The nurse is caring for a client who experienced multiple invasive trauma from a motor vehicle collision and has developed systemic inflammatory response syndrome (SIRS). Which pathophysiological process is most likely associated with the development of SIRS in this client?

Multiple organ dysfunction.

Acute kidney injury.

Intestinal obstruction.

Sepsis.

Answer and Explanation

The Correct Answer is A

A) Multiple organ dysfunction:

Correct. Systemic inflammatory response syndrome (SIRS) is a widespread inflammatory response to a variety of severe clinical insults, including trauma, infection, burns, or other sources of tissue injury. In the context of trauma from a motor vehicle collision, the body may mount a systemic inflammatory response involving multiple organ systems. This can progress to multiple organ dysfunction syndrome (MODS), where there is progressive dysfunction of two or more organ systems.

B) Acute kidney injury:

Acute kidney injury (AKI) can certainly occur in the context of severe trauma and systemic inflammation, such as in SIRS. However, AKI is a specific manifestation rather than the overarching pathophysiological process associated with the development of SIRS.

C) Intestinal obstruction:

Intestinal obstruction is a mechanical obstruction of the intestines and is not typically associated with the development of SIRS unless there is associated ischemia or perforation leading to systemic inflammation.

D) Sepsis:

Sepsis is a severe infection that has spread throughout the body and triggers a systemic inflammatory response. While sepsis can lead to SIRS, it is not the only cause. In this scenario, trauma from a motor vehicle collision is the primary cause of the systemic inflammatory response, rather than infection.

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Correct Answer is A

Explanation

A) Flank pain and profound hypotension:

Correct. Flank pain, often described as a deep, constant, gnawing, or throbbing sensation in the abdomen or back, can be a sign of impending rupture or dissection of an abdominal aortic aneurysm (AAA). Profound hypotension may occur if the AAA ruptures, leading to massive internal bleeding and shock. Prompt recognition of these signs is crucial for early intervention and surgical repair to prevent catastrophic consequences.

B) Acute shortness of breath and chest pain:

Acute shortness of breath and chest pain are more indicative of cardiovascular or pulmonary conditions such as myocardial infarction, pulmonary embolism, or acute coronary syndrome rather than an abdominal aortic aneurysm. While aortic dissection can present with chest pain, it is typically described as severe, tearing, or ripping pain that radiates to the back, not as acute shortness of breath.

C) Absent pedal pulses and darkened toes:

Absent pedal pulses and darkened toes may indicate peripheral vascular disease or critical limb ischemia but are not specific signs of an abdominal aortic aneurysm. While AAA can lead to peripheral ischemia in advanced cases, it is not typically associated with acute changes in pedal pulses or toe discoloration.

D) Tea-colored urine and decreased output:

Tea-colored urine and decreased urine output may indicate acute kidney injury or rhabdomyolysis but are not specific signs of an abdominal aortic aneurysm. While a ruptured AAA can lead to renal ischemia and acute kidney injury due to hypoperfusion, these symptoms are not the primary manifestations of AAA

A. Presbycusis. B. Conductive. C. Endolymphatic. D. Sensorineural.

Correct Answer is B

Explanation

Otosclerosis is a condition characterized by abnormal bone growth in the middle ear, specifically involving the stapes bone. This abnormal bone growth interferes with the transmission of sound vibrations from the middle ear to the inner ear, resulting in conductive hearing loss. Here's a breakdown of each option:

A) Presbycusis:

Presbycusis refers to age-related hearing loss, typically involving sensorineural components such as the degeneration of hair cells in the inner ear or changes in the auditory nerve. While presbycusis is a common cause of hearing loss in older adults, it is not directly related to otosclerosis or previous ear surgeries.

B) Conductive:

Correct. Otosclerosis primarily affects the middle ear by causing abnormal bone growth around the stapes bone, which can immobilize it and interfere with sound transmission to the inner ear. As a result, individuals with otosclerosis often experience conductive hearing loss, where sound is not effectively conducted from the outer or middle ear to the inner ear.

C) Endolymphatic:

Endolymphatic hydrops, also known as Ménière's disease, involves abnormal fluid accumulation in the inner ear, leading to symptoms such as vertigo, tinnitus, and fluctuating sensorineural hearing loss. While inner ear disorders like endolymphatic hydrops can cause sensorineural hearing loss, otosclerosis primarily affects the conductive components of hearing.

D) Sensorineural:

Sensorineural hearing loss occurs due to dysfunction or damage to the inner ear (cochlea) or auditory nerve pathways leading to the brain. This type of hearing loss is typically permanent and can result from various factors, including age-related changes, noise exposure, and certain medical conditions. While sensorineural hearing loss can coexist with conductive hearing loss in some cases, otosclerosis primarily causes conductive hearing loss rather than sensorineural hearing loss.

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The nurse is caring for a client who experienced multiple invasive trauma from a motor vehicle collision and has developed systemic inflammatory response syndrome (SIRS). Which pathophysiological process is most likely associated with the development of SIRS in this client?

Nursing Test Bank

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When planning care for a client who is diagnosed with a large abdominal aortic aneurysm (AAA), the nurse should carefully monitor for which signs and symptoms?

Correct Answer is A

Explanation

The nurse is providing care for a client with a diagnosis of otosclerosis due to previous ear surgeries. Which type of pathological hearing loss supports the client's clinical history?

Correct Answer is B

Explanation

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