proteins
C. To store genetic information
D. To regulate cell growth

Correct answer: A

Rationale: The correct answer is A: To produce energy in the form of ATP. Mitochondria are known as the powerhouse of the cell because they are responsible for producing energy in the form of ATP through a process called cellular respiration. This energy is essential for various cellular activities. Choice B is incorrect because protein synthesis primarily occurs in the ribosomes. Choice C is incorrect as the genetic information is stored in the cell's nucleus. Choice D is incorrect as the regulation of cell growth involves various other organelles and processes within the cell.

5. A patient with a history of cardiovascular disease is prescribed hormone replacement therapy (HRT). What should the nurse emphasize regarding the long-term risks associated with HRT?

A. HRT is associated with an increased risk of cardiovascular events, including heart attack and stroke.
B. HRT may decrease the risk of osteoporosis.
C. HRT may improve mood and energy levels.
D. HRT may increase the risk of breast cancer.

Correct answer: A

Rationale: HRT is associated with an increased risk of cardiovascular events, including heart attack and stroke, particularly in patients with a history of cardiovascular disease.