TEST BANK for Pathophysiology Concepts Of Human Disease 1st Edition by Matthew Sorenson, Quinn, Dian by ACADEMIAMILL

Pathophysiology Concepts Of Human Disease 1st Edition Sorenson Test Bank Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 1 Introduction to the Basics of Pathophysiology 1) Which pathophysiological concept should the nurse consider when developing a plan of care for a patient with myocardial ischemia? A) There is a decrease in the amount of oxygen and glucose reaching the myocardium. B) There is a lack of oxygen reaching the myocardium, but the supply of glucose is adequate. C) There is a lack of glucose reaching the myocardium, but the supply of oxygen is adequate. D) There is a complete lack of both oxygen and glucose reaching the myocardium. Answer: A Explanation: A) A decrease in blood flow to the myocardium means that there is a decrease in the amount of oxygen and glucose to the heart muscle. A related term is hypoxia, which refers to a lack of oxygen to tissue. This can occur from disruptions of the respiratory system. B) A decrease in blood flow to the myocardium means that there is a decrease in the amount of oxygen and glucose to the heart muscle. A related term is hypoxia, which refers to a lack of oxygen to tissue. This can occur from disruptions of the respiratory system. C) A decrease in blood flow to the myocardium means that there is a decrease in the amount of oxygen and glucose to the heart muscle. A related term is hypoxia, which refers to a lack of oxygen to tissue. This can occur from disruptions of the respiratory system. D) A decrease in blood flow to the myocardium means that there is a decrease in the amount of oxygen and glucose to the heart muscle. A related term is hypoxia, which refers to a lack of oxygen to tissue. This can occur from disruptions of the respiratory system. Page Ref: 7 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 1.1 Define the conceptual basis for and the language used in the study of pathophysiology. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Recognize the conceptual basis for and the language used in the study of pathophysiology.

2) The nurse is assessing a patient's risk factors for disease at an annual physical examination. Which question would the nurse ask to assess lifestyle risk factors? A) "Does your neighborhood have parks and sidewalks?" B) "Tell me about the health of your parents." C) "What is the highest level of education that you completed?" D) "How would you describe your diet?" Answer: D Explanation: A) Risk factors emerge from a number of sources. One is the genetic blueprint provided to each of us at birth, and another is lifestyle factors. Lifestyle factors reflect decisions about diet, exercise, smoking, and other variables that influence health. Social determinants of health are factors related to where one lives, educational level, income, availability of fresh food, public transportation, and a number of other considerations that can affect health. B) Risk factors emerge from a number of sources. One is the genetic blueprint provided to each of us at birth, and another is lifestyle factors. Lifestyle factors reflect decisions about diet, exercise, smoking, and other variables that influence health. Social determinants of health are factors related to where one lives, educational level, income, availability of fresh food, public transportation, and a number of other considerations that can affect health. C) Risk factors emerge from a number of sources. One is the genetic blueprint provided to each of us at birth, and another is lifestyle factors. Lifestyle factors reflect decisions about diet, exercise, smoking, and other variables that influence health. Social determinants of health are factors related to where one lives, educational level, income, availability of fresh food, public transportation, and a number of other considerations that can affect health. D) Risk factors emerge from a number of sources. One is the genetic blueprint provided to each of us at birth, and another is lifestyle factors. Lifestyle factors reflect decisions about diet, exercise, smoking, and other variables that influence health. Social determinants of health are factors related to where one lives, educational level, income, availability of fresh food, public transportation, and a number of other considerations that can affect health. Page Ref: 9 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 1.2 Describe characteristics of and risk factors associated with health and illness. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Consider the characteristics of and risk factors associated with health and illness.

3) The occupational health nurse is assessing a manufacturing plant for chemical agents that may cause disease in the employees. The nurse should be alert for: A) stress levels. B) helminths. C) radiation. D) lead. Answer: D Explanation: A) Endogenous disease etiologies arise from within the body. Examples are abnormal immune reactions, gene mutations, coagulation defects, stress, and metabolic abnormalities. B) Etiologic agents may be exogenous, that is, arising from the external environment, such as chemical, physical, and infectious agents. Examples of infectious etiologic agents are bacteria, viruses, fungi, and helminths. C) Etiologic agents may be exogenous, that is, arising from the external environment, such as chemical, physical, and infectious agents. Examples of physical etiologic agents are extremes in environmental temperatures, radiation, trauma, and electricity. D) Etiologic agents may be exogenous, that is, arising from the external environment, such as chemical, physical, and infectious agents. Examples of chemical etiologic agents are alcohol, lead, mercury, air pollutants, carbon monoxide, pesticides, and adverse effects of medications. Page Ref: 10 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 1.3 Outline the structure of this program, including the pathogenesis and etiology of disease; the clinical manifestations of disorders; how pathophysiology is linked to diagnosis and treatment; and the impact of genetics, nutrition, and lifespan on health and illness. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Consider the characteristics of and risk factors associated with health and illness.

4) A patient has been diagnosed with idiopathic pulmonary fibrosis. The nurse explains to the patient that idiopathic means: A) the disease is inherited. B) the cause is unknown. C) it was caused by an error in care. D) the disease is secondary to another illness. Answer: B Explanation: A) A disease that is inherited is a genetic or hereditary disorder. B) When the cause of a disease cannot be determined, its etiology is said to be idiopathic. C) The etiology of conditions that are caused unintentionally by a treatment, a diagnostic procedure, or an error caused by a healthcare provider are called iatrogenic. D) A condition that is caused by another disease is called a secondary disorder. Page Ref: 10 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 1.3 Outline the structure of this program, including the pathogenesis and etiology of disease; the clinical manifestations of disorders; how pathophysiology is linked to diagnosis and treatment; and the impact of genetics, nutrition, and lifespan on health and illness. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate how the key factors and basic principles that inform pathophysiology impact health and illness.

5) The nurse is documenting the assessment findings from a patient being seen in the clinic. Which of the following does the nurse document as a subjective finding? A) Nausea B) Breath sounds C) Fever D) Skin color Answer: A Explanation: A) A symptom is a subjective sensation that is perceived by the affected individual but not observable by the person examining the individual. Examples of symptoms include pain, nausea, dyspnea, and numbness. A sign is an objective indication of disease that is observable by the person conducting a physical assessment. Examples of signs include abnormal heart or lung sounds, rash, fever, a change in the respiratory or heart rate, sluggish or absent pupil reaction to light, and changes in skin color. B) A symptom is a subjective sensation that is perceived by the affected individual but not observable by the person examining the individual. Examples of symptoms include pain, nausea, dyspnea, and numbness. A sign is an objective indication of disease that is observable by the person conducting a physical assessment. Examples of signs include abnormal heart or lung sounds, rash, fever, a change in the respiratory or heart rate, sluggish or absent pupil reaction to light, and changes in skin color. C) A symptom is a subjective sensation that is perceived by the affected individual but not observable by the person examining the individual. Examples of symptoms include pain, nausea, dyspnea, and numbness. A sign is an objective indication of disease that is observable by the person conducting a physical assessment. Examples of signs include abnormal heart or lung sounds, rash, fever, a change in the respiratory or heart rate, sluggish or absent pupil reaction to light, and changes in skin color. D) A symptom is a subjective sensation that is perceived by the affected individual but not observable by the person examining the individual. Examples of symptoms include pain, nausea, dyspnea, and numbness. A sign is an objective indication of disease that is observable by the person conducting a physical assessment. Examples of signs include abnormal heart or lung sounds, rash, fever, a change in the respiratory or heart rate, sluggish or absent pupil reaction to light, and changes in skin color. Page Ref: 10 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 1.3 Outline the structure of this program, including the pathogenesis and etiology of disease; the clinical manifestations of disorders; how pathophysiology is linked to diagnosis and treatment; and the impact of genetics, nutrition, and lifespan on health and illness. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Recognize the conceptual basis for and the language used in the study of pathophysiology. 5

6) How should the nurse respond when a patient asks the difference between acute and chronic hip pain? A) "An acute illness develops over a longer period of time than a chronic one." B) "A chronic illness is more serious than an acute illness." C) "A chronic illness is enduring while an acute illness is short term." D) "A chronic illness is life threatening while an acute illness is not." Answer: C Explanation: A) An acute injury or disease is one that appears quickly; a chronic condition has an enduring quality with lasting implications. An important point is that neither of these terms relates to severity or degree of injury or disease. For example, when an individual sprains an ankle, an acute injury, the injury is sudden but might not have significant lasting implications. In contrast, with a chronic disease, there are several states that may be enduring and lasting (such as a mild case of osteoarthritis) but without significant impairment of functional ability. B) An acute injury or disease is one that appears quickly; a chronic condition has an enduring quality with lasting implications. An important point is that neither of these terms relates to severity or degree of injury or disease. For example, when an individual sprains an ankle, an acute injury, the injury is sudden but might not have significant lasting implications. In contrast, with a chronic disease, there are several states that may be enduring and lasting (such as a mild case of osteoarthritis) but without significant impairment of functional ability. C) An acute injury or disease is one that appears quickly; a chronic condition has an enduring quality with lasting implications. An important point is that neither of these terms relates to severity or degree of injury or disease. For example, when an individual sprains an ankle, an acute injury, the injury is sudden but might not have significant lasting implications. In contrast, with a chronic disease, there are several states that may be enduring and lasting (such as a mild case of osteoarthritis) but without significant impairment of functional ability. D) An acute injury or disease is one that appears quickly; a chronic condition has an enduring quality with lasting implications. An important point is that neither of these terms relates to severity or degree of injury or disease. For example, when an individual sprains an ankle, an acute injury, the injury is sudden but might not have significant lasting implications. In contrast, with a chronic disease, there are several states that may be enduring and lasting (such as a mild case of osteoarthritis) but without significant impairment of functional ability. Page Ref: 11 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 1.3 Outline the structure of this program, including the pathogenesis and etiology of disease; the clinical manifestations of disorders; how pathophysiology is linked to diagnosis and treatment; and the impact of genetics, nutrition, and lifespan on health and illness. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Recognize the conceptual basis for and the language used in the study of pathophysiology. 6

7) A nurse researcher involved in epigenomics is studying: A) the role of specific genes. B) the function of groups of genes in mediating physiologic function. C) genetic variations and modifications that influence a particular cell. D) the origin of the structural and functional events leading to disease. Answer: C Explanation: A) Through genetics, the role of specific genes is studied. This study involves examining how genetic variations are passed through familial inheritance. B) Genomics refers to the study of the function of groups of genes in terms of mediating physiologic function. Genomics studies how an inherited genetic trait, such as sickle cell trait, influences the likelihood that an individual will develop sickle cell disease. C) The study of all genetic variations or modifications that have influenced a particular cell is referred to as epigenomics. The focus is on the broader picture in terms of studying a complete set of modifications to cellular DNA. D) The pathogenesis of a disease refers to origin of, or the underlying mechanisms responsible for, the clinical manifestations of that disease. Pathogenesis is the origin of the sequence of events to structural and/or functional alterations in cells, tissues, or organs resulting in disease. Page Ref: 10-11 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 1.3 Outline the structure of this program, including the pathogenesis and etiology of disease; the clinical manifestations of disorders; how pathophysiology is linked to diagnosis and treatment; and the impact of genetics, nutrition, and lifespan on health and illness. | QSEN Competencies: III.B. 1 Participate effectively in appropriate data collection and other research activities | AACN Essential Competencies: III. 2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Recognize the conceptual basis for and the language used in the study of pathophysiology.

8) When planning a program to educate the community about healthy nutrition, the community health nurse should tell adults to consume: A) 100% of grain intake as whole grains. B) at least 3.5 cups of fruits and vegetables each day. C) more highly pigmented fruits and vegetables. D) 3 to 5 servings of dairy each day. Answer: C Explanation: A) At least half of our daily intake of grains should be whole grains. The words "whole wheat" as the first ingredient indicates a whole grain product. Other good choices are common foods as oatmeal and popcorn. Less familiar grains such as quinoa or whole-grain couscous could also be included. B) Adults are advised to consume at least 4.5 cups of fruits and vegetables daily for a variety of vitamins, minerals, phytochemicals, and fiber. C) The more highly pigmented the fruits and vegetables are, the better. Beets, spinach, squash, and berries are all good picks. D) Most Americans should consume two to three servings of low-fat dairy foods such as milk, yogurt, or low-fat cheese daily. Page Ref: 12 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 1.3 Outline the structure of this program, including the pathogenesis and etiology of disease; the clinical manifestations of disorders; how pathophysiology is linked to diagnosis and treatment; and the impact of genetics, nutrition, and lifespan on health and illness. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and selfcare management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Consider the characteristics of and risk factors associated with health and illness.

9) When developing a care plan to teach a patient with hypertension about sodium intake, the nurse should include limiting sodium intake to: A) 2,300-2,500 mg/day. B) 2,000-2,300 mg/day. C) 1,500-2,000 mg/day. D) less than 1,500 mg/day. Answer: D Explanation: A) Sodium should be limited to 2,300 mg/day for individuals younger than 51 years of age and less than 1,500 mg/day for those 51 years of age or older, African Americans, and individuals with hypertension, diabetes, or chronic kidney disease. B) Sodium should be limited to 2,300 mg/day for individuals younger than 51 years of age and less than 1,500 mg/day for those 51 years of age or older, African Americans, and individuals with hypertension, diabetes, or chronic kidney disease. C) Sodium should be limited to 2,300 mg/day for individuals younger than 51 years of age and less than 1,500 mg/day for those 51 years of age or older, African Americans, and individuals with hypertension, diabetes, or chronic kidney disease. D) Sodium should be limited to 2,300 mg/day for individuals younger than 51 years of age and less than 1,500 mg/day for those 51 years of age or older, African Americans, and individuals with hypertension, diabetes, or chronic kidney disease. Page Ref: 13 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 1.3 Outline the structure of this program, including the pathogenesis and etiology of disease; the clinical manifestations of disorders; how pathophysiology is linked to diagnosis and treatment; and the impact of genetics, nutrition, and lifespan on health and illness. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and selfcare management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Consider the characteristics of and risk factors associated with health and illness.

10) Which of the following statements describes the role of a nurse involved in epidemiology? A) The nurse studies an individual's risk for disease. B) The nurse provides care to individuals with certain diseases. C) The nurse studies the distribution of disease in a population. D) The nurse provides care to a population. Answer: C Explanation: A) Epidemiology is broadly defined as the study of how disease is distributed in populations and identification of the factors influencing the distribution. B) Epidemiology is broadly defined as the study of how disease is distributed in populations and identification of the factors influencing the distribution. C) Epidemiology is broadly defined as the study of how disease is distributed in populations and identification of the factors influencing the distribution. D) Epidemiology is broadly defined as the study of how disease is distributed in populations and identification of the factors influencing the distribution. Page Ref: 14 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 1.4 Describe the study of epidemiology, and outline the leading indicators of morbidity and mortality in the United States. | QSEN Competencies: II.A.2 Describe scopes of practice and roles of health care team members | AACN Essential Competencies: VII.1 Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities and populations NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Associate the study epidemiology and the leading indicators of morbidity and mortality in the U.S.

11) Which statement represents the epidemiology nurse's calculation of the incidence of asthma? A) There were 10 new cases of asthma diagnosed in adults ages 24 to 65 years in the past 12 months in Centerville. B) There were a total of 3,600 people with a diagnosis of diabetes in Centerville in 2015. C) There were 2 people diagnosed with Lyme disease in Centerville last year. D) There were 20 cases of opioid overdose in adults ages 18 to 24 years in Centerville. Answer: A Explanation: A) Incidence is the number of new cases of a condition within a defined period and for a defined population, such as the number of individuals who experienced a spinal cord injury within the past 12 months in the United States. Other defined populations could include adults, children, and athletes. Incidence provides a sense of frequency of occurrence in a particular group or population. Prevalence is the number of individuals of a defined population who already have a disease or condition, such as the number of adults in the United States with a spinal cord injury. B) Incidence is the number of new cases of a condition within a defined period and for a defined population, such as the number of individuals who experienced a spinal cord injury within the past 12 months in the United States. Other defined populations could include adults, children, and athletes. Incidence provides a sense of frequency of occurrence in a particular group or population. Prevalence is the number of individuals of a defined population who already have a disease or condition, such as the number of adults in the United States with a spinal cord injury. C) Incidence is the number of new cases of a condition within a defined period and for a defined population, such as the number of individuals who experienced a spinal cord injury within the past 12 months in the United States. Other defined populations could include adults, children, and athletes. Incidence provides a sense of frequency of occurrence in a particular group or population. Prevalence is the number of individuals of a defined population who already have a disease or condition, such as the number of adults in the United States with a spinal cord injury. D) Incidence is the number of new cases of a condition within a defined period and for a defined population, such as the number of individuals who experienced a spinal cord injury within the past 12 months in the United States. Other defined populations could include adults, children, and athletes. Incidence provides a sense of frequency of occurrence in a particular group or population. Prevalence is the number of individuals of a defined population who already have a disease or condition, such as the number of adults in the United States with a spinal cord injury. Page Ref: 14 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 1.4 Describe the study of epidemiology, and outline the leading indicators of morbidity and mortality in the United States. | QSEN Competencies: II.A.2 Describe scopes of practice and roles of health care team members | AACN Essential Competencies: VII. 11. Participate in clinical prevention and populationfocused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Associate the study epidemiology and the leading indicators of morbidity and mortality in the U.S.

12) In developing a plan for teaching community health nurses about the role of the nurse in epidemiology, the epidemiology nurse should include: A) diagnosing the cause of a disease. B) treating the disease. C) evaluating therapeutic measures. D) reducing risk factors for disease. Answer: C Explanation: A) The objectives of epidemiology are to identify the cause of the disease and the risk factors, to determine the extent of the disease in the community, to study the natural history and the prognosis of the disease, to evaluate both existing and newly developed preventive and therapeutic measures and modes of healthcare delivery, and to provide the basis for developing public policy related to a variety of measures. B) The objectives of epidemiology are to identify the cause of the disease and the risk factors, to determine the extent of the disease in the community, to study the natural history and the prognosis of the disease, to evaluate both existing and newly developed preventive and therapeutic measures and modes of healthcare delivery, and to provide the basis for developing public policy related to a variety of measures. C) The objectives of epidemiology are to identify the cause of the disease and the risk factors, to determine the extent of the disease in the community, to study the natural history and the prognosis of the disease, to evaluate both existing and newly developed preventive and therapeutic measures and modes of healthcare delivery, and to provide the basis for developing public policy related to a variety of measures. D) The objectives of epidemiology are to identify the cause of the disease and the risk factors, to determine the extent of the disease in the community, to study the natural history and the prognosis of the disease, to evaluate both existing and newly developed preventive and therapeutic measures and modes of healthcare delivery, and to provide the basis for developing public policy related to a variety of measures. Page Ref: 14 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 1.4 Describe the study of epidemiology, and outline the leading indicators of morbidity and mortality in the United States. | QSEN Competencies: II.A.2 Describe scopes of practice and roles of health care team members | AACN Essential Competencies: VII.1 Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities and populations NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Associate the study epidemiology and the leading indicators of morbidity and mortality in the U.S.

13) When planning community health promotion and prevention programs, the nurse should be aware that the leading cause of death in the United States is: A) accidents. B) suicide. C) heart disease. D) cancer. Answer: C Explanation: A) The leading causes of death in the United States in 2015 were: heart disease 614,348; cancer (all forms) 591,699; chronic lower respiratory diseases 147,101; accidents (unintentional injuries) 136,053; stroke (cerebrovascular diseases) 133,103; Alzheimer disease 93,541; diabetes 76,488; influenza and pneumonia 55,227; nephritis, nephrotic syndrome, and nephrosis 48,146; and intentional self-harm (suicide) 42,773. B) The leading causes of death in the United States in 2015 were: heart disease 614,348; cancer (all forms) 591,699; chronic lower respiratory diseases 147,101; accidents (unintentional injuries) 136,053; stroke (cerebrovascular diseases) 133,103; Alzheimer disease 93,541; diabetes 76,488; influenza and pneumonia 55,227; nephritis, nephrotic syndrome, and nephrosis 48,146; and intentional self-harm (suicide) 42,773. C) The leading causes of death in the United States in 2015 were: heart disease 614,348; cancer (all forms) 591,699; chronic lower respiratory diseases 147,101; accidents (unintentional injuries) 136,053; stroke (cerebrovascular diseases) 133,103; Alzheimer disease 93,541; diabetes 76,488; influenza and pneumonia 55,227; nephritis, nephrotic syndrome, and nephrosis 48,146; and intentional self-harm (suicide) 42,773. D) The leading causes of death in the United States in 2015 were: heart disease 614,348; cancer (all forms) 591,699; chronic lower respiratory diseases 147,101; accidents (unintentional injuries) 136,053; stroke (cerebrovascular diseases) 133,103; Alzheimer disease 93,541; diabetes 76,488; influenza and pneumonia 55,227; nephritis, nephrotic syndrome, and nephrosis 48,146; and intentional self-harm (suicide) 42,773. Page Ref: 15 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Disease Prevention Standards: Nursing Process: Planning | Learning Outcome: 1.4 Describe the study of epidemiology, and outline the leading indicators of morbidity and mortality in the United States. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII.1 Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities and populations NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Associate the study epidemiology and the leading indicators of morbidity and mortality in the U.S.

14) Which information about risk factors should the school nurse use when developing a program to reduce modifiable risk factors in high school students? A) Sickle cell anemia is an inherited disorder. B) Heart disease develops at an earlier age in men. C) Many high school students do not get enough physical activity. D) Certain ethnic variables increase the risk for chronic disease. Answer: C Explanation: A) Age, gender, and racial/ethnic differences are unmodifiable risk factors for many diseases. B) Age, gender, and racial/ethnic differences are unmodifiable risk factors for many diseases. C) The four most important modifiable health risk behaviors are physical inactivity, poor nutrition, tobacco use, and excessive alcohol consumption. Only 33% of U.S. high school students participate in daily physical education classes. D) Age, gender, and racial/ethnic differences are unmodifiable risk factors for many diseases. Page Ref: 15-16 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 1.4 Describe the study of epidemiology, and outline the leading indicators of morbidity and mortality in the United States. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII.1 Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities and populations NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Consider the characteristics of and risk factors associated with health and illness.

15) A woman with type 1 diabetes is being seen for her first prenatal examination. Which information should the nurse include in the woman's care plan? A) Teaching the signs and symptoms of preeclampsia B) Explaining the fetal risk of microsomia C) Discussing symptoms of placental abruption to report D) Reinforcing that there will be no risk to the fetus Answer: A Explanation: A) Women who had type 1 or type 2 diabetes before becoming pregnant can have a variety of adverse fetal and maternal outcomes, such as increased risk for preeclampsia, hypertension during pregnancy, cesarean delivery, miscarriage, birth defects, preterm delivery, macrosomia (very large baby), hypoglycemia, fetal death, and infant death. B) Women who had type 1 or type 2 diabetes before becoming pregnant can have a variety of adverse fetal and maternal outcomes, such as increased risk for preeclampsia, hypertension during pregnancy, cesarean delivery, miscarriage, birth defects, preterm delivery, macrosomia (very large baby), hypoglycemia, fetal death, and infant death. C) Women who had type 1 or type 2 diabetes before becoming pregnant can have a variety of adverse fetal and maternal outcomes, such as increased risk for preeclampsia, hypertension during pregnancy, cesarean delivery, miscarriage, birth defects, preterm delivery, macrosomia (very large baby), hypoglycemia, fetal death, and infant death. D) Women who had type 1 or type 2 diabetes before becoming pregnant can have a variety of adverse fetal and maternal outcomes, such as increased risk for preeclampsia, hypertension during pregnancy, cesarean delivery, miscarriage, birth defects, preterm delivery, macrosomia (very large baby), hypoglycemia, fetal death, and infant death. Page Ref: 16 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 1.4 Describe the study of epidemiology, and outline the leading indicators of morbidity and mortality in the United States. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Consider the characteristics of and risk factors associated with health and illness.

16) A nurse working on a busy medical unit has noticed an increase in the incidence of pressure ulcers in the patient population. Which action demonstrates the principles of evidence-based practice (EBP)? A) Reviewing the literature for current best evidence pressure ulcer prevention B) Reviewing the literature for informational articles on best methods to prevent pressure ulcers C) Reviewing hospital policy and procedures to make sure they are being followed correctly D) Reviewing patient charts to audit nursing interventions to prevent pressure ulcers Answer: A Explanation: A) EBP is "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research." B) EBP should be based on research and best evidence and not informational articles. C) Policy and procedures may not reflect the most current EBP. They should be reviewed to determine if they are based on current best evidence. D) Auditing nursing care is not an example of EBP. Page Ref: 17 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: Nursing Process: Planning | Learning Outcome: 1.5 Explain the importance of evidence-based practice. | QSEN Competencies: III.A. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.8. Implement evidencebased nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate how the key factors and basic principles that inform pathophysiology impact health and illness.

17) Which action by the nurse shows an understanding of integrating evidence-based principles into practice? A) Creating a care plan and then presenting it to the patient B) Making the best decisions for the patient C) Seeking patient preferences about his care D) Providing written information explaining the patient's care Answer: C Explanation: A) The process of implementing evidence into practice relies on melding clinical expertise with existing research evidence in providing care that also respects the values and preferences of the patient. Without acknowledging patient preferences and experience, the healthcare provider could implement interventions supported by the literature but find a patient who is not adhering to the recommendations because of different goals or values. B) The process of implementing evidence into practice relies on melding clinical expertise with existing research evidence in providing care that also respects the values and preferences of the patient. Without acknowledging patient preferences and experience, the healthcare provider could implement interventions supported by the literature but find a patient who is not adhering to the recommendations because of different goals or values. C) The process of implementing evidence into practice relies on melding clinical expertise with existing research evidence in providing care that also respects the values and preferences of the patient. Without acknowledging patient preferences and experience, the healthcare provider could implement interventions supported by the literature but find a patient who is not adhering to the recommendations because of different goals or values. D) The process of implementing evidence into practice relies on melding clinical expertise with existing research evidence in providing care that also respects the values and preferences of the patient. Without acknowledging patient preferences and experience, the healthcare provider could implement interventions supported by the literature but find a patient who is not adhering to the recommendations because of different goals or values. Page Ref: 17 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: Nursing Process: Planning | Learning Outcome: 1.5 Explain the importance of evidence-based practice. | QSEN Competencies: III.A. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.8. Implement evidencebased nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate how the key factors and basic principles that inform pathophysiology impact health and illness.

18) When developing a care plan for a patient with asthma, the nurse needs to understand which pathophysiological subconcept? A) Infection B) Coagulation C) Inflammation D) Perfusion Answer: C Explanation: A) Asthma is a condition of reactive airway constriction, in which parts of the respiratory tract are sensitive to allergens. In the presence of an environmental allergen, parts of the respiratory tract constrict, restricting the flow of air into the lung. The reduction in air flow leads to decreases in the concentration of oxygen in the bloodstream. The allergen stimulates the immune system, which releases inflammatory mediators. The resulting inflammation contributes to the reduction of airflow. B) Asthma is a condition of reactive airway constriction, in which parts of the respiratory tract are sensitive to allergens. In the presence of an environmental allergen, parts of the respiratory tract constrict, restricting the flow of air into the lung. The reduction in air flow leads to decreases in the concentration of oxygen in the bloodstream. The allergen stimulates the immune system, which releases inflammatory mediators. The resulting inflammation contributes to the reduction of airflow. C) Asthma is a condition of reactive airway constriction, in which parts of the respiratory tract are sensitive to allergens. In the presence of an environmental allergen, parts of the respiratory tract constrict, restricting the flow of air into the lung. The reduction in air flow leads to decreases in the concentration of oxygen in the bloodstream. The allergen stimulates the immune system, which releases inflammatory mediators. The resulting inflammation contributes to the reduction of airflow. D) Asthma is a condition of reactive airway constriction, in which parts of the respiratory tract are sensitive to allergens. In the presence of an environmental allergen, parts of the respiratory tract constrict, restricting the flow of air into the lung. The reduction in air flow leads to decreases in the concentration of oxygen in the bloodstream. The allergen stimulates the immune system, which releases inflammatory mediators. The resulting inflammation contributes to the reduction of airflow. Page Ref: 7 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 1.1 Define the conceptual basis for and the language used in the study of pathophysiology. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Recognize the conceptual basis for and the language used in the study of pathophysiology.

19) When the nurse teaches parents how transmitting the sickle cell trait to offspring influences the development of sickle cell disease, the nurse is applying principles of: A) genomics. B) genetics. C) epigenomics. D) gene. Answer: A Explanation: A) Genomics refers to the study of the function of groups of genes in terms of mediating physiologic function. Genomics explains how an inherited genetic trait, such as sickle cell trait, influences the likelihood that an individual will develop sickle cell disease. B) Genetics is the study of how gene variations are passed through familial inheritance. C) Epigenomics is the study of all genetic variations or modifications that have influenced a particular cell. The focus is on the broader picture in terms of studying a complete set of modifications to cellular DNA. D) Genes, made up of DNA, are the genetic material of inheritance within a cell. Page Ref: 11 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 1.3 Outline the structure of this program, including the pathogenesis and etiology of disease; the clinical manifestations of disorders; how pathophysiology is linked to diagnosis and treatment; and the impact of genetics, nutrition, and lifespan on health and illness. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and selfcare management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate how the key factors and basic principles that inform pathophysiology impact health and illness.

20) The nurse is reviewing literature to determine the death rate due to cardiovascular disease in the United States. The nurse understands that the information he is seeking indicates: A) morbidity. B) mortality. C) disability-adjusted life-years. D) prevalence. Answer: B Explanation: A) Morbidity is defined as a departure from physiologic or psychologic well-being and encompasses disease, injury, and disability. B) Mortality is defined as the number of deaths in a given population. C) Disability-adjusted life-years (DALYs) are defined as the years of potential life lost due to premature mortality and the years of productive life lost due to disability for people living with the health condition or its sequelae. D) Prevalence is the number of individuals of a defined population who already have a disease or condition. Page Ref: 14-15 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: Nursing Process: Planning | Learning Outcome: 1.4 Describe the study of epidemiology, and outline the leading indicators of morbidity and mortality in the United States. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: III.2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate how the key factors and basic principles that inform pathophysiology impact health and illness.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 2 Genetics, Genomics, and Epigenomics 1) The community health nurse is planning a program for a local health fair on genetics and health, using Healthy People 2020 goals. Which concepts should guide the nurse's planning for the program? A) People should know their family health history. B) All people should have genetic testing done. C) Genetic testing determines what diseases a person will develop. D) All diseases have a genetic basis. Answer: A Explanation: A) Research substantiates the benefits of taking a family health history and the use of genetic and genomic tests to identify risk factors, diagnose disease, and guide the use of screening tests and treatment options. B) Research substantiates the benefits of taking a family health history and the use of genetic and genomic tests to identify risk factors, diagnose disease, and guide the use of screening tests and treatment options. If a family history does not suggest the presence of genomic and genomic risk factors, genetic testing is not indicated. C) Research substantiates the benefits of taking a family health history and the use of genetic and genomic tests to identify risk factors, diagnose disease, and guide the use of screening tests and treatment options. Having a risk factor for a disease does not mean that the person will develop the disease. D) Although not all diseases have a genetic basis, genomics plays a role in 9 out of 10 of the leading causes of death, including heart disease, cancer, stroke, diabetes, and Alzheimer's disease. Genomics also plays a role in a variety of neuromuscular, immune, vision, and hearing disorders. Page Ref: 24 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 2.1 Describe the impact of genetics, genomics, and epigenomics on personalized healthcare, and explain the concepts related to them. | QSEN Competencies: I.C.10 Value active partnership with patients or designated surrogates in planning, implementation, and evaluation of care | AACN Essential Competencies: VII.1 Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities and populations NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Recognize the concepts and relationships of human genetics, genomics, and epigenomics.

2) Which statement would be most appropriate for the nurse to make to a patient newly diagnosed with colorectal cancer? A) "There is no need for genetic testing as you have already been diagnosed with colorectal cancer." B) "With genetic testing, family members will not need colonoscopies." C) "Genetic testing will help identify familial colorectal cancer syndromes." D) "Family members will be able to determine if they will get colon cancer." Answer: C Explanation: A) One objective of Healthy People 2020 related to genomics is to "increase the proportion of persons with newly diagnosed colorectal cancer who receive genetic testing to identify familial colorectal cancer syndromes." One purpose of this objective is to increase the early diagnosis and treatment of asymptomatic individuals with colorectal cancer, thereby improving survival. Another purpose is to identify individuals at risk who need more frequent screening, such as colonoscopy. B) One objective of Healthy People 2020 related to genomics is to "increase the proportion of persons with newly diagnosed colorectal cancer who receive genetic testing to identify familial colorectal cancer syndromes." One purpose of this objective is to increase the early diagnosis and treatment of asymptomatic individuals with colorectal cancer, thereby improving survival. Another purpose is to identify individuals at risk who need more frequent screening, such as colonoscopy. C) One objective of Healthy People 2020 related to genomics is to "increase the proportion of persons with newly diagnosed colorectal cancer who receive genetic testing to identify familial colorectal cancer syndromes." One purpose of this objective is to increase the early diagnosis and treatment of asymptomatic individuals with colorectal cancer, thereby improving survival. Another purpose is to identify individuals at risk who need more frequent screening, such as colonoscopy. D) One objective of Healthy People 2020 related to genomics is to "increase the proportion of persons with newly diagnosed colorectal cancer who receive genetic testing to identify familial colorectal cancer syndromes." One purpose of this objective is to increase the early diagnosis and treatment of asymptomatic individuals with colorectal cancer, thereby improving survival. Another purpose is to identify individuals at risk who need more frequent screening, such as colonoscopy. Page Ref: 24 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 2.1 Describe the impact of genetics, genomics, and epigenomics on personalized healthcare, and explain the concepts related to them. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX. 2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Examine genetic factors and disorders and how they affect individual health. 2

3) Which concept does the nurse use when explaining the inheritance of genetic disorders to a couple beginning to think about starting a family? A) Humans have 46 pairs of chromosomes. B) Egg and sperm cells each have 23 pairs of chromosomes. C) Males have two X chromosomes. D) A person inherits one chromosome from a chromosome pair from each parent. Answer: D Explanation: A) Humans have a total of 46 chromosomes in most cells of the body, which are grouped in 23 pairs. Think of them as 23 pairs of shoes, with a total of 46 shoes. B) Humans have a total of 46 chromosomes in most cells of the body, which are grouped in 23 pairs. Think of them as 23 pairs of shoes, with a total of 46 shoes. For each pair of chromosomes, an individual inherits one chromosome from each parent. C) The 23rd pair are the sex chromosomes and are designated either X or Y. Individuals with two X chromosomes are female, and those with an X chromosome and a Y chromosome are male. D) Humans have a total of 46 chromosomes in most cells of the body, which are grouped in 23 pairs. Think of them as 23 pairs of shoes, with a total of 46 shoes. For each pair of chromosomes, an individual inherits one chromosome from each parent. Page Ref: 26 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 2.2 Identify components of the genetic code and the organization of genes on chromosomes. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Consider gene replication, transcription, translation and their impact on health.

4) The nurse involved in genomics engages in which of the following activities? A) Studying the entire genome. B) Studying individual genes. C) Studying mutations. D) Studying chemicals that instruct the genome. Answer: A Explanation: A) Genomics is a field of science that examines mechanisms of health and disease by studying the entire genome versus individual genes. B) Genomics is a field of science that examines mechanisms of health and disease by studying the entire genome versus individual genes. C) Genomics is a field of science that examines mechanisms of health and disease by studying the entire genome versus individual genes. It is not the study of gene mutations. D) Genomics is a field of science that examines mechanisms of health and disease by studying the entire genome versus individual genes. It is not the study of the chemical compounds that instruct the genome where and when genes are expressed. Page Ref: 27 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 2.3 Understand the differences between the human genome and epigenome and the mechanisms by which epigenetic modifications occur and affect gene expression. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Recognize the concepts and relationships of human genetics, genomics, and epigenomics.

5) While taking a family history and drawing a genetic pedigree, the nurse explains to the patient that: A) individuals in the same generation are arranged vertically. B) offspring are in the row below the parents. C) individuals who have had children together are connected by a vertical line. D) circles represent males. Answer: B Explanation: A) In clinical practice, it is often useful to draw a genetic pedigree through several generations so that the pattern of genetic disease can be visualized. Individuals of the same generation are on one row, and their offspring are drawn in a row below, connected by a vertical line to their parents. B) In clinical practice, it is often useful to draw a genetic pedigree through several generations so that the pattern of genetic disease can be visualized. Individuals of the same generation are on one row, and their offspring are drawn in a row below, connected by a vertical line to their parents. C) Individuals who have had children together are linked by a horizontal line. D) In a pedigree, circles represent women, and squares represent men. Page Ref: 35 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 2.6 Compare the characteristics and patterns of inheritance of genetic disorders caused by abnormalities of chromosome number or structure to those caused by autosomal, X-linked, and mitochondrial disorders. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX. 2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Examine genetic factors and disorders and how they affect individual health.

6) The nurse is answering nursing students' questions about the process of meiosis and mitosis. Which statement by a student should the nurse correct? A) "In mitosis, cells divide to form an identical cell." B) "Gonadal cells contain 23 chromosomes." C) "Sperm and egg cells are diploid cells." D) "Haploid cells have 23 chromosomes." Answer: C Explanation: A) The process of cell division used to create identical copies of a cell is called mitosis. B) Gonadal cells, that is egg and sperm cells, have only half of the genetic information (one of each chromosome pair), or 23 chromosomes total. C) In meiosis, egg and sperm cells are created for reproduction. Meiosis begins with a cell that has 46 total chromosomes, two of each chromosome type. However, the goal is to place one of every chromosome pair into a cell. This occurs by following DNA replication with two sets of cell divisions, and the end product is four daughter cells, each with a total of 23 chromosomes, one of each chromosome pair. These are called haploid cells. D) In meiosis, egg and sperm cells are created for reproduction. Meiosis begins with a cell that has 46 total chromosomes, two of each chromosome type. However, the goal is to place one of every chromosome pair into a cell. This occurs by following DNA replication with two sets of cell divisions, and the end product is four daughter cells, each with a total of 23 chromosomes,one of each chromosome pair. These are called haploid cells. Page Ref: 28-29 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Evaluation | Learning Outcome: 2.4 Explain the function and sequence of events involved in gene replication during mitosis and meiosis, transcription, and translation. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: VIII.13. Articulate the value of pursuing practice excellence, lifelong learning and professional engagement to foster professional growth and development NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Consider gene replication, transcription, translation and their impact on health.

7) The nurse explains to the parents of a child with Prader-Willi syndrome that this disease is caused by: A) genetic imprinting. B) mosaicism. C) single-nucleotide polymorphism (SNP). D) missense mutation. Answer: A Explanation: A) In genetic imprinting, some genes have differential expression based on the parent from whom the genes are inherited. For example, a deletion of a portion of chromosome 15 leads to a disorder called Prader-Willi syndrome when inherited from the father, but the same gene deletion leads to a different condition called Angelman syndrome when inherited from the mother. B) Nondisjunction can occur during meiosis (creation of sperm and egg cells). This can also occur shortly after conception, causing the presence of more than one genetic cell line in a person, a condition called mosaicism. The clinical effects of the mosaicism often depend on how many abnormal cells are present, but this is not the cause of Prader-Willi syndrome. C) Not all genetic changes among individuals are pathogenic. When present in at least 1% of the population, a change is referred to as a single-nucleotide polymorphism (SNP). Some polymorphisms may just result in human variation with no clinical impact at all; others may contribute to disease, but this is not the cause of Prader-Willi syndrome. D) A missense mutation causes a change in the amino acid sequence, but this is not the cause of Prader-Willi syndrome. Page Ref: 33-34 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 2.5 Compare singlenucleotide polymorphisms and the various types of gene mutations, including point mutations, insertions, deletions, and translocations, in regard to their characteristics and possible clinical consequences. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX. 2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Examine genetic factors and disorders and how they affect individual health.

8) Which statement indicates that a pregnant woman requires more teaching about prenatal screening? A) "Screening tests assess a woman's risk of having a baby with chromosome problems." B) "Amniocentesis obtains fetal cells to assess chromosome number and structure." C) "Chorionic villus sampling can diagnose chromosome problems." D) "Screening tests can diagnose all chromosome abnormalities." Answer: D Explanation: A) Prenatal screening can assess whether the woman is at a higher risk of having a baby with certain chromosomal problems. This can be done with ultrasound and maternal serum screening by blood. B) Chorionic villus sampling and amniocentesis obtain cells from the growing fetus to assess fetal chromosome number and structure. C) While screening tests can assess risk of certain chromosome problems, diagnosis can occur only with the use of invasive procedures, such as chorionic villus sampling or amniocentesis. D) While screening tests can assess risk of certain chromosome problems, diagnosis can occur only with the use of invasive procedures, such as chorionic villus sampling or amniocentesis. Page Ref: 34 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Evaluation | Learning Outcome: 2.6 Compare the characteristics and patterns of inheritance of genetic disorders caused by abnormalities of chromosome number or structure to those caused by autosomal, X-linked, and mitochondrial disorders. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX. 2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Recognize diagnostic tests, genetic- and genome-based therapies, and future advances in the provision of personalized health care.

9) Which manifestation would the nurse expect to find in a child with Down syndrome? A) Downward slanting eyes with an epicanthal fold. B) A prominent brow and nose C) Wide, short hands and fingers D) Increased muscle tone and lack of flexibility Answer: C Explanation: A) The physical manifestations of Down syndrome are decreased or poor muscle tone; short neck; flattened facial profile and nose; small head, ears, and mouth; upward slanting eyes, often with epicanthal fold; wide, short hands and fingers; single deep crease across the palm; and deep groove between first and second toes. B) The physical manifestations of Down syndrome are decreased or poor muscle tone; short neck; flattened facial profile and nose; small head, ears, and mouth; upward slanting eyes, often with epicanthal fold; wide, short hands and fingers; single deep crease across the palm; and deep groove between first and second toes. C) The physical manifestations of Down syndrome are decreased or poor muscle tone; short neck; flattened facial profile and nose; small head, ears, and mouth; upward slanting eyes, often with epicanthal fold; wide, short hands and fingers; single deep crease across the palm; and deep groove between first and second toes. D) The physical manifestations of Down syndrome are decreased or poor muscle tone; short neck; flattened facial profile and nose; small head, ears, and mouth; upward slanting eyes, often with epicanthal fold; wide, short hands and fingers; single deep crease across the palm; and deep groove between first and second toes. Page Ref: 35 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 2.6 Compare the characteristics and patterns of inheritance of genetic disorders caused by abnormalities of chromosome number or structure to those caused by autosomal, X-linked, and mitochondrial disorders. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Examine genetic factors and disorders and how they affect individual health.

10) When providing genetic counseling, the nurse explains that the observable clinical expression of genetic coding is called: A) phenotype. B) genotype. C) variable expressivity. D) reduced penetrance. Answer: A Explanation: A) Genotype is the actual genetic code in a person, whereas phenotype is the clinical expression related to the genotype. B) Genotype is the actual genetic code in a person, whereas phenotype is the clinical expression related to the genotype. C) The clinical phenotype in individuals with mutations in the same gene can be different. This is called variable expressivity. Reduced penetrance means that not everyone who inherits a mutation will have clinical symptoms. D) The clinical phenotype in individuals with mutations in the same gene can be different. This is called variable expressivity. Reduced penetrance means that not everyone who inherits a mutation will have clinical symptoms. Page Ref: 35 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 2.6 Compare the characteristics and patterns of inheritance of genetic disorders caused by abnormalities of chromosome number or structure to those caused by autosomal, X-linked, and mitochondrial disorders. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Examine genetic factors and disorders and how they affect individual health.

11) Which statement indicates that an individual with an autosomal recessive disorder understands its pattern of inheritance? A) A carrier will not express the trait. B) The trait will be expressed with one copy of the gene. C) The affected gene is on the sex chromosome. D) More females are affected than males Answer: A Explanation: A) The word autosomal means that the gene of interest is on one of the non-sex chromosomes. Thus, males or females can be affected. Recessive inheritance indicates that both copies of a gene must not be working to express the trait. A person who inherits only one copy of a mutated gene will be a carrier but will not express the trait. B) The word autosomal means that the gene of interest is on one of the non-sex chromosomes. Thus, males or females can be affected. Recessive inheritance indicates that both copies of a gene must not be working to express the trait. A person who inherits only one copy of a mutated gene will be a carrier but will not express the trait. C) The word autosomal means that the gene of interest is on one of the non-sex chromosomes. Thus, males or females can be affected. Recessive inheritance indicates that both copies of a gene must not be working to express the trait. A person who inherits only one copy of a mutated gene will be a carrier but will not express the trait. D) The word autosomal means that the gene of interest is on one of the non-sex chromosomes. Thus, males or females can be affected. Recessive inheritance indicates that both copies of a gene must not be working to express the trait. A person who inherits only one copy of a mutated gene will be a carrier but will not express the trait. Page Ref: 35 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Evaluation | Learning Outcome: 2.6 Compare the characteristics and patterns of inheritance of genetic disorders caused by abnormalities of chromosome number or structure to those caused by autosomal, X-linked, and mitochondrial disorders. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX. 2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Examine genetic factors and disorders and how they affect individual health.

12) The nurse explains to parents that if both of them are carriers of an autosomal recessive genetic mutation, the chance of each child inheriting the disease is: A) 0%. B) 25%. C) 50%. D) 100%. Answer: B Explanation: A) When both parents are carriers of an autosomal recessive gene mutation, there is a 25% chance in each pregnancy that the child will inherit two mutated genes and thus have the disease. B) When both parents are carriers of an autosomal recessive gene mutation, there is a 25% chance in each pregnancy that the child will inherit two mutated genes and thus have the disease. C) When both parents are carriers of an autosomal recessive gene mutation, there is a 25% chance in each pregnancy that the child will inherit two mutated genes and thus have the disease. D) When both parents are carriers of an autosomal recessive gene mutation, there is a 25% chance in each pregnancy that the child will inherit two mutated genes and thus have the disease. Page Ref: 35 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 2.6 Compare the characteristics and patterns of inheritance of genetic disorders caused by abnormalities of chromosome number or structure to those caused by autosomal, X-linked, and mitochondrial disorders. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX. 2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Examine genetic factors and disorders and how they affect individual health.

13) How should the nurse respond when the parents of a child with cystic fibrosis ask how their male child inherited this autosomal recessive disorder when neither parent has the disease? A) "Two carriers may pass on the mutation to their child." B) "The disease often skips a generation." C) "The gene for this disorder is on the Y chromosome." D) "Are you sure there is no history of cystic fibrosis in either family?" Answer: A Explanation: A) Often in an autosomal recessive condition, such as cystic fibrosis, there is not a family history of the condition. The disease occurs only when two carriers have a child together, and both carriers pass on the mutation to that child. B) Often in an autosomal recessive condition, such as cystic fibrosis, there is not a family history of the condition. The disease occurs only when two carriers have a child together, and both carriers pass on the mutation to that child. The disease does not skip a generation. C) The disorder is not sex-linked. D) Often in an autosomal recessive condition, such as cystic fibrosis, there is not a family history of the condition. The disease occurs only when two carriers have a child together, and both carriers pass on the mutation to that child. Page Ref: 36 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 2.6 Compare the characteristics and patterns of inheritance of genetic disorders caused by abnormalities of chromosome number or structure to those caused by autosomal, X-linked, and mitochondrial disorders. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX. 2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Examine genetic factors and disorders and how they affect individual health.

14) When counseling parents about genetic transmission of an X-linked disorder, which concept does the nurse keep in mind? A) A male can pass an X-linked mutation to a son or a daughter. B) A female can only pass an X-liked disorder to a son. C) A male with a mutation in an X-linked gene will manifest the disease. D) An X-linked disorder can be traced through the paternal lineage. Answer: C Explanation: A) A female can pass an X-linked mutation to a son or daughter, but only the son will manifest the severe form of the disease. A father cannot pass on the X-linked condition to his sons because a male inherits his X chromosome from his mother and the Y chromosome from his father. Therefore, in an X-linked condition, it is likely that only males will be affected, and the condition can be traced through the maternal lineage. B) A female can pass an X-linked mutation to a son or daughter, but only the son will manifest the severe form of the disease. A father cannot pass on the X-linked condition to his sons because a male inherits his X chromosome from his mother and the Y chromosome from his father. Therefore, in an X-linked condition, it is likely that only males will be affected, and the condition can be traced through the maternal lineage. C) A female can pass an X-linked mutation to a son or daughter, but only the son will manifest the severe form of the disease. A father cannot pass on the X-linked condition to his sons because a male inherits his X chromosome from his mother and the Y chromosome from his father. Therefore, in an X-linked condition, it is likely that only males will be affected, and the condition can be traced through the maternal lineage. D) A female can pass an X-linked mutation to a son or daughter, but only the son will manifest the severe form of the disease. A father cannot pass on the X-linked condition to his sons because a male inherits his X chromosome from his mother and the Y chromosome from his father. Therefore, in an X-linked condition, it is likely that only males will be affected, and the condition can be traced through the maternal lineage. Page Ref: 36 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 2.6 Compare the characteristics and patterns of inheritance of genetic disorders caused by abnormalities of chromosome number or structure to those caused by autosomal, X-linked, and mitochondrial disorders. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX. 2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Examine genetic factors and disorders and how they affect individual health.

15) Which statement by a patient indicates an understanding of why phenotypic variations in disease occur? A) "Disease presentation is the same in all people with the same genetic mutations." B) "Disease presentation only relies on lifestyle choices." C) "Disease presentation is only due to environmental influences." D) "Disease presentation usually depends on multiple genes, environment, and lifestyle." Answer: D Explanation: A) Manifesting multifactorial disease depends on multiple genes, environmental influences, and lifestyle choices. Therefore, significant variation in disease presentation exists. However, single-gene disorders can also have quite a bit of variation in clinical presentation, owing to factors such as reduced penetrance, as in familial cancer syndromes, and variable expressivity. B) Manifesting multifactorial disease depends on multiple genes, environmental influences, and lifestyle choices. Therefore, significant variation in disease presentation exists. However, singlegene disorders can also have quite a bit of variation in clinical presentation, owing to factors such as reduced penetrance, as in familial cancer syndromes, and variable expressivity. C) Manifesting multifactorial disease depends on multiple genes, environmental influences, and lifestyle choices. Therefore, significant variation in disease presentation exists. However, singlegene disorders can also have quite a bit of variation in clinical presentation, owing to factors such as reduced penetrance, as in familial cancer syndromes, and variable expressivity. D) Manifesting multifactorial disease depends on multiple genes, environmental influences, and lifestyle choices. Therefore, significant variation in disease presentation exists. However, singlegene disorders can also have quite a bit of variation in clinical presentation, owing to factors such as reduced penetrance, as in familial cancer syndromes, and variable expressivity. Page Ref: 38 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Evaluation | Learning Outcome: 2.7 Differentiate the mechanisms responsible for phenotypic variations in human disease. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and wellbeing, and self-care management | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Examine genetic factors and disorders and how they affect individual health.

16) The plan of care for a woman newly diagnosed with a BRCA1 mutation should include which strategy? A) Preoperative planning for immediate prophylactic double mastectomies B) A recommendation for enhanced screening for breast and ovarian cancer C) Reassurance that male offspring with BRCA1 do not develop breast cancer D) Reassurance that the BRCA1 gene protects against ovarian cancer Answer: B Explanation: A) Up to 5% of all cases of breast cancer are due to autosomal dominant inheritance of a mutation in either the BRCA1 or BRCA2 gene. Having a BRCA1 or BRCA2 mutation confers a very high lifetime risk of both breast cancer and ovarian cancer. Even males with a BRCA1 or BRCA2 gene mutation have an increased risk of breast cancer. Early identification of a gene mutation may allow for enhanced screening and some prophylactic options for early detection and/or decreasing the risk of cancer. The choice of prophylactic mastectomy is very personal and should be made by the woman in conjunction with her family and healthcare team. B) Up to 5% of all cases of breast cancer are due to autosomal dominant inheritance of a mutation in either the BRCA1 or BRCA2 gene. Having a BRCA1 or BRCA2 mutation confers a very high lifetime risk of both breast cancer and ovarian cancer. Even males with a BRCA1 or BRCA2 gene mutation have an increased risk of breast cancer. Early identification of a gene mutation may allow for enhanced screening and some prophylactic options for early detection and/or decreasing the risk of cancer. C) Up to 5% of all cases of breast cancer are due to autosomal dominant inheritance of a mutation in either the BRCA1 or BRCA2 gene. Having a BRCA1 or BRCA2 mutation confers a very high lifetime risk of both breast cancer and ovarian cancer. Even males with a BRCA1 or BRCA2 gene mutation have an increased risk of breast cancer. Early identification of a gene mutation may allow for enhanced screening and some prophylactic options for early detection and/or decreasing the risk of cancer. D) Up to 5% of all cases of breast cancer are due to autosomal dominant inheritance of a mutation in either the BRCA1 or BRCA2 gene. Having a BRCA1 or BRCA2 mutation confers a very high lifetime risk of both breast cancer and ovarian cancer. Even males with a BRCA1 or BRCA2 gene mutation have an increased risk of breast cancer. Early identification of a gene mutation may allow for enhanced screening and some prophylactic options for early detection and/or decreasing the risk of cancer. Page Ref: 39 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 2.8 Understand the role of genetic and epigenomic factors in cancer. | QSEN Competencies: I.C.10 Value active partnership with patients or designated surrogates in planning, implementation, and evaluation of care | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Recognize diagnostic tests, genetic- and genome-based therapies, and future advances in the provision of personalized health care. 16

17) The nurse explains to a patient undergoing karyotyping that this test will: A) examine nucleotide changes in a gene. B) detect small deletions or structural abnormalities of the chromosomes and DNA. C) examine the visual appearance of chromosome structure and number. D) detect single gene mutations. Answer: C Explanation: A) Single-gene sequencing is designed to detect nucleotide changes anywhere in the gene. B) Fluorescence in situ hybridization (FISH) has been utilized both for rapid detection of chromosome number and for targeting specific DNA sequences. This test can detect small deletions or structural abnormalities that are not seen in standard karyotyping. C) Karyotyping is a test used to examine the visual appearance of chromosome structure and number. This type of genetic testing can identify aneuploidy and triploidy as well as translocations and other gross chromosomal structural abnormalities. However, it cannot detect single-gene mutations. D) Single-gene sequencing is designed to detect nucleotide changes anywhere in the gene. Page Ref: 39 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 2.9 Apply the following tests to the appropriate clinical situation: karyotyping, fluorescence in situ hybridization, single-gene testing, and genome-wide association studies. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and selfcare management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Recognize diagnostic tests, genetic- and genome-based therapies, and future advances in the provision of personalized health care.

18) The nurse explains to a patient with chronic myelogenous leukemia that the therapeutic action of Gleevec (Imatinib) is to: A) bind directly DNA or RNA to block the aberrant cancer-causing gene product. B) silence genes that are implicated in causing the growth of cancer causing cells. C) selectively increase transcription levels of certain genes. D) promote the replication of healthy genetic material. Answer: A Explanation: A) Cancer treatments have been developed in which an antisense oligonucleotide (sequence of complementary nucleotides) is used to directly bind the DNA or RNA to block the aberrant gene product. Gleevec (Imatinib) is the most publicized example of this approach in the treatment of chronic myelogenous leukemia, which is caused by the BCR-ABL fusion gene. B) Gene replacement therapy works by expressing or silencing genes that are implicated in disease processes. DNA or RNA is engineered to be delivered (often via virus) into an individual so that target cells take up the gene and then express its protein product. C) Transcription factor modulators selectively increase or decrease transcription levels of certain genes. Not being cell specific, transcription modulation must be used carefully, considering the potential side effects, but these may be limited in the future by cell-specific targeting. D) Gene replacement therapy works by expressing or silencing genes that are implicated in disease processes. DNA or RNA is engineered to be delivered (often via virus) into an individual so that target cells take up the gene and then express its protein product. It does not promote the replication of healthy genetic material. Page Ref: 40-41 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Implementation | Learning Outcome: 2.10 Apply the following genetic-based therapies to appropriate clinical situations: gene replacement therapy, pharmacogenomics, antisense nucleotides, and transcription factor | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Recognize diagnostic tests, genetic- and genome-based therapies, and future advances in the provision of personalized health care.

19) When teaching a genetics class to nursing students in a baccalaureate nursing program, the nurse educator explains that the International HapMap Project: A) studies genomic elements to determine commonalities in the human genome. B) explores the genetic basis for diseases around the world. C) studies the human genome within a population. D) analyzes genetic elements to determine what makes people different from one another. Answer: D Explanation: A) With data and technologies generated from the Human Genome Project, a worldwide collaborative study of different ancestries to develop a haplotype map of the human genome, called the International HapMap Project, was undertaken. The Human Genome Project revealed that humans are genetically 99.9% identical, and the International Hap-Map Project focuses on analyzing the 0.1% of the genomic elements that make us different from one another. Data from the International HapMap Project revealed 3.1 million common single nucleotide polymorphisms in the human genome across geographically diverse populations. B) With data and technologies generated from the Human Genome Project, a worldwide collaborative study of different ancestries to develop a haplotype map of the human genome, called the International HapMap Project, was undertaken. The Human Genome Project revealed that humans are genetically 99.9% identical, and the International Hap-Map Project focuses on analyzing the 0.1% of the genomic elements that make us different from one another. Data from the International HapMap Project revealed 3.1 million common single nucleotide polymorphisms in the human genome across geographically diverse populations. C) With data and technologies generated from the Human Genome Project, a worldwide collaborative study of different ancestries to develop a haplotype map of the human genome, called the International HapMap Project, was undertaken. The Human Genome Project revealed that humans are genetically 99.9% identical, and the International Hap-Map Project focuses on analyzing the 0.1% of the genomic elements that make us different from one another. Data from the International HapMap Project revealed 3.1 million common single nucleotide polymorphisms in the human genome across geographically diverse populations. D) With data and technologies generated from the Human Genome Project, a worldwide collaborative study of different ancestries to develop a haplotype map of the human genome, called the International HapMap Project, was undertaken. The Human Genome Project revealed that humans are genetically 99.9% identical, and the International Hap-Map Project focuses on analyzing the 0.1% of the genomic elements that make us different from one another. Data from the International HapMap Project revealed 3.1 million common single nucleotide polymorphisms in the human genome across geographically diverse populations. Page Ref: 41 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 2.11 Analyze the impact of advances in genomics and epigenomics on personalized healthcare. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care 19

MNL Learning Outcome: LO 4: Recognize diagnostic tests, genetic- and genome-based therapies, and future advances in the provision of personalized health care. 20) The nurse is explaining the inheritance of Huntington disease to a newly diagnosed patient whose partner does not have the gene mutation. Which statement should the nurse make regarding family planning? A) There is a 0% chance with each pregnancy that the child will inherit the gene for Huntington disease. B) There is a 25% chance with each pregnancy that the child will inherit the gene for Huntington disease. C) There is a 50% chance with each pregnancy that the child will inherit the gene for Huntington disease. D) There is a 100% chance with each pregnancy that the child will inherit the gene for Huntington disease. Answer: C Explanation: A) Dominant inheritance indicates that only one copy of a mutated gene is required to cause disease. When a parent has an autosomal dominant gene mutation, there is a 50% chance in each pregnancy that the child will inherit the mutation and manifest disease. B) Dominant inheritance indicates that only one copy of a mutated gene is required to cause disease. When a parent has an autosomal dominant gene mutation, there is a 50% chance in each pregnancy that the child will inherit the mutation and manifest disease. C) Dominant inheritance indicates that only one copy of a mutated gene is required to cause disease. When a parent has an autosomal dominant gene mutation, there is a 50% chance in each pregnancy that the child will inherit the mutation and manifest disease. D) Dominant inheritance indicates that only one copy of a mutated gene is required to cause disease. When a parent has an autosomal dominant gene mutation, there is a 50% chance in each pregnancy that the child will inherit the mutation and manifest disease. Page Ref: 36 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 2.6 Compare the characteristics and patterns of inheritance of genetic disorders caused by abnormalities of chromosome number or structure to those caused by autosomal, X-linked, and mitochondrial disorders. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Examine genetic factors and disorders and how they affect individual health.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 3 Environmental Health Influences on Disease and Injury 1) The public health nurse is assessing the social environment of a community. Which of the following would be included in this assessment? A) Convenience of public transportation B) Availability of health education C) Presence of sidewalks D) Accessibility to parks Answer: B Explanation: A) The built environment is human made and includes public transportation, presence of sidewalks, and accessibility to parks. B) The social environment includes community factors such as the availability of health education. Other social factors include social networks and resources, the level of shared commitment for the values and rights of others, the general level of wealth or impoverishment of the community, the level of psychosocial stress, and the availability and accessibility of goods (e.g., sufficient food). C) The built environment is human made and includes public transportation, presence of sidewalks, and accessibility to parks. D) The built environment is human made and includes public transportation, presence of sidewalks, and accessibility to parks. Page Ref: 48 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 3.1 Describe the relationship between social environment, physical environment, built environment, genetic endowment, and health outcomes, and discuss concepts related to environmental health. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences, values | AACN Essential Competencies: VII.1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities and populations NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Consider the mechanisms that impact the relationship between environmental hazards and health.

2) The public health nurse is planning health programs using the Healthy People 2020 objectives. Which objective would be included to address the objective of reducing toxic substances and hazardous wastes? A) Encouraging use of mass transit B) Reducing lead blood levels in children C) Increasing the number of days when beaches are open and safe D) Reducing indoor mouse and cockroach allergens Answer: B Explanation: A) Healthy People objectives to improve air quality include increased use of alternative modes of transportation and mass transit to decrease emissions from motor vehicles. This objective does not address the issue of toxic substances and reducing wastes. B) An objective to reduce toxic substances and hazardous wastes includes reductions in lead blood levels in children. C) A Healthy People objective related to water quality is to increase the number of days when beaches are open and safe. This objective does not address the issue of toxic substances and reducing wastes. D) To improve the quality of home and community environments, a Healthy People objective includes reducing indoor mouse and cockroach allergens. Page Ref: 49 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 3.1 Describe the relationship between social environment, physical environment, built environment, genetic endowment, and health outcomes, and discuss concepts related to environmental health. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Recognize the effect of environmental epidemiology on the health of a population.

3) The occupational health nurse is assessing environmental hazards in a manufacturing facility that produces loud noises. This is considered which type of environmental hazard? A) Biological B) Chemical C) Physical D) Psychosocial Answer: C Explanation: A) Biological hazards are primarily exposures to microorganisms and parasites. B) Chemical hazards consist of both inorganic and organic (i.e., carbon-based) agents. C) Transfer of energy in the environment poses a physical hazard. Sources of energy include electricity, kinetic (mechanical) forces, light, radiation, sound waves, and thermal energy. D) Psychosocial hazards are stressors resulting from human interaction with the social environment that produce uncertainty, anxiety, or lack of control, often referred to as stress. Page Ref: 52 Cognitive Level: Understanding Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Assessment | Learning Outcome: 3.2 Classify environmental hazards according to their nature, transport media, routes of exposure, and outcomes. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: VII.1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities and populations NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Consider the mechanisms that impact the relationship between environmental hazards and health.

4) The nurse is teaching a prenatal class to prospective parents. Which route of exposure does the nurse teach is involved in the development of fetal alcohol syndrome? A) Inhalation B) Ingestion C) Dermal absorption D) Transplacental Answer: D Explanation: A) The actual route of exposure–how the contaminant contacts or enters the human body–can be through inhalation, ingestion, dermal absorption, or transplacentally. Inhalation occurs through the lungs. B) The actual route of exposure–how the contaminant contacts of enters the human body–can be through inhalation, ingestion, dermal absorption, or transplacentally. Ingestion occurs through the gastrointestinal tract. C) The actual route of exposure–how the contaminant contacts of enters the human body–can be through inhalation, ingestion, dermal absorption, or transplacentally. Dermal absorption occurs through the skin and mucous membranes. D) The actual route of exposure–how the contaminant contacts of enters the human body–can be through inhalation, ingestion, dermal absorption, or transplacentally. The transfer of a substance, such as alcohol, from the mother to fetus occurs transplacentally. Page Ref: 52 Cognitive Level: Understanding Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Implementation | Learning Outcome: 3.2 Classify environmental hazards according to their nature, transport media, routes of exposure, and outcomes. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Consider the mechanisms that impact the relationship between environmental hazards and health.

5) When teaching a patient about risk factors for heart disease, the nurse should explain that: A) the presence of a risk factor increases the chance of developing heart disease. B) the presence of a risk factor lowers the risk of developing heart disease. C) the presence of a risk factor determines that heart disease will develop. D) the absence of a risk factor excludes the possibility that heart disease will develop. Answer: A Explanation: A) The presence of a risk factor increases the chances of developing a disease. For example, high cholesterol increases the risk of having a heart attack. B) The presence of a risk increases, not decreases, the chances of developing a disease. C) The presence of a risk factor increases the risk of developing a disease, it does not guarantee that the disease will develop. D) The absence of a risk factor reduces the risk of developing a disease, it does not guarantee that the disease will not develop. Page Ref: 49 Cognitive Level: Remembering Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 3.3 Discuss how key concepts from environmental health related sciences are applied in the assessment, intervention, and evaluation process to control or prevent environmental health problems. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Recognize the effect of environmental epidemiology on the health of a population.

6) Which of the following is not the role of the epidemiology nurse? A) Caring for individual patients in need of health care B) Studying the distribution of disease in a population C) Controlling disease outbreaks D) Analyzing health data Answer: A Explanation: A) Epidemiology does not involve the care of individual patients. Epidemiology is the study of the distribution of the health status and outcomes in defined populations, associated factors of influence, and interventions to prevent or control health problems on the basis of epidemiologic findings. It also involves the collection, analysis, and interpretation of health data on populations to design and implement interventions to prevent and control health problems. B) Epidemiology is the study of the distribution of the health status and outcomes in defined populations. C) Epidemiology is the study of interventions to prevent or control health problems and disease outbreaks. D) Epidemiology involves the collection, analysis, and interpretation of health data on populations to design and implement interventions to prevent and control health problems. Page Ref: 53 Cognitive Level: Remembering Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 3.3 Discuss how key concepts from environmental health related sciences are applied in the assessment, intervention, and evaluation process to control or prevent environmental health problems. | QSEN Competencies: II.A.2. Describe scopes of practice and roles of health care team members | AACN Essential Competencies: Describe scopes of practice and roles of health care team members NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Recognize the effect of environmental epidemiology on the health of a population.

7) What activities are performed by the public health nurse engaged in the process surveillance? A) Providing direct care to patients in a clinic B) Administering vaccinations in an elementary school C) Collecting data from occupational health records D) Providing community education on dangers of lead poisoning in children Answer: C Explanation: A) Surveillance does not entail providing direct care to individual patients. B) Surveillance does not include administering vaccinations. C) Surveillance is a public health function in which health data on populations are systematically collected, analyzed, and interpreted and used to design and implement interventions to prevent and control health problems. Surveillance includes screening individuals for exposure to hazards and disease and injury outcomes. It uses various data sources, including clinical and occupational records, disease registries, birth and death records, and environmental monitoring. It does not include actions taken as a result of this surveillance. D) Surveillance does not include educating the community. Page Ref: 53 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 3.3 Discuss how key concepts from environmental health related sciences are applied in the assessment, intervention, and evaluation process to control or prevent environmental health problems. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: VII.3 Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities and populations. NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Recognize the effect of environmental epidemiology on the health of a population.

8) Which of the following would be considered a sentinel health event by the public health nurse? A) Several nonsmokers in a community who develop lung cancer B) An individual nonsmoker who develops cancer C) Genetically related nonsmoking family members who develop lung cancer D) A cluster of smokers in a community who develop lung cancer Answer: A Explanation: A) Some diseases are considered sentinel health events, meaning that they herald an environmental health problem not just for an individual, but also potentially for others in the home, work, and community environments. Environmental sentinel health events involve atypical health occurrences and are more likely to be recognized through population-based surveillance conducted by public health agencies, such as lung cancer that develops in people who are nonsmokers. B) Sentinel health events involve atypical health occurrences and are more likely to be recognized through population-based surveillance conducted by public health agencies, such as lung cancer that develops in people who are nonsmokers or in a cluster of genetically unrelated people. C) Environmental sentinel health events involve atypical health occurrences and are more likely to be recognized through population-based surveillance conducted by public health agencies, such as lung cancer that develops in people who are nonsmokers or in a cluster of genetically unrelated people. D) A cluster of smokers who develop lung cancer is not atypical and therefore not a sentinel event. Page Ref: 54 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 3.3 Discuss how key concepts from environmental health related sciences are applied in the assessment, intervention, and evaluation process to control or prevent environmental health problems. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Recognize the effect of environmental epidemiology on the health of a population.

9) In planning care for the elderly population, the nurse should be aware that this population is susceptible to environmental hazards due to: A) increased metabolic rate. B) increased surface-to-body mass ratio. C) increased blood flow. D) reduced cell-mediated immunity. Answer: D Explanation: A) Older adults have a lower (not higher) metabolic rate than middle-aged adults or children, and this does not make them more susceptible to environmental hazards. B) Children have a greater surface-to-body mass ratio causing them to absorb more toxicants per kilogram than an adult. C) Older adults have a reduced, not increased, blood flow to the liver and kidneys, resulting in reduced ability to detoxify and eliminate toxicants. D) A decline in cell-mediated immunity increases older adults' risks for viruses and cancer. Page Ref: 59 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 3.3 Discuss how key concepts from environmental health related sciences are applied in the assessment, intervention, and evaluation process to control or prevent environmental health problems. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Examine the basic pathophysiological mechanisms underlying alterations caused by environmental hazards.

10) The nurse is teaching a community program on ways to reduce mercury in the diet. Which of the following should the nurse include in the teaching sessions? A) Smaller fish have less mercury. B) Larger fish have less mercury. C) Cooking fish destroys mercury. D) Removing skin reduces the amount of mercury. Answer: A Explanation: A) Larger fish and fish that are higher on the food chain bioconcentrate methylmercury deposits found in the muscle tissue of their prey (smaller fish). Therefore, smaller fish contain less mercury. B) Larger fish and fish that are higher on the food chain bioconcentrate methylmercury deposits found in the muscle tissue of their prey (smaller fish). Therefore, larger fish will have more methylmercury deposits. C) Cooking methods cannot decrease the amount of methylmercury in fish because mercury binds tightly to protein that forms the muscle tissue, which is consumed. D) Removing the skin does not decrease the amount of methylmercury in fish because mercury binds tightly to protein that forms the muscle tissue, which is consumed. Page Ref: 62 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 3.3 Discuss how key concepts from environmental health related sciences are applied in the assessment, intervention, and evaluation process to control or prevent environmental health problems. | QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Recognize how environmental health-related sciences are applied to control or prevent environmental health problems.

11) When the occupational health nurse reviews a manufacturing plant's policies regarding airborne health hazards in the workplace, which principle of industrial hygiene is most important? A) Mandating the use of a personal mask or respirator B) Reducing the quantities of particles released in the air C) Conducting training sessions on improving air quality D) Developing polices regarding reduction exposure to airborne particles Answer: B Explanation: A) Principles of industrial hygiene include the concept of a hierarchy of controls ranking engineering controls as first and foremost and administrative controls/education and personal protective equipment as important but not to be used instead of engineering controls. B) Principles of industrial hygiene include the concept of a hierarchy of controls ranking engineering controls as first and foremost. Engineering controls limit exposures by modifying the source of contaminants or reducing the quantity of contaminants released into the environment. C) Principles of industrial hygiene include the concept of a hierarchy of controls ranking engineering controls as first and foremost and administrative controls/education and personal protective equipment as important but not to be used instead of engineering controls. D) Principles of industrial hygiene include the concept of a hierarchy of controls ranking engineering controls as first and foremost and administrative controls (such as developing policies regarding reduction of exposure), education, and personal protective equipment as important but not to be used instead of engineering controls Page Ref: 62 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Assessing | Learning Outcome: 3.3 Discuss how key concepts from environmental health related sciences are applied in the assessment, intervention, and evaluation process to control or prevent environmental health problems. | QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Recognize how environmental health-related sciences are applied to control or prevent environmental health problems.

12) When planning for a community education program on injury prevention, what statistic should the nurse keep in mind? A) Homicide is the leading cause of death for people ages 15 to 34 years B) Suicide is the leading cause of death for people ages 10 to 35 years C) Motor vehicle accidents are the fourth-leading cause of death for people in all age groups D) Unintentional injuries is the leading cause of death for people ages 1 to 44 years Answer: D Explanation: A) In 2014 in the United States, homicide was the third-leading cause of death for people ages 1-4 years and 15-34 years. B) In 2014 in the United States, suicide was the second-leading cause of death for people ages 10-34 years and the fourth-leading cause for those ages 35-54 years. C) In 2014 in the United States, motor vehicle crashes were the fourth-leading cause of nonfatal injuries overall. D) In 2014 in the United States, unintentional injuries ranked as the fourth-leading cause of death overall and the leading cause for persons ages 1-44 years, followed by motor vehicle crashes, suicide, and homicide. Page Ref: 65 Cognitive Level: Remembering Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 3.4 Explain how environmental epidemiology is used to understand and protect the health of individuals, communities, and populations regarding environmental hazards. | QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Recognize the effect of environmental epidemiology on the health of a population.

13) The occupational health nurse is teaching industrial plant employees about the routes of exposure for chemicals used in the plant. The nurse bases the program on the knowledge that the main route of occupational exposure is: A) inhalation. B) ingestion. C) dermal absorption. D) transplacentally. Answer: A Explanation: A) The actual route of exposure–how the contaminant contacts or enters the human body–can be through inhalation, ingestion, dermal absorption, or transplacentally. The primary route of exposure in occupational settings is inhalation. B) The primary route of exposure to chemicals in the environment (e.g., at home, at school, during recreational activities) is ingestion. C) Dermal absorption may occur in the workplace; however, the primary route of exposure in occupational settings is inhalation. D) Transplacental exposure occurs when chemicals cross the placental barrier to the fetus; however, the primary route of exposure in occupational settings is inhalation. Page Ref: 62 Cognitive Level: Remembering Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Implementation | Learning Outcome: 3.2 Classify environmental hazards according to their nature, transport media, routes of exposure, and outcomes. | QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Recognize the effect of environmental epidemiology on the health of a population.

14) The school nurse is planning health prevention programs for the parents of elementary school-age children. The nurse should take into account that which condition is caused 100% by environmental exposure? A) Lead poisoning B) Asthma C) Cancer D) Behavioral disorders Answer: A Explanation: A) Environmental exposure is the source of 100% of lead poisonings. B) Environmental exposure is the source of 30% of cases of asthma. C) Environmental exposure is the source of 5% of cancers. D) Environmental exposure is the source of 10% of cases of autism, cerebral palsy, and mental retardation. Page Ref: 65 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 3.4 Explain how environmental epidemiology is used to understand and protect the health of individuals, communities, and populations regarding environmental hazards. | QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Recognize the effect of environmental epidemiology on the health of a population.

15) The nurse is explaining the epigenetic transgenerational inheritance due to diethylstilbestrol (DES) to a patient whose mother took DES while pregnant with her. What statement indicates that the patient understands the inheritance of epigenetic-induced changes? A) "My children won't be affected because I didn't take DES." B) "I can pass on these changes to my children." C) "Changes cannot be passed on to my grandchildren." D) "DES changes are not inherited." Answer: B Explanation: A) Exposure of a pregnant woman to such an agent as DES can result in epigenetic-induced changes that may be passed on to successive generations (i.e., great grandchildren and beyond) whether or not they are exposed to DES. B) Epigenetic transgenerational inheritance due to environmental exposures results in altered epigenetic information of the germ line that is passed on to subsequent generations without continued environmental exposures. Thus, exposure of a pregnant woman to such an agent as DES can result in epigenetic-induced changes that may be passed on to successive generations (i.e., great grandchildren and beyond) whether or not they are exposed to DES. C) Exposure of a pregnant woman to such an agent as DES can result in epigenetic-induced changes that may be passed on to successive generations (i.e., great grandchildren and beyond) whether or not they are exposed to DES. D) Epigenetic transgenerational inheritance due to environmental exposures results in altered epigenetic information of the germ line that is passed on to subsequent generations without continued environmental exposures. Page Ref: 67 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Evaluation | Learning Outcome: 3.5 Explain the basic pathophysiologic mechanisms underlying alterations caused by environmental hazards. | QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX. 2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Examine the basic pathophysiological mechanisms underlying alterations caused by environmental hazards.

16) Which assessment data will give the nurse the best information to determine exposure to environmental hazards? A) Physical examination B) Laboratory tests C) Health history D) Nutritional history Answer: C Explanation: A) A physical examination may help to find exposure illnesses to environmental hazards, but has to be accompanied first by a health history. B) Depending on the health history, biomonitoring of actual exposures may be done that often includes venous blood, urine samples, or other specimens. C) The patient's health history is the most critical means to determine exposure to environmental agents. To be effective, the health history must include details about exposure to biological, chemical, physical, and psychosocial agents at work, in the home, and in the community for both present and past exposures. In addition, the health history should elicit information regarding the degree to which engineering, work practices, and PPEs are and were used to control hazards. D) Based on the patient's health history, nutritional history may be performed, but is not the top priority for assessment. Page Ref: 69 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 3.6 Analyze the relationship between various hazardous agents and the health effects they produce. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Examine the basic pathophysiological mechanisms underlying alterations caused by environmental hazards.

17) An occupational health nurse works in a chemical plant that follows the precautionary principle. Which of the following actions exemplifies this principle? A) Taking preventative action even with uncertainty about the threat to health B) Taking preventative action only when scientific evidence points to a threat to health C) Taking action only when a cause-and-effect relationship has been proven D) Taking action only when the risk is unacceptable Answer: A Explanation: A) One approach to risk assessment is precautionary principle, which asserts that interventions must be taken when an environmental threat to human health is feasible, even if scientific evidence is not conclusive. B) Although risk assessments are done on environmental exposure, there may not be scientific evidence on every cause; therefore, the prevention principle covers what may occur in a setting. C) The precautionary principle asserts that interventions must be taken when an environmental threat to human health is feasible. Not taking action unless an effect is seen may be too late and is not sound nursing practice. D) Again, sound nursing practice is taking action to prevent a risk, not waiting for one to occur and cause injury. Page Ref: 71 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 3.6 Analyze the relationship between various hazardous agents and the health effects they produce. | QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Recognize how environmental health-related sciences are applied to control or prevent environmental health problems.

18) When assessing physiological responses to psychosocial hazards, which assessment data indicates that a patient is showing physiological effects of these hazards? A) Constipation B) Hypotension C) Bradycardia D) Hypoglycemia Answer: A Explanation: A) Physiologic ramifications of psychological stress may include increases in heart rate, blood pressure, and respiration as well as increased production of stress hormones (causing hyperglycemia for fight-or-flight reaction) and decreased digestive motility (leading to constipation). B) Physiologic ramifications of psychological stress may include increases in heart rate, blood pressure, and respiration as well as increased production of stress hormones (causing hyperglycemia for fight-or-flight reaction) and decreased digestive motility (leading to constipation). C) Physiologic ramifications of psychological stress may include increases in heart rate, blood pressure, and respiration as well as increased production of stress hormones (causing hyperglycemia for fight-or-flight reaction) and decreased digestive motility (leading to constipation). D) Physiologic ramifications of psychological stress may include increases in heart rate, blood pressure, and respiration as well as increased production of stress hormones (causing hyperglycemia for fight-or-flight reaction) and decreased digestive motility (leading to constipation). Page Ref: 71 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 3.6 Analyze the relationship between various hazardous agents and the health effects they produce. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes MNL Learning Outcome: LO 4: Examine the basic pathophysiological mechanisms underlying alterations caused by environmental hazards.

19) According to the Evans and Stoddart ecological model, which of the following is part of the social environment at the individual level? A) Respect for the rights of others B) Availability of sufficient food C) Access to health education D) Employment status Answer: D Explanation: A) At the local community level, the social environment includes neighborhood and community factors such as social networks and resources, shared commitment toward and respect for the values and rights of others, the general level of wealth or impoverishment of the community, the level of psychosocial stress, and the availability and accessibility of goods (e.g., sufficient food) and services, including health and education. B) At the local community level, the social environment includes neighborhood and community factors such as social networks and resources, shared commitment toward and respect for the values and rights of others, the general level of wealth or impoverishment of the community, the level of psychosocial stress, and the availability and accessibility of goods (e.g., sufficient food) and services, including health and education. C) At the local community level, the social environment includes neighborhood and community factors such as social networks and resources, shared commitment toward and respect for the values and rights of others, the general level of wealth or impoverishment of the community, the level of psychosocial stress, and the availability and accessibility of goods (e.g., sufficient food) and services, including health and education. D) The social environment at the individual level include both social and psychosocial factors in the environment such as gender, education, employment status, social networks, and interpersonal interactions. Page Ref: 48 Cognitive Level: Remembering Client Need & Sub: Psychosocial Integrity Standards: Nursing Process: Assessment | Learning Outcome: 3.1 Describe the relationship between social environment, physical environment, built environment, genetic endowment, and health outcomes, and discuss concepts related to environmental health. | QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Consider the mechanisms that impact the relationship between environmental hazards and health.

20) The occupational health nurse is biomonitoring workers for exposure to chemicals in the workplace. When should the nurse obtain blood and urine samples? A) At the beginning of the work shift B) In the middle of the work shift C) At the end of the work shift D) During the pre-employment physical Answer: C Explanation: A) Workers have not been exposed to a chemical at the beginning of a shift, and therefore, biomonitoring may not show any results. B) The biomonitoring of workers should take place when workers have been exposed to hazards for 8 or more hours. C) For biomonitoring of workers, venous blood, urine samples, or other specimens (depending on the chemical or metabolites measured) should be taken at the end of a work shift after workers have been exposed for 8 or more hours to obtain the best results of exposure. D) Unless the individual has been exposed to chemicals at a recent, former job, this would not be necessary for a pre-employment physical. Page Ref: 69 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 3.6 Analyze the relationship between various hazardous agents and the health effects they produce. | QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Examine the basic pathophysiological mechanisms underlying alterations caused by environmental hazards.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 4 Stress and Adaptation 1) Which statement by a patient indicates to the nurse that more teaching about the effects of stress is needed? A) "Stress is a psychological and physiological response." B) "Stress can lead to poor health." C) "Coping strategies help a person adapt to stress." D) "Smoking is a useful coping strategy." Answer: D Explanation: A) Stress is the psychologic and physiologic response of an organism to an event that is often perceived as a threat or challenge. B) Stress is the psychologic and physiologic response of an organism to an event that is often perceived as a threat or challenge. Most conceptualizations of stress propose that this negative perception produces a state of physiologic arousal that ultimately has adverse health consequences for the individual. C) Coping is the dynamic process through which individuals apply psychologic and behavioral measures to handle internal and external stress demands. The individual's ability to adapt depends on the resources that are available and the coping strategies that can be implemented at the time. D) Stress elicits responses, either physiologic or psychologic (e.g., smoking, substance use), that can place the individual at risk for disease. Page Ref: 78 Cognitive Level: Applying Client Need & Sub: Psychological Integrity Standards: Nursing Process: Evaluation | Learning Outcome: 4.1 Define stress, coping, and adaptation, and list concepts related to stress. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and selfcare management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine concepts of stress and how the body responds.

2) When planning care for a trauma patient, which statement does the nurse understand best describes the body's response to stress? A) The stress response is the result of stimulation of the sympathetic nervous system. B) The stress response boosts the adaptive immune response. C) The stress response suppresses the hypothalamic-pituitary-adrenal axis. D) The stress response has a negative effect on the endogenous opioid pathway. Answer: A Explanation: A) Stress activates various central nervous system pathways, including the hypothalamic-pituitary-adrenal axis, the sympathetic nervous system, and the endogenous opioid pathway. Activation of these pathways increases the levels of neuroendocrine hormones, which subsequently lead to suppressed innate and adaptive immune responses. B) Stress activates various central nervous system pathways, including the hypothalamicpituitary-adrenal axis, the sympathetic nervous system, and the endogenous opioid pathway. Activation of these pathways increases the levels of neuroendocrine hormones, which subsequently lead to suppressed innate and adaptive immune responses. C) Stress activates various central nervous system pathways, including the hypothalamicpituitary-adrenal axis, the sympathetic nervous system, and the endogenous opioid pathway. Activation of these pathways increases the levels of neuroendocrine hormones, which subsequently lead to suppressed innate and adaptive immune responses. D) Stress activates various central nervous system pathways, including the hypothalamicpituitary-adrenal axis, the sympathetic nervous system, and the endogenous opioid pathway. Activation of these pathways increases the levels of neuroendocrine hormones, which subsequently lead to suppressed innate and adaptive immune responses. Page Ref: 79 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 4.2 Summarize the major conceptual approaches to the study of stress. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine concepts of stress and how the body responds.

3) Which manifestations is the nurse likely to assess in a patient with stimulating effects of acute stress? A) Dry skin, reduced respiratory rate B) Increased blood glucose levels, pupil dilation C) Hypotension, reduced visual perception D) Decreased urine production, hypoglycemia Answer: B Explanation: A) Stimulating consequences of stress include increased blood flow to brain, improved hearing ability, improved visual perception, pupil dilation, increased perspiration, increased respiration rate, increased blood-clotting ability, increased heart rate, increased blood pressure, release of glucose into the bloodstream, and increased blood flow to muscles. Inhibiting consequences of stress include reduced digestive system activity, reduced immune system activity, and reduced urine production. B) Stimulating consequences of stress include increased blood flow to brain, improved hearing ability, improved visual perception, pupil dilation, increased perspiration, increased respiration rate, increased blood-clotting ability, increased heart rate, increased blood pressure, release of glucose into the bloodstream, and increased blood flow to muscles. Inhibiting consequences of stress include reduced digestive system activity, reduced immune system activity, and reduced urine production. C) Stimulating consequences of stress include increased blood flow to brain, improved hearing ability, improved visual perception, pupil dilation, increased perspiration, increased respiration rate, increased blood-clotting ability, increased heart rate, increased blood pressure, release of glucose into the bloodstream, and increased blood flow to muscles. Inhibiting consequences of stress include reduced digestive system activity, reduced immune system activity, and reduced urine production. D) Stimulating consequences of stress include increased blood flow to brain, improved hearing ability, improved visual perception, pupil dilation, increased perspiration, increased respiration rate, increased blood-clotting ability, increased heart rate, increased blood pressure, release of glucose into the bloodstream, and increased blood flow to muscles. Inhibiting consequences of stress include reduced digestive system activity, reduced immune system activity, and reduced urine production. Page Ref: 79 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 4.2 Summarize the major conceptual approaches to the study of stress. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Examine the pathogenesis and clinical manifestations of stress on health.

4) The patient with chronic stress is likely to exhibit which immune response? A) Increased leukocyte mobilization to the skin B) Suppressed delayed-type hypersensitivity responses C) Enhanced production of chemokines D) Enhanced production of cytokines Answer: B Explanation: A) Chronic stress significantly suppresses delayed-type hypersensitivity responses and decreases leukocyte mobilization to the skin. Acute stress enhances the delayed-type hypersensitivity response and increases leukocyte mobilization. In response to immunologic challenge, acutely stressed individuals show significantly greater leukocyte infiltration and enhanced production of chemokines and cytokines. B) Chronic stress significantly suppresses delayed-type hypersensitivity responses and decreases leukocyte mobilization to the skin. Acute stress enhances the delayed-type hypersensitivity response and increases leukocyte mobilization. In response to immunologic challenge, acutely stressed individuals show significantly greater leukocyte infiltration and enhanced production of chemokines and cytokines. C) Chronic stress significantly suppresses delayed-type hypersensitivity responses and decreases leukocyte mobilization to the skin. Acute stress enhances the delayed-type hypersensitivity response and increases leukocyte mobilization. In response to immunologic challenge, acutely stressed individuals show significantly greater leukocyte infiltration and enhanced production of chemokines and cytokines. D) Chronic stress significantly suppresses delayed-type hypersensitivity responses and decreases leukocyte mobilization to the skin. Acute stress enhances the delayed-type hypersensitivity response and increases leukocyte mobilization. In response to immunologic challenge, acutely stressed individuals show significantly greater leukocyte infiltration and enhanced production of chemokines and cytokines. Page Ref: 80 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 4.2 Summarize the major conceptual approaches to the study of stress. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Examine the pathogenesis and clinical manifestations of stress on health.

5) When describing the state of homeostasis to nursing students, the nurse explains that: A) it is a state of internal stability. B) it is a state of positive feedback. C) it is a state of flux and change. D) it is a state the drives the body away from its resting or set point. Answer: A Explanation: A) Homeostasis indicates the presence of an internal state of balance. B) The concept of homeostasis is built around the idea of negative feedback. The presence of a physiologic mediator can serve to shut off its own release or the release of another mediator. C) The body is in a continual state of flux, with some physiologic mechanisms in play and others at rest, so the body must respond appropriately to a multitude of environmental demands. This state of flux is referred to as allostasis. D) Emotional states can trigger a defensive response by stimulating arousal of the SNS. This sympathetic response could be seen as causing the body to deviate from a normal resting or set point. Other physiologic mechanisms are then brought into play in an attempt to return to the body to the set point–to a state of balance. Page Ref: 81-82 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 4.3 Compare and contrast homeostasis and allostasis. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine concepts of stress and how the body responds.

6) The nurse is assessing a patient who was recently divorced and is now living in a temporary shelter after losing her home in a hurricane. Which finding indicates that the patient is experiencing allostatic load? A) The patient is in a state of exhaustion. B) The patient is using available resources to respond to stress. C) The patient is making healthy lifestyle choices. D) The patient is in an internal state of balance. Answer: A Explanation: A) The individual experiences multiple stressors that may be novel or to which the individual cannot attach appropriate meaning. The experience of uncertain or novel events puts the individual in the position of experiencing repeated stressful events, each of which evokes a stress response. The mechanisms involved in responding to stress can cause the individual to experience a state of exhaustion. These mechanisms may also fail to cease function after removal of the stressing event, or falter in providing a response to the initial event. When these situations occur, the individual is experiencing a state of allostatic load. B) In allostatic load, adaptation fails, and the individual is no longer capable of adapting or adjusting to environmental events. The stress response is inappropriately prolonged, and the normative suppressing mechanisms fail. C) In allostatic load, adaptation fails, and the individual is no longer capable of adapting or adjusting to environmental events. The stress response is inappropriately prolonged, and the normative suppressing mechanisms fail. D) In allostatic load, the individual's physiologic response is inadequate to meet the imposed demands. This leads to a process of secondary activation of other mediator mechanisms in an attempt to respond to the demand. Page Ref: 82 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity Standards: Nursing Process: Assessment | Learning Outcome: 4.3 Compare and contrast homeostasis and allostasis. | QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Examine the pathogenesis and clinical manifestations of stress on health.

7) The nurse in the student health center is counseling a college student who reports high levels of stress before each exam, causing his heart to race and affecting his ability to concentrate. The nurse assesses that this student is in which stage of the general adaptation syndrome during an exam? A) Stage of alarm B) Stage of resistance C) Stage of exhaustion D) Stage of resolution Answer: A Explanation: A) During the stage of alarm, there is a rapid production of catecholamine causing increases in both heart rate and mean arterial blood pressure. Alarm is a pattern of physiologic activation originally conceptualized as occurring in response to the injection of noxious agents or physical stressors. Physical stressors include issues that reflect overall health and can place the individual at increased risk. These changes are even found to occur in anticipation of a stressor, as when an individual becomes anxious before a test. B) The stage of resistance could be viewed as a period of homeostasis. An individual cannot tolerate the physiologic changes that occur during the stage of alarm for long. The pattern of response that is seen in the stage of alarm is eventually countered by the release of cortisol and other mediators in the stage of resistance. C) In the stage of exhaustion, the individual has lost the capacity to sustain a defense against stress. The organs are no longer able to release balancing mediators, and organ damage begins to occur. D) The stage of resolution is not part of the general adaptation syndrome. Page Ref: 82 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 4.4 Compare and contrast the various models of stress response. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Examine the pathogenesis and clinical manifestations of stress on health.

8) Using a transactional approach to stress, the nurse recognizes that a person's response to stress depends on: A) the nature of the environmental threat that requires a response. B) a physiological response to stress C) the person's perceived meaning of the stressful event. D) the fight-or-flight response. Answer: C Explanation: A) Using the stimulus conceptualization of stress, stress is seen as an environmental threat or danger that requires response, such as a physical threat or the death of a loved one. B) The General Adaptation Syndrome (GAS) focuses on the body's physiologic response to stress. It is best viewed as an adaptive response to stress that consists of three distinct stages: a pattern of alarm followed by a stage of resistance as the individual attempts to compensate for changes induced by the stage of alarm. A stage of exhaustion can follow if the individual cannot successfully adapt to the physiologic changes that occur during the stage of resistance. C) The conceptualization of stress as a transaction emphasizes individual perception (or appraisal) of the given event as the most significant factor in the process. The response depends on how the event or situation interacts with the individual's existing coping resources and the perceived meaning of the event. D) In the GAS, the sympathetic system is responsible for the release of catecholamines (norepinephrine, epinephrine), which activate the fight-or-flight response. Page Ref: 82-83 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Psychosocial Integrity Standards: Nursing Process: Assessment | Learning Outcome: 4.4 Compare and contrast the various models of stress response. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate the mechanisms whereby stress contributes to the development or exacerbation of mental health disorders.

9) Which of the following concepts should guide a nurse's plan of care for a pregnant woman who has just lost her home due to a forest fire? A) The symptoms of acute stress disorder (ASD) develop more than one month after the traumatic event B) Pathologic stress responses can affect the encoding and retrieval of memories C) The release of dopamine in the medulla oblongata contributes to the development of posttraumatic stress disorder (PTSD) D) Elevated stress levels during pregnancy are not associated with adverse fetal outcomes. Answer: B Explanation: A) In ASD, symptoms are expected to occur within 1 month of the traumatic event, and symptoms are not expected to last longer than 4 weeks. In PTSD, symptoms are expected to take longer than 1 month to develop. B) The acute stress state leads to increased release of norepinephrine within the hippocampus and other brain areas, which in turn affects the encoding and retrieval of memory. C) The release of dopamine from the prefrontal cortex is enhanced in the presence of stressors of great intensity or long duration. This release of dopamine has been thought to contribute to the development of PTSD. D) Heightened stress levels during pregnancy are associated with lower fetal birth weight and preterm birth. Page Ref: 89 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity Standards: Nursing Process: Planning | Learning Outcome: 4.6 Explain the mechanisms whereby stress contributes to the development or exacerbation of psychiatric disorders such as depression, anxiety, and posttraumatic stress disorder. | QSEN Competencies: I.A.9 Discuss principles of effective communication | AACN Essential Competencies: IX.21. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship NLN Competencies: Relationship Centered Care: Effective Communication MNL Learning Outcome: LO 2: Examine the pathogenesis and clinical manifestations of stress on health.

10) While teaching a prenatal class, a participant asks about the effects of stress on the fetus. Which response should the nurse make? A) "The placenta protects the baby from maternal stress." B) "High levels of stress can lead to preterm birth." C) "Heightened stress can lead to a higher fetal birth weight." D) "The baby is not affected by maternal stress." Answer: B Explanation: A) Heightened stress levels during pregnancy are associated with lower fetal birth weight and preterm birth. The placenta does not offer protection to the effects of stress. B) Heightened stress levels during pregnancy are associated with lower fetal birth weight and preterm birth. C) Heightened stress levels during pregnancy are associated with lower fetal birth weight and preterm birth. D) Heightened stress levels during pregnancy are associated with lower fetal birth weight and preterm birth. Page Ref: 89 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 4.6 Explain the mechanisms whereby stress contributes to the development or exacerbation of psychiatric disorders such as depression, anxiety, and posttraumatic stress disorder. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4.6: Explain the mechanisms whereby stress contributes to the development or exacerbation of psychiatric disorders such as depression, anxiety, and posttraumatic stress disorder.

11) The nurse should expect to observe which behavior in a patient with posttraumatic stress disorder? A) Normal memory recall B) Hyporeflexia C) Euphoria D) Hypervigilance Answer: D Explanation: A) The HPA axis plays a role in affecting the memory of individuals with PTSD. The experiencing of intrusive thoughts and memories in a manner beyond the person's control may result in increased cortisol levels. A period of exposure to levels of cortisol often associated with psychologic and physical stress has been shown to produce reversible alterations of declarative memory, which governs the conscious recall of long-term memories. B) Stressors that are seen as uncontrollable may lead to a sensitization of catecholamine receptors that manifests as hypervigilance, increased autonomic nervous system hyperreactivity, and increased startle response. C) Stressors that are seen as uncontrollable may lead to a sensitization of catecholamine receptors that manifests as hypervigilance, increased autonomic nervous system hyperreactivity, and increased startle response. D) The release of dopamine from the prefrontal cortex is enhanced in the presence of stressors of great intensity or long duration. This release of dopamine has been thought to contribute to the development of PTSD through effects on neurons in the prefrontal cortex, leading a state of hypervigilance. Page Ref: 89 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity Standards: Nursing Process: Assessment | Learning Outcome: 4.6 Explain the mechanisms whereby stress contributes to the development or exacerbation of psychiatric disorders such as depression, anxiety, and posttraumatic stress disorder. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate the mechanisms whereby stress contributes to the development or exacerbation of mental health disorders.

12) Which response by a patient indicates an understanding of the effects of stress on her asthma? A) "Stress decreases my rate of breathing and makes my breathing easier." B) "Stress decreases the amount of oxygen I need and helps my breathing." C) "Stress dilates my airways, allowing me to get more oxygen." D) "Stress causes inflammation of the airways which can trigger asthma attacks." Answer: D Explanation: A) Through activation of sympathetic pathways, stress results in increased respiratory and heart rates. This results in an increase in the rate of oxygen consumption. There is evidence that psychologic stress can worsen asthma through induction of respiratory constriction. Such stress-induced inflammation could be associated with increased stress responsivity on the part of certain asthma patients. B) Through activation of sympathetic pathways, stress results in increased respiratory and heart rates. This results in an increase in the rate of oxygen consumption. There is evidence that psychologic stress can worsen asthma through induction of respiratory constriction. Such stressinduced inflammation could be associated with increased stress responsivity on the part of certain asthma patients. C) Through activation of sympathetic pathways, stress results in increased respiratory and heart rates. This results in an increase in the rate of oxygen consumption. There is evidence that psychologic stress can worsen asthma through induction of respiratory constriction. Such stressinduced inflammation could be associated with increased stress responsivity on the part of certain asthma patients. D) Through activation of sympathetic pathways, stress results in increased respiratory and heart rates. This results in an increase in the rate of oxygen consumption. There is evidence that psychologic stress can worsen asthma through induction of respiratory constriction. Such stressinduced inflammation could be associated with increased stress responsivity on the part of certain asthma patients. Page Ref: 89 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 4.7 Explain the mechanisms whereby stress contributes to the development or exacerbation of physiologic disorders such as multiple sclerosis, inflammatory bowel disease, and coronary artery disease. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Relate the mechanisms whereby stress contributes to the development or exacerbation of physiologic disorders.

13) When reviewing the medical history of a patient with multiple sclerosis (MS), the nurse is most likely to observe which of the following? A) Elevated IL-12 B) Decreased interferon gamma C) Elevated IL-10 D) Decreased tumor necrosis factor alpha Answer: A Explanation: A) Individuals with MS have demonstrated a cytokine profile characterized by elevated levels of select pro-inflammatory cytokines, such as IL-12, interferon gamma, IL-6, and tumor necrosis factor alpha, in conjunction with decreased production of anti-inflammatory (particularly IL-10) cytokines. B) Individuals with MS have demonstrated a cytokine profile characterized by elevated levels of select pro-inflammatory cytokines, such as IL-12, interferon gamma, IL-6, and tumor necrosis factor alpha, in conjunction with decreased production of anti-inflammatory (particularly IL-10) cytokines. C) Individuals with MS have demonstrated a cytokine profile characterized by elevated levels of select pro-inflammatory cytokines, such as IL-12, interferon gamma, IL-6, and tumor necrosis factor alpha, in conjunction with decreased production of anti-inflammatory (particularly IL-10) cytokines. D) Individuals with MS have demonstrated a cytokine profile characterized by elevated levels of select pro-inflammatory cytokines, such as IL-12, interferon gamma, IL-6, and tumor necrosis factor alpha, in conjunction with decreased production of anti-inflammatory (particularly IL-10) cytokines. Page Ref: 90 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 4.7 Explain the mechanisms whereby stress contributes to the development or exacerbation of physiologic disorders such as multiple sclerosis, inflammatory bowel disease, and coronary artery disease. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Relate the mechanisms whereby stress contributes to the development or exacerbation of physiologic disorders.

14) Which concept of stress should the nurse apply when planning care for the patient with inflammatory bowel disease? A) Stress may cause increased gastric emptying time. B) Stress may increase catecholamine production. C) Stress may reduce sympathetic responsiveness. D) Stress exacerbates the hypothalamic-pituitary-adrenal (HPA) response. Answer: B Explanation: A) Stress has been shown to slow gastric emptying and to increase motility of the colon. B) A state of hypervigilance and increased catecholamine production can contribute to the development of inflammatory bowel disease by increasing motor activity of the colon. C) The development of a pattern of increased sympathetic responsiveness to stress may play a role in the development of inflammatory bowel disease. D) A blunted HPA response may be present in individuals with inflammatory bowel disease, contributing to disease by the individual's inability to limit the sympathetic response to stress. Page Ref: 90 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 4.7 Explain the mechanisms whereby stress contributes to the development or exacerbation of physiologic disorders such as multiple sclerosis, inflammatory bowel disease, and coronary artery disease. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Relate the mechanisms whereby stress contributes to the development or exacerbation of physiologic disorders.

15) A 38-year-old woman, with no history of diabetes, has an elevated blood glucose level on the first postoperative day following an elective hysterectomy. Which response should the nurse give the patient? A) "This means that you are at risk for developing diabetes." B) "You probably have diabetes but did not know it." C) "This is a normal stress response following surgery." D) "Do you have a family history of diabetes?" Answer: C Explanation: A) The presence of stress, either physical (such as postoperative or posttraumatic) or psychological, can lead to elevations in blood glucose level. Such elevations do not mean that the patient had developed diabetes; they indicate transient elevations due to the release of cortisol influencing the production and release of glucose. B) The presence of stress, either physical (such as postoperative or posttraumatic) or psychological, can lead to elevations in blood glucose level. Such elevations do not mean that the patient had developed diabetes; they indicate transient elevations due to the release of cortisol influencing the production and release of glucose. C) The presence of stress, either physical (such as postoperative or posttraumatic) or psychological, can lead to elevations in blood glucose level. Such elevations do not mean that the patient had developed diabetes; they indicate transient elevations due to the release of cortisol influencing the production and release of glucose. D) The presence of stress, either physical (such as postoperative or posttraumatic) or psychological, can lead to elevations in blood glucose level. Such elevations do not mean that the patient had developed diabetes; they indicate transient elevations due to the release of cortisol influencing the production and release of glucose. Page Ref: 91 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 4.7 Explain the mechanisms whereby stress contributes to the development or exacerbation of physiologic disorders such as multiple sclerosis, inflammatory bowel disease, and coronary artery disease. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Examine the pathogenesis and clinical manifestations of stress on health.

16) Which laboratory value would the nurse expect in a patient with chronic stress and a reduced cell-mediated immune response to viral infection? A) Increased natural killer cell activity B) Reduced CD8+ activity C) Increased cytotoxic T lymphocyte activity D) Increased B lymphocyte (CD19+) activity Answer: B Explanation: A) Natural killer (NK) cells constitute the body's first line of defense against virus infections. These cells are a component of the innate immune system and play a key role in controlling and lysing virus infected cells during the early phase of a viral infection. Greater NK cell numbers and/or greater cytolytic activity increases one's natural resistance to viruses. Chronic stress results in lowered innate and adaptive immune responses in humans and is associated with increased incidence, duration, and severity of infection and decreased survival. B) Protection against viral infections is also mediated by two arms of the adaptive immune system. One of these is the cell-mediated immune response, which against viral infections is primarily mediated by cytotoxic T lymphocytes (CD8+). The other arm of the adaptive immune system is the humoral immune response by B lymphocytes (CD19+), which produce antibodies. Chronic stress results in lowered innate and adaptive immune responses in humans and is associated with increased incidence, duration, and severity of infection and decreased survival. C) Protection against viral infections is also mediated by two arms of the adaptive immune system. One of these is the cell-mediated immune response, which against viral infections is primarily mediated by cytotoxic T lymphocytes (CD8+). The other arm of the adaptive immune system is the humoral immune response by B lymphocytes (CD19+), which produce antibodies. Chronic stress results in lowered innate and adaptive immune responses in humans and is associated with increased incidence, duration, and severity of infection and decreased survival. D) Protection against viral infections is also mediated by two arms of the adaptive immune system. One of these is the cell-mediated immune response, which against viral infections is primarily mediated by cytotoxic T lymphocytes (CD8+). The other arm of the adaptive immune system is the humoral immune response by B lymphocytes (CD19+), which produce antibodies. Chronic stress results in lowered innate and adaptive immune responses in humans and is associated with increased incidence, duration, and severity of infection and decreased survival. Page Ref: 91 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 4.7 Explain the mechanisms whereby stress contributes to the development or exacerbation of physiologic disorders such as multiple sclerosis, inflammatory bowel disease, and coronary artery disease. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Relate the mechanisms whereby stress contributes to the development or exacerbation of physiologic disorders.

17) Which information should the nurse include in a teaching plan about cortisol for a patient who is HIV-positive? A) Chronically high levels of cortisol accelerate immune decline. B) Cortisol levels that are lowest in the morning boost the immune response. C) A flattened cortisol circadian pattern indicates a healthy immune system. D) Low cortisol levels are associated with the development of AIDS. Answer: A Explanation: A) Elevated cortisol levels predict accelerated immune decline and development of AIDS in individuals who are HIV-positive. B) HIV-infected individuals display physiologic changes that are consistent with chronic elevations of resting levels of cortisol, as evidenced by muted cortisol responsivity (due to downregulated receptors), and a flattened cortisol circadian rhythm. Cortisol is secreted in a circadian pattern, with high levels in the morning that decrease to low levels at bedtime. Elevated cortisol levels predict accelerated immune decline. C) HIV-infected individuals display physiologic changes that are consistent with chronic elevations of resting levels of cortisol, as evidenced by muted cortisol responsivity (due to downregulated receptors), and a flattened cortisol circadian rhythm. Cortisol is secreted in a circadian pattern, with high levels in the morning that decrease to low levels at bedtime. Elevated cortisol levels predict accelerated immune decline. D) Elevated cortisol levels predict accelerated immune decline and development of AIDS in individuals who are HIV-positive. Page Ref: 92 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 4.7 Explain the mechanisms whereby stress contributes to the development or exacerbation of physiologic disorders such as multiple sclerosis, inflammatory bowel disease, and coronary artery disease. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Relate the mechanisms whereby stress contributes to the development or exacerbation of physiologic disorders.

18) The nurse recommends the influenza vaccination to a 72-year-old woman who is the primary caregiver of her elderly mother who has Alzheimer's disease. Which instruction should the nurse include in the teaching plan for this vaccine? A) The vaccine is not needed because chronic stress boosts the immune response. B) Older adult caregivers have an accentuated immune response to influenza vaccine. C) Chronic stress may blunt the efficacy of the influenza vaccine in older adults. D) The effects of chronic stress on the immune system improve immediately when the stress is removed. Answer: C Explanation: A) Studies demonstrate that people who report higher levels of stress exhibit lower levels of protective antibodies against microbial pathogens including influenza, hepatitis B, and pneumonia. B) Studies of older adults, who experienced chronic stress as caregivers for family members suffering from dementia, exhibit a blunted antibody response to influenza vaccines and to bacterial pneumonia vaccines when compared to matched control individuals. C) Studies of older adults, who experienced chronic stress as caregivers for family members suffering from dementia, exhibit a blunted antibody response to influenza vaccines and to bacterial pneumonia vaccines when compared to matched control individuals. D) The deficits in antibody response persisted years after the family member had died, suggesting that chronic severe stressors may have long-term adverse consequences on the immune system. Page Ref: 93 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 4.7 Explain the mechanisms whereby stress contributes to the development or exacerbation of physiologic disorders such as multiple sclerosis, inflammatory bowel disease, and coronary artery disease. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Relate the mechanisms whereby stress contributes to the development or exacerbation of physiologic disorders.

19) The nurse is teaching a community class on risk factors for heart disease. Which fact should be included about the effects of stress on the heart? A) Hostility and anxiety are risk factors for heart disease. B) Psychosocial stress has a protective effect on the heart. C) A positive emotional state is a risk factor for heart disease. D) Psychosocial stress is not a risk factor for acute myocardial infarction. Answer: A Explanation: A) The presence of increased levels of hostility and anxiety are associated with the incidence of coronary artery disease, and individuals whose personality is characterized by increased negative affect are more likely to experience increased cardiovascular mortality and morbidity. B) Psychosocial stress has been found to be a major contributing factor to acute myocardial infarction. C) Positive emotional states are associated with lower levels of aortic calcification and were associated with a lowered risk of ischemic events. D) Psychosocial stress has been found to be a major contributing factor to acute myocardial infarction. Page Ref: 91 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 4.7 Explain the mechanisms whereby stress contributes to the development or exacerbation of physiologic disorders such as multiple sclerosis, inflammatory bowel disease, and coronary artery disease. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Relate the mechanisms whereby stress contributes to the development or exacerbation of physiologic disorders.

20) Which statement by a patient would the nurse not expect to find with a diagnosis of posttraumatic stress disorder (PTSD) as a result of a motor vehicle accident? A) "I keep seeing the accident in my dreams." B) "I find that I am avoiding riding in cars." C) "I startle easily with loud noises." D) "I find myself emotionally expressive." Answer: D Explanation: A) Three distinct criteria define PTSD: (1) persistent reexperiencing of the traumatic event through flashbacks or dreams, (2) persistent attempts to avoid stimuli perceived to be associated with the traumatic event in combination with a general lack of interest in activities along with a lack of affect, and (3) persistent symptoms of increased arousal. B) Three distinct criteria define PTSD: (1) persistent reexperiencing of the traumatic event through flashbacks or dreams, (2) persistent attempts to avoid stimuli perceived to be associated with the traumatic event in combination with a general lack of interest in activities along with a lack of affect, and (3) persistent symptoms of increased arousal. C) Three distinct criteria define PTSD: (1) persistent reexperiencing of the traumatic event through flashbacks or dreams, (2) persistent attempts to avoid stimuli perceived to be associated with the traumatic event in combination with a general lack of interest in activities along with a lack of affect, and (3) persistent symptoms of increased arousal. D) Three distinct criteria define PTSD: (1) persistent re-experiencing of the traumatic event through flashbacks or dreams, (2) persistent attempts to avoid stimuli perceived to be associated with the traumatic event in combination with a general lack of interest in activities along with a lack of affect, and (3) persistent symptoms of increased arousal. Page Ref: 88 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity Standards: Nursing Process: Assessment | Learning Outcome: 4.6 Explain the mechanisms whereby stress contributes to the development or exacerbation of psychiatric disorders such as depression, anxiety, and posttraumatic stress disorder. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Examine the pathogenesis and clinical manifestations of stress on health.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 5 Health Risks of Obesity and Physical Inactivity 1) Which assessment data indicates that an adult male client has metabolic syndrome? A) Waist circumference of 35 inches, triglyceride level of 150 mg/dL, high-density lipoprotein level of 50 mg/dL B) Fasting blood glucose level of 90 mg/dL, waist circumference of 41 inches, blood pressure of 120/20 mmHg C) Waist circumference of 41 inches, triglyceride level of 151 mg/dL, blood pressure 140/86 mmHg D) Waist circumference of 34 inches, fasting blood glucose level of 100 mg/dL, triglyceride level of 148 mg/dL Answer: C Explanation: A) Metabolic syndrome is a condition characterized by insulin resistance, increased visceral and abdominal fat, increased release of free fatty acids (which impair insulin clearance by the liver), and alterations in peripheral metabolism. An adult individual who has three of the five criteria has metabolic syndrome: Increased waist circumference: men > 40 inches; women > 35 inches; elevated triglyceride levels > 150 mg per dL; elevated blood pressure: > 130/85 mmHg; elevated fasting glucose level > 100 mg per dL; reduced high-density lipoprotein (HDL) cholesterol levels: men < 40 mg/dL; women < 50 mg/dL. B) Metabolic syndrome is a condition characterized by insulin resistance, increased visceral and abdominal fat, increased release of free fatty acids (which impair insulin clearance by the liver), and alterations in peripheral metabolism. An adult individual who has three of the five criteria has metabolic syndrome: Increased waist circumference: men > 40 inches; women > 35 inches; elevated triglyceride levels > 150 mg per dL; elevated blood pressure: > 130/85 mmHg; elevated fasting glucose level > 100 mg per dL; reduced high-density lipoprotein (HDL) cholesterol levels: men < 40 mg/dL; women < 50 mg/dL. C) Metabolic syndrome is a condition characterized by insulin resistance, increased visceral and abdominal fat, increased release of free fatty acids (which impair insulin clearance by the liver), and alterations in peripheral metabolism. An adult individual who has three of the five criteria has metabolic syndrome: Increased waist circumference: men > 40 inches; women > 35 inches; elevated triglyceride levels > 150 mg per dL; elevated blood pressure: > 130/85 mmHg; elevated fasting glucose level > 100 mg per dL; reduced high-density lipoprotein (HDL) cholesterol levels: men < 40 mg/dL; women < 50 mg/dL. D) Metabolic syndrome is a condition characterized by insulin resistance, increased visceral and abdominal fat, increased release of free fatty acids (which impair insulin clearance by the liver), and alterations in peripheral metabolism. An adult individual who has three of the five criteria has metabolic syndrome: Increased waist circumference: men > 40 inches; women > 35 inches; elevated triglyceride levels > 150 mg per dL; elevated blood pressure: > 130/85 mmHg; elevated fasting glucose level > 100 mg per dL; reduced high-density lipoprotein (HDL) cholesterol levels: men < 40 mg/dL; women < 50 mg/dL. Page Ref: 10 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation

Standards: Nursing Process: Assessment | Learning Outcome: 5.2 Describe the etiology of obesity and outline the pathophysiologic consequences, including chronic diseases and metabolic syndrome. | QSEN Competencies: III.A. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 5.2: Examine factors related to the etiology and pathophysiology of obesity. 2) The public health nurse is preparing community programming on obesity following the Healthy People 2020 guidelines. Which of the following would the nurse include? A) Increase the consumption of calories from fats in those 2 years old and older. B) Reduce iron intake in pregnant females. C) Reduce consumption of whole grains in those 2 years and older. D) Eliminate food insecurity in children. Answer: D Explanation: A) The overall goal of the Nutrition and Weight Status objectives for Healthy People 2020 is to promote health and reduce the risk of chronic disease through healthful diets and the achievement and maintenance of healthy body weights. This includes eliminating food insecurity among children as well as reducing iron deficiency in pregnant females, reducing consumption of calories from fats in children age 2 years old and older, and increasing consumption of whole grains in those age 2 years old and older. B) The overall goal of the Nutrition and Weight Status objectives for Healthy People 2020 is to promote health and reduce the risk of chronic disease through healthful diets and the achievement and maintenance of healthy body weights. This includes eliminating food insecurity among children as well as reducing iron deficiency in pregnant females, reducing consumption of calories from fats in children age 2 years old and older, and increasing consumption of whole grains in those age 2 years old and older. C) The overall goal of the Nutrition and Weight Status objectives for Healthy People 2020 is to promote health and reduce the risk of chronic disease through healthful diets and the achievement and maintenance of healthy body weights. This includes eliminating food insecurity among children as well as reducing iron deficiency in pregnant females, reducing consumption of calories from fats in children age 2 years old and older, and increasing consumption of whole grains in those age 2 years old and older. D) The overall goal of the Nutrition and Weight Status objectives for Healthy People 2020 is to promote health and reduce the risk of chronic disease through healthful diets and the achievement and maintenance of healthy body weights. This includes eliminating food insecurity among children as well as reducing iron deficiency in pregnant females, reducing consumption of calories from fats in children age 2 years old and older, and increasing consumption of whole grains in those 2 years old and older. Page Ref: 2 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance

Standards: Nursing Process: Planning | Learning Outcome: 5.1 Outline the global prevalence of, medical conditions associated with, and concepts related to obesity and physical inactivity. | QSEN Competencies: III.A. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: VII. 11. Participate in clinical prevention and populationfocused interventions with attention to effectiveness, efficiency, cost-effectiveness, and equity NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 5.1: Examine the prevalence of obesity, goals of Healthy People 2020, and regulation of food uptake. 3) The nurse would expect a client with a body mass index of 21.2 to be classified as: A) underweight. B) normal weight. C) overweight. D) obese. Answer: B Explanation: A) Obesity is conceptually defined as an excess of body fat and is clinically defined by the body mass index (BMI). BMI (calculated as the weight in kilograms divided by the square of height in meters) is classified as follows: normal 18.5-24.9, overweight 25.0-29.9, and obese > 30.0. B) Obesity is conceptually defined as an excess of body fat and is clinically defined by the body mass index (BMI). BMI (calculated as the weight in kilograms divided by the square of height in meters) is classified as follows: normal 18.5-24.9, overweight 25.0-29.9, and obese > 30.0. C) Obesity is conceptually defined as an excess of body fat and is clinically defined by the body mass index (BMI). BMI (calculated as the weight in kilograms divided by the square of height in meters) is classified as follows: normal 18.5-24.9, overweight 25.0-29.9, and obese > 30.0. D) Obesity is conceptually defined as an excess of body fat and is clinically defined by the body mass index (BMI). BMI (calculated as the weight in kilograms divided by the square of height in meters) is classified as follows: normal 18.5-24.9, overweight 25.0-29.9, and obese > 30.0. Page Ref: 11 Cognitive Level: Remembering Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 5.3 Outline the health risks and functional outcomes associated with obesity. | QSEN Competencies: III.A. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 5.3: Analyze the health risks and functional outcomes associated with obesity.

4) The nurse is teaching an obese client about dietary changes to achieve weight loss. Which statement indicates to the nurse that the client understands the dietary instructions? A) "I will eat an unlimited amount of fruits and vegetables." B) "I will limit my intake of fat and follow recommendations for daily calorie intake." C) "I will eat only protein." D) "I will avoid antioxidants." Answer: B Explanation: A) Lifestyle changes include caloric restriction with limitation of fat intake and increased ingestion of foods rich in antioxidants, such as fruits and vegetables within a balanced diet. B) Lifestyle changes include caloric restriction with limitation of fat intake and increased ingestion of foods rich in antioxidants, such as fruits and vegetables within a balanced diet. C) Lifestyle changes include caloric restriction with limitation of fat intake and increased ingestion of foods rich in antioxidants, such as fruits and vegetables within a balanced diet. D) Lifestyle changes include caloric restriction with limitation of fat intake and increased ingestion of foods rich in antioxidants, such as fruits and vegetables within a balanced diet. Page Ref: 15 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Lifestyle Choices Standards: Nursing Process: Implementation | Learning Outcome: 5.3 Outline the health risks and functional outcomes associated with obesity. | QSEN Competencies: III.A. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 5.3: Analyze the health risks and functional outcomes associated with obesity.

5) In evaluating the effectiveness of an exercise program in an obese client, the nurse should expect the following outcomes: A) reduced bone density. B) reduced insulin sensitivity. C) increased joint pain. D) enhanced feelings of well-being. Answer: D Explanation: A) Bone density of the hip and spine can be increased or the rate of decline can be decreased through exercise. B) Exercise is associated with increased insulin sensitivity. C) Low impact exercise can reduce joint pain. D) Physical activity appears to protect against symptoms of depression and have a beneficial effect on mood. Page Ref: 17 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Evaluation | Learning Outcome: 5.4 Discuss the role of physical inactivity/activity in the development and progression of chronic diseases and recommendations for physical activity. | QSEN Competencies: IV.A. Describes strategies for earning about the outcomes of care in the setting in which one is engage in clinical practice. | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 5.3: Analyze the health risks and functional outcomes associated with obesity.

6) A client is preparing for a laparoscopic gastric banding procedure to promote weight loss. Which statement indicates to the nurse that the client understands the procedure? A) "Food will bypass my stomach." B) "My stomach will be vertically divided." C) "An adjustable silicone band will be placed around my stomach." D) "My stomach will be removed." Answer: C Explanation: A) In laparoscopic gastric banding procedure, an adjustable silicone band is placed around the upper stomach. A pouch is created above the band, while there is a narrowing of the upper stomach diameter below. The stomach is not bypassed, divided vertically, or removed. B) In laparoscopic gastric banding procedure, an adjustable silicone band is placed around the upper stomach. A pouch is created above the band, while there is a narrowing of the upper stomach diameter below. The stomach is not bypassed, divided vertically, or removed. C) In laparoscopic gastric banding procedure, an adjustable silicone band is placed around the upper stomach. A pouch is created above the band, while there is a narrowing of the upper stomach diameter below. The stomach is not bypassed, divided vertically, or removed. D) In laparoscopic gastric banding procedure, an adjustable silicone band is placed around the upper stomach. A pouch is created above the band, while there is a narrowing of the upper stomach diameter below. The stomach is not bypassed, divided vertically, or removed. Page Ref: 18 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Evaluation | Learning Outcome: 5.2 Describe the etiology of obesity and outline the pathophysiologic consequences, including chronic diseases and metabolic syndrome. | QSEN Competencies: I.B. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 5.2: Examine factors related to the etiology and pathophysiology of obesity.

7) The nurse explains to the parents of an obese child with congenital leptin deficiency that treatment includes: A) subcutaneous injections of recombinant leptin. B) oral doses of recombinant leptin. C) subcutaneous long-acting insulin. D) oral hypoglycemic agents. Answer: A Explanation: A) People with congenital leptin deficiency can be successfully treated with subcutaneous injections of recombinant leptin. B) People with congenital leptin deficiency can be successfully treated with subcutaneous injections of recombinant leptin. C) People with congenital leptin deficiency can be successfully treated with subcutaneous injections of recombinant leptin. D) People with congenital leptin deficiency can be successfully treated with subcutaneous injections of recombinant leptin. Page Ref: 7 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 5.2 Describe the etiology of obesity and outline the pathophysiologic consequences, including chronic diseases and metabolic syndrome. | QSEN Competencies: I.B. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 5.2: Examine factors related to the etiology and pathophysiology of obesity.

8) When taking a health history from a client with increased visceral fat as determined by waist size, the nurse would also expect to find an increased possibility of which of the following conditions? A) Type 2 diabetes B) Hyperthyroidism C) Chronic renal disease D) Hypotension Answer: A Explanation: A) The increased visceral (central) adiposity leads to insulin resistance and endothelial dysfunction, which lead to metabolic syndrome, type 2 diabetes, and atherosclerosis. The constellation of abnormalities in metabolic syndrome includes central adiposity, hypertension, insulin resistance, hyperinsulinemia, glucose intolerance, dyslipidemias (hypertriglyceridemia, decreased HDL cholesterol, and small LDL diameter), and increased plasminogen activator inhibitor-1. Central adiposity does not increase the risk of hyperthyroidism, renal disease, or hypotension. B) The increased visceral (central) adiposity leads to insulin resistance and endothelial dysfunction, which lead to metabolic syndrome, type 2 diabetes, and atherosclerosis. The constellation of abnormalities in metabolic syndrome includes central adiposity, hypertension, insulin resistance, hyperinsulinemia, glucose intolerance, dyslipidemias (hypertriglyceridemia, decreased HDL cholesterol, and small LDL diameter), and increased plasminogen activator inhibitor-1. Central adiposity does not increase the risk of hyperthyroidism, renal disease, or hypotension. C) The increased visceral (central) adiposity leads to insulin resistance and endothelial dysfunction, which lead to metabolic syndrome, type 2 diabetes, and atherosclerosis. The constellation of abnormalities in metabolic syndrome includes central adiposity, hypertension, insulin resistance, hyperinsulinemia, glucose intolerance, dyslipidemias (hypertriglyceridemia, decreased HDL cholesterol, and small LDL diameter), and increased plasminogen activator inhibitor-1. Central adiposity does not increase the risk of hyperthyroidism, renal disease, or hypotension. D) The increased visceral (central) adiposity leads to insulin resistance and endothelial dysfunction, which lead to metabolic syndrome, type 2 diabetes, and atherosclerosis. The constellation of abnormalities in metabolic syndrome includes central adiposity, hypertension, insulin resistance, hyperinsulinemia, glucose intolerance, dyslipidemias (hypertriglyceridemia, decreased HDL cholesterol, and small LDL diameter), and increased plasminogen activator inhibitor-1. Central adiposity does not increase the risk of hyperthyroidism, renal disease, or hypotension. Page Ref: 10 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 5.2 Describe the etiology of obesity and outline the pathophysiologic consequences, including chronic diseases and metabolic syndrome. | QSEN Competencies: III.A. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: VII.1 Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities, and populations. NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care 8

MNL Learning Outcome: LO 5.2: Examine factors related to the etiology and pathophysiology of obesity. 9) In formulating a plan of care for an obese woman who is trying to conceive, the nurse should include which information? A) It is preferred that weight loss occur prior to becoming pregnant. B) It is safe to pursue weight loss during pregnancy. C) Weight loss should not be pursued until after delivery of the baby. D) Obesity will have no effect on the fetus or newborn. Answer: A Explanation: A) Because of the risks to both mother and fetus associated with obesity during pregnancy, it is important for overweight and obese women to have weight counseling before conception so that they can achieve weight loss before becoming pregnant. Obesity during pregnancy is associated with increased maternal and fetal risks. Furthermore, the effects of maternal obesity extend beyond the perinatal period. B) Because of the risks to both mother and fetus associated with obesity during pregnancy, it is important for overweight and obese women to have weight counseling before conception so that they can achieve weight loss before becoming pregnant. Obesity during pregnancy is associated with increased maternal and fetal risks. Furthermore, the effects of maternal obesity extend beyond the perinatal period. C) Because of the risks to both mother and fetus associated with obesity during pregnancy, it is important for overweight and obese women to have weight counseling before conception so that they can achieve weight loss before becoming pregnant. Obesity during pregnancy is associated with increased maternal and fetal risks. Furthermore, the effects of maternal obesity extend beyond the perinatal period. D) Because of the risks to both mother and fetus associated with obesity during pregnancy, it is important for overweight and obese women to have weight counseling before conception so that they can achieve weight loss before becoming pregnant. Obesity during pregnancy is associated with increased maternal and fetal risks. Furthermore, the effects of maternal obesity extend beyond the perinatal period. Page Ref: 12 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 5.3 Outline the health risks and functional outcomes associated with obesity. | QSEN Competencies: III.A. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 5.3: Analyze the health risks and functional outcomes associated with obesity.

10) The public health nurse serves a population where food insecurity is prevalent. When assessing for food insecurity, the nurse is likely to observe which behavior? A) A lack of knowledge about proper nutrition B) A lack of cooking skills C) Making poor food choices at the grocery store D) An inability to secure nutritious food Answer: D Explanation: A) Food insecurity is the inability to access sufficient safe, nutritious food that is needed to maintain a healthy and active life. It is not a lack of knowledge about nutrition, a lack of ability to cook, or making poor food choices. B) Food insecurity is the inability to access sufficient safe, nutritious food that is needed to maintain a healthy and active life. It is not a lack of knowledge about nutrition, a lack of ability to cook, or making poor food choices. C) Food insecurity is the inability to access sufficient safe, nutritious food that is needed to maintain a healthy and active life. It is not a lack of knowledge about nutrition, a lack of ability to cook, or making poor food choices. D) Food insecurity is the inability to access sufficient safe, nutritious food that is needed to maintain a healthy and active life. It is not a lack of knowledge about nutrition, a lack of ability to cook, or making poor food choices. Page Ref: 3 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 5.1 Outline the global prevalence of, medical conditions associated with, and concepts related to obesity and physical inactivity. | QSEN Competencies: I.A.1. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values | AACN Essential Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 5.1: Examine the prevalence of obesity, goals of Healthy People 2020, and regulation of food uptake.

11) What is the best response by the nurse when the obese mother of an obese child asks if she passed on the gene for obesity to her child? A) "Obesity is due to multiple factors, including heredity." B) "Obesity is only due to behavioral factors." C) "Only Environmental factors cause obesity." D) "Only Lifestyle factors cause obesity." Answer: A Explanation: A) Obesity arises from multiple genetic, behavioral, metabolic, environmental, and socioeconomic factors. These factors are also associated with the development of a physically inactive and sedentary lifestyle. B) This response is not correct because it only addresses the behavioral cause of obesity, which is a multifactorial disorder. C) This response is not correct because it only addresses the environmental cause of obesity, which is a multifactorial disorder. D) This response is not correct because it only addresses the lifestyle cause of obesity, which is a multifactorial disorder. Page Ref: 4 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 5.1 Outline the global prevalence of, medical conditions associated with, and concepts related to obesity and physical inactivity. | QSEN Competencies: III.A. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: VII.1 Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities, and populations. NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 5.1: Examine the prevalence of obesity, goals of Healthy People 2020, and regulation of food uptake.

12) Which assessment data indicates to the nurse that a 10-year-old child is obese? A) A body mass index at or below the 95th percentile on the CDC growth chart for a child of the same age and sex. B) A body mass index at or above the 95th percentile on the CDC growth chart for a child of the same age and sex. C) A body mass index at or below the 85th percentile on the CDC growth chart for a child of the same age and sex. D) A body mass index in the 100th percentile on the CDC growth chart for a child of the same age and sex. Answer: B Explanation: A) For children and adolescents (age 2-19 years), the BMI value is plotted on the CDC growth charts to determine the BMI-for-age percentile. In this classification, overweight is defined as a BMI at or above the 85th percentile and lower than the 95th percentile. Obesity is defined as a BMI at or above the 95th percentile for children of the same age and sex. B) For children and adolescents (age 2-19 years), the BMI value is plotted on the CDC growth charts to determine the BMI-for-age percentile. In this classification, overweight is defined as a BMI at or above the 85th percentile and lower than the 95th percentile. Obesity is defined as a BMI at or above the 95th percentile for children of the same age and sex. C) For children and adolescents (age 2-19 years), the BMI value is plotted on the CDC growth charts to determine the BMI-for-age percentile. In this classification, overweight is defined as a BMI at or above the 85th percentile and lower than the 95th percentile. Obesity is defined as a BMI at or above the 95th percentile for children of the same age and sex. D) For children and adolescents (age 2-19 years), the BMI value is plotted on the CDC growth charts to determine the BMI-for-age percentile. In this classification, overweight is defined as a BMI at or above the 85th percentile and lower than the 95th percentile. Obesity is defined as a BMI at or above the 95th percentile for children of the same age and sex. Page Ref: 11 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 5.3 Outline the health risks and functional outcomes associated with obesity. | QSEN Competencies: III.A. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 5.3: Analyze the health risks and functional outcomes associated with obesity.

13) The nurse explains to parents of an obese child that which of the following methods is most successful in treating obesity? A) Only increased physical activity B) Only reduced caloric intake C) Use of peer support groups D) Family behavioral therapy Answer: D Explanation: A) While increased physical activity, reduced caloric intake, and peer support are helpful in reducing obesity in children, of greatest importance, however, is parental and familial involvement with family behavioral therapy; this has been cited as the most widely supported treatment for children. B) While increased physical activity, reduced caloric intake, and peer support are helpful in reducing obesity in children, of greatest importance, however, is parental and familial involvement with family behavioral therapy; this has been cited as the most widely supported treatment for children. C) While increased physical activity, reduced caloric intake, and peer support are helpful in reducing obesity in children, of greatest importance, however, is parental and familial involvement with family behavioral therapy; this has been cited as the most widely supported treatment for children. D) While increased physical activity, reduced caloric intake, and peer support are helpful in reducing obesity in children, of greatest importance, however, is parental and familial involvement with family behavioral therapy; this has been cited as the most widely supported treatment for children. Page Ref: 11 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity Standards: Nursing Process: Implementation | Learning Outcome: 5.3 Outline the health risks and functional outcomes associated with obesity. | QSEN Competencies: I.A.1. Describe how diverse cultural, ethnic and social backgrounds function as sources of patient, family, and community values | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 5.3: Analyze the health risks and functional outcomes associated with obesity.

14) Which manifestation would the nurse expect to find in a client with nonalcoholic fatty liver disease? A) Ventricular hypertrophy B) Splenomegaly C) Hepatomegaly D) Hydronephrosis Answer: C Explanation: A) Nonalcoholic fatty liver disease and nonalcoholic steatohepatitis are terms that describe a group of liver abnormalities associated with obesity. These abnormalities include hepatomegaly (enlarged liver) and elevated liver enzymes and, in the case of nonalcoholic steatohepatitis, include abnormal changes in the histology of the liver, including fibrosis and cirrhosis. Ventricular hypertrophy is an enlargement of the left ventricle of the heart, splenomegaly is an enlarged spleen, and hydronephrosis is an enlarged kidney. B) Nonalcoholic fatty liver disease and nonalcoholic steatohepatitis are terms that describe a group of liver abnormalities associated with obesity. These abnormalities include hepatomegaly (enlarged liver) and elevated liver enzymes and, in the case of nonalcoholic steatohepatitis, include abnormal changes in the histology of the liver, including fibrosis and cirrhosis. Ventricular hypertrophy is an enlargement of the left ventricle of the heart, splenomegaly is an enlarged spleen, and hydronephrosis is an enlarged kidney. C) Nonalcoholic fatty liver disease and nonalcoholic steatohepatitis are terms that describe a group of liver abnormalities associated with obesity. These abnormalities include hepatomegaly (enlarged liver) and elevated liver enzymes and, in the case of nonalcoholic steatohepatitis, include abnormal changes in the histology of the liver, including fibrosis and cirrhosis. Ventricular hypertrophy is an enlargement of the left ventricle of the heart, splenomegaly is an enlarged spleen, and hydronephrosis is an enlarged kidney. D) Nonalcoholic fatty liver disease and nonalcoholic steatohepatitis are terms that describe a group of liver abnormalities associated with obesity. These abnormalities include hepatomegaly (enlarged liver) and elevated liver enzymes and, in the case of nonalcoholic steatohepatitis, include abnormal changes in the histology of the liver, including fibrosis and cirrhosis. Ventricular hypertrophy is an enlargement of the left ventricle of the heart, splenomegaly is an enlarged spleen, and hydronephrosis is an enlarged kidney. Page Ref: 13 Cognitive Level: Remembering Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 5.3 Outline the health risks and functional outcomes associated with obesity. | QSEN Competencies: III.A. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 5.3: Analyze the health risks and functional outcomes associated with obesity.

15) In planning a program of health-related physical fitness, the nurse explains to the obese client that a goal of this program is to: A) increase cardiorespiratory endurance. B) improve agility. C) increase speed of movement. D) build muscle strength and power. Answer: A Explanation: A) The primary components of health-related physical fitness include cardiorespiratory endurance, skeletal muscle endurance, skeletal muscle strength, body composition, and flexibility. The primary components of performance-related physical fitness include agility, balance, coordination, muscle strength and power, speed of movement, and reaction time. B) The primary components of health-related physical fitness include cardiorespiratory endurance, skeletal muscle endurance, skeletal muscle strength, body composition, and flexibility. The primary components of performance-related physical fitness include agility, balance, coordination, muscle strength and power, speed of movement, and reaction time. C) The primary components of health-related physical fitness include cardiorespiratory endurance, skeletal muscle endurance, skeletal muscle strength, body composition, and flexibility. The primary components of performance-related physical fitness include agility, balance, coordination, muscle strength and power, speed of movement, and reaction time. D) The primary components of health-related physical fitness include cardiorespiratory endurance, skeletal muscle endurance, skeletal muscle strength, body composition, and flexibility. The primary components of performance-related physical fitness include agility, balance, coordination, muscle strength and power, speed of movement, and reaction time. Page Ref: 16 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 5.4 Discuss the role of physical inactivity/activity in the development and progression of chronic diseases and recommendations for physical activity. | QSEN Competencies: III.A. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, costeffectiveness and equity NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 5.4: Relate physical inactivity, activity, and therapeutic options to the progression of chronic diseases due to obesity.

16) Which of the following outcomes should a nurse expect in a client who exercises regularly? A) Reduced glucose transport into cells B) Reduced cardiorespiratory fitness (VO2 max) C) Increased insulin sensitivity D) Reduced metabolic rate Answer: C Explanation: A) Exercise is associated with increased insulin sensitivity, enhanced glucose transport into muscle cells, improvements in cardiorespiratory fitness (VO2 max), and increased metabolic rate. B) Exercise is associated with increased insulin sensitivity, enhanced glucose transport into muscle cells, improvements in cardiorespiratory fitness (VO2 max), and increased metabolic rate. C) Exercise is associated with increased insulin sensitivity, enhanced glucose transport into muscle cells, improvements in cardiorespiratory fitness (VO2 max), and increased metabolic rate. D) Exercise is associated with increased insulin sensitivity, enhanced glucose transport into muscle cells, improvements in cardiorespiratory fitness (VO2 max), and increased metabolic rate. Page Ref: 17 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Evaluation | Learning Outcome: 5.4 Discuss the role of physical inactivity/activity in the development and progression of chronic diseases and recommendations for physical activity. | QSEN Competencies: III.A. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, costeffectiveness and equity NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 5.4: Relate physical inactivity, activity, and therapeutic options to the progression of chronic diseases due to obesity.

17) Which musculoskeletal finding should the nurse expect in a client who engages in regular physical activity? A) Increased skeletal muscle mass B) Prevention of osteoarthritis C) Reduced bone mineral density of the hip D) Increased risk of hip fractures Answer: A Explanation: A) Physical activity is beneficial for musculoskeletal health. Physical activity is inversely associated with risk of hip and spine fracture. Bone mineral density in the spine or the hip is responsive to exercise training. For example, the bone mineral density in the spine or the hip can be increased or the rate of decline can be modified by exercise training. In addition, physical activity can increase skeletal muscle mass, strength, power, and neuromuscular activation. There is no evidence to support the idea that physical activity or exercise can prevent osteoarthritis. B) Physical activity is beneficial for musculoskeletal health. Physical activity is inversely associated with risk of hip and spine fracture. Bone mineral density in the spine or the hip is responsive to exercise training. For example, the bone mineral density in the spine or the hip can be increased or the rate of decline can be modified by exercise training. In addition, physical activity can increase skeletal muscle mass, strength, power, and neuromuscular activation. There is no evidence to support the idea that physical activity or exercise can prevent osteoarthritis. C) Physical activity is beneficial for musculoskeletal health. Physical activity is inversely associated with risk of hip and spine fracture. Bone mineral density in the spine or the hip is responsive to exercise training. For example, the bone mineral density in the spine or the hip can be increased or the rate of decline can be modified by exercise training. In addition, physical activity can increase skeletal muscle mass, strength, power, and neuromuscular activation. There is no evidence to support the idea that physical activity or exercise can prevent osteoarthritis. D) Physical activity is beneficial for musculoskeletal health. Physical activity is inversely associated with risk of hip and spine fracture. Bone mineral density in the spine or the hip is responsive to exercise training. For example, the bone mineral density in the spine or the hip can be increased or the rate of decline can be modified by exercise training. In addition, physical activity can increase skeletal muscle mass, strength, power, and neuromuscular activation. There is no evidence to support the idea that physical activity or exercise can prevent osteoarthritis. Page Ref: 17 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 5.4 Discuss the role of physical inactivity/activity in the development and progression of chronic diseases and recommendations for physical activity. | QSEN Competencies: III.A. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, costeffectiveness and equity NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 5.4: Relate physical inactivity, activity, and therapeutic options to the progression of chronic diseases due to obesity.

18) In evaluating the effectiveness of lorcaserin for a client with obesity, the nurse should expect the client to report: A) increased hunger. B) a decreased consumption of food. C) an increased sense of well-being. D) reduced satiety. Answer: B Explanation: A) Lorcaserin is a selective serotonin 2c receptor (5-HT2C) that produces hypophagia through action on hypothalamic neurons, resulting in hypophagia, increased satiety, and decreased food consumption. Bupropion plus naltrexone, used in weight loss, may result in increased feelings of well-being. Lorcaserin leads to increased, not decreased, satiety. B) Lorcaserin is a selective serotonin 2c receptor (5-HT2C) that produces hypophagia through action on hypothalamic neurons, resulting in hypophagia, increased satiety, and decreased food consumption and satiety. Bupropion plus naltrexone, used in weight loss, may result in increased feelings of well-being. Lorcaserin leads to increased, not decreased, satiety. C) Lorcaserin is a selective serotonin 2c receptor (5-HT2C) that produces hypophagia through action on hypothalamic neurons, resulting in hypophagia, increased satiety, and decreased food consumption and satiety. Bupropion plus naltrexone, used in weight loss, may result in increased feelings of well-being. Lorcaserin leads to increased, not decreased, satiety. D) Lorcaserin is a selective serotonin 2c receptor (5-HT2C) that produces hypophagia through action on hypothalamic neurons, resulting in hypophagia, increased satiety, and decreased food consumption and satiety. Bupropion plus naltrexone, used in weight loss, may result in increased feelings of well-being. Lorcaserin leads to increased, not decreased, satiety. Page Ref: 18 Cognitive Level: Remembering Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Evaluation | Learning Outcome: 5.2 Describe the etiology of obesity and outline the pathophysiologic consequences, including chronic diseases and metabolic syndrome. | QSEN Competencies: III.A. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 5.2: Examine factors related to the etiology and pathophysiology of obesity.

19) Which statement by a client indicates that a nurse's teaching about obesity has been effective? A) "Obesity is an increase in weight." B) "Obesity is excessive accumulation of fat." C) "Obesity in an excessive intake of calories." D) "Obesity is an accumulation of triglycerides." Answer: B Explanation: A) The World Health Organization (WHO) defines obesity as abnormal or excessive fat accumulation that may impair health. B) The World Health Organization (WHO) defines obesity as abnormal or excessive fat accumulation that may impair health. C) The World Health Organization (WHO) defines obesity as abnormal or excessive fat accumulation that may impair health. D) The World Health Organization (WHO) defines obesity as abnormal or excessive fat accumulation that may impair health. Page Ref: 3 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Evaluation | Learning Outcome: 5.1 Outline the global prevalence of, medical conditions associated with, and concepts related to obesity and physical inactivity. | QSEN Competencies: III.A. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: VII. 11. Participate in clinical prevention and populationfocused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 5.1: Examine the prevalence of obesity, goals of Healthy People 2020, and regulation of food uptake.

20) The nurse is planning an education program on nutrition and weight management following the Healthy People 2020 guidelines. Which of the following would be an appropriate primary objective for the nurse to use in planning this program? A) Increase the number of countries with nutrition standards for foods and beverages provided to preschool-age children in child care. B) Increase the proportion of schools that offer nutritious foods and beverages outside school meals. C) Increase the number of federal policies that incentivize food retail outlets to provide foods that are encouraged by the Dietary Guidelines for Americans. D) Increase the proportion of people globally who have access to a food retail outlet that sells a variety of foods that are encouraged by the Dietary Guidelines for Americans. Answer: B Explanation: A) The primary Nutrition and Weight Status objectives for Healthy People 2020 are to: Increase the number of states with nutrition standards for foods and beverages provided to preschool-aged children in child care; increase the proportion of schools that offer nutritious foods and beverages outside of school meals; increase the number of states that have state-level policies that incentivize food retail outlets to provide foods that are encouraged by the Dietary Guidelines for Americans; and increase the proportion of Americans who have access to a food retail outlet that sells a variety of foods that are encouraged by the Dietary Guidelines for Americans. B) The primary Nutrition and Weight Status objectives for Healthy People 2020 are to: Increase the number of states with nutrition standards for foods and beverages provided to preschool-aged children in child care; increase the proportion of schools that offer nutritious foods and beverages outside of school meals; increase the number of states that have state-level policies that incentivize food retail outlets to provide foods that are encouraged by the Dietary Guidelines for Americans; and increase the proportion of Americans who have access to a food retail outlet that sells a variety of foods that are encouraged by the Dietary Guidelines for Americans. C) The primary Nutrition and Weight Status objectives for Healthy People 2020 are to: Increase the number of states with nutrition standards for foods and beverages provided to preschool-aged children in child care; increase the proportion of schools that offer nutritious foods and beverages outside of school meals; increase the number of states that have state-level policies that incentivize food retail outlets to provide foods that are encouraged by the Dietary Guidelines for Americans; and increase the proportion of Americans who have access to a food retail outlet that sells a variety of foods that are encouraged by the Dietary Guidelines for Americans. D) The primary Nutrition and Weight Status objectives for Healthy People 2020 are to: Increase the number of states with nutrition standards for foods and beverages provided to preschool-aged children in child care; increase the proportion of schools that offer nutritious foods and beverages outside of school meals; increase the number of states that have state-level policies that incentivize food retail outlets to provide foods that are encouraged by the Dietary Guidelines for Americans; and increase the proportion of Americans who have access to a food retail outlet that sells a variety of foods that are encouraged by the Dietary Guidelines for Americans. Page Ref: 3 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 6 Risks Related to Substance Use Disorders 1) When planning care, the nurse in a substance abuse clinic understands that the majority of people who abuse alcohol die from: A) cirrhosis. B) alcoholic hepatitis. C) hepatic encephalopathy. D) smoking-related diseases. Answer: D Explanation: A) Studies report that as many as 80% of people who abuse alcohol smoke regularly; rather than dying from alcohol-related diseases, the majority of these people die from smoking-related diseases. B) Studies report that as many as 80% of people who abuse alcohol smoke regularly; rather than dying from alcohol-related diseases, the majority of these people die from smoking-related diseases. C) Studies report that as many as 80% of people who abuse alcohol smoke regularly; rather than dying from alcohol-related diseases, the majority of these people die from smoking-related diseases. D) Studies report that as many as 80% of people who abuse alcohol smoke regularly; rather than dying from alcohol-related diseases, the majority of these people die from smoking-related diseases. Page Ref: 122 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 6.1 Identify common substances of abuse and related pathophysiology concepts. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of substance use disorders to diagnosis and treatment.

2) When assessing a patient in the withdrawal stage of substance abuse, the nurse will most likely observe: A) an increased sensitivity to stress. B) positive emotions. C) balancing desire for drug with the will to abstain. D) consideration of possibility of relapse. Answer: A Explanation: A) The major concepts associated with addiction include binge and intoxication, withdrawal and negative effect, and preoccupation and anticipation. Binge and intoxication are associated with increased release of dopamine and activation of the brain's reward system. Withdrawal is associated with activation of the brain regions associated with emotions, resulting in increased sensitivity to stress and negative emotions. Preoccupation is associated with decreased function of the prefrontal cortex. During preoccupation, the individual attempts to balance the desire for the drug, the will to abstain, the possibility of relapse, and the continued cycle of addiction. B) The major concepts associated with addiction include binge and intoxication, withdrawal and negative effect, and preoccupation and anticipation. Binge and intoxication are associated with increased release of dopamine and activation of the brain's reward system. Withdrawal is associated with activation of the brain regions associated with emotions, resulting in increased sensitivity to stress and negative emotions. Preoccupation is associated with decreased function of the prefrontal cortex. During preoccupation, the individual attempts to balance the desire for the drug, the will to abstain, the possibility of relapse, and the continued cycle of addiction. C) The major concepts associated with addiction include binge and intoxication, withdrawal and negative effect, and preoccupation and anticipation. Binge and intoxication are associated with increased release of dopamine and activation of the brain's reward system. Withdrawal is associated with activation of the brain regions associated with emotions, resulting in increased sensitivity to stress and negative emotions. Preoccupation is associated with decreased function of the prefrontal cortex. During preoccupation, the individual attempts to balance the desire for the drug, the will to abstain, the possibility of relapse, and the continued cycle of addiction. D) The major concepts associated with addiction include binge and intoxication, withdrawal and negative effect, and preoccupation and anticipation. Binge and intoxication are associated with increased release of dopamine and activation of the brain's reward system. Withdrawal is associated with activation of the brain regions associated with emotions, resulting in increased sensitivity to stress and negative emotions. Preoccupation is associated with decreased function of the prefrontal cortex. During preoccupation, the individual attempts to balance the desire for the drug, the will to abstain, the possibility of relapse, and the continued cycle of addiction. Page Ref: 122 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 6.1 Identify common substances of abuse and related pathophysiology concepts. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care 2

MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of substance use disorders. 3) Which statement by a patient indicates that the nurse's teaching about drug tolerance has been ineffective? A) "If I stop the drug suddenly, withdrawal will occur." B) "Drug tolerance means that I will need more drug to feel good." C) "I take this drug because it makes me feel good." D) "Drug tolerance develops after using the drug for the first time." Answer: D Explanation: A) Symptoms of withdrawal, which vary among substances, are the defining characteristic of physical dependence on a substance. B) Tolerance occurs as the body attempts to maintain homeostasis. After repeated use, the drug does not produce the same central nervous system effect as it did before, and thus more of the drug is needed to achieve the desired effect. C) Increased levels of dopamine are associated with the feelings of well-being, exhilaration, and pleasure; consequently, the formation of positive memories and reinforcement for continued substance use occurs, leading to psychologic dependence. If the drug is unavailable, a state of uneasiness or dissatisfaction occurs, and the person may experience emotional or motivational withdrawal symptoms. D) Tolerance occurs as the body attempts to maintain homeostasis. After repeated use, the drug does not produce the same central nervous system effect as it did before, and thus more of the drug is needed to achieve the desired effect. Page Ref: 124 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Evaluation | Learning Outcome: 6.2 Describe the neurobiology of the brain and how it relates to substance use disorders. | QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and wellbeing, and self-care management | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Examine the etiology, incidence and pathogenesis of substance use disorders.

4) The nurse in the health center on a college campus is talking to freshman students about the consequences of drinking alcohol. The nurse defines a standard drink as: A) 12 ounces of regular beer. B) 6 ounces of malt liquor. C) 4 ounces of table wine. D) 3 ounce shot of whiskey. Answer: A Explanation: A) One standard drink is the equivalent of 12 fl. oz regular beer, 8-9 fl. oz malt liquor, 5 fl. oz table wine, and 1.5 fl. oz shot of 80-proof spirits (hard liquor–whiskey, gin, rum, vodka, tequila, etc.). All of these contain ½ ounce of ethyl alcohol. B) One standard drink is the equivalent of 12 fl. oz regular beer, 8-9 fl. oz malt liquor, 5 fl. oz table wine, and 1.5 fl. oz shot of 80-proof spirits (hard liquor–whiskey, gin, rum, vodka, tequila, etc.). All of these contain ½ ounce of ethyl alcohol. C) One standard drink is the equivalent of 12 fl. oz regular beer, 8-9 fl. oz malt liquor, 5 fl. oz table wine, and 1.5 fl. oz shot of 80-proof spirits (hard liquor–whiskey, gin, rum, vodka, tequila, etc.). All of these contain ½ ounce of ethyl alcohol. D) One standard drink is the equivalent of 12 fl. oz regular beer, 8-9 fl. oz malt liquor, 5 fl. oz table wine, and 1.5 fl. oz shot of 80-proof spirits (hard liquor–whiskey, gin, rum, vodka, tequila, etc.). All of these contain ½ ounce of ethyl alcohol. Page Ref: 126 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 6.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of and the general treatment strategies for alcohol use disorder. | QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Examine the etiology, incidence and pathogenesis of substance use disorders.

5) The nurse in the health center on a college campus is talking to freshman students about the consequences of drinking alcohol. Which statement by a freshman student indicates that the nurse's teaching has been effective? A) "To reduce absorption, I should take alcohol on an empty stomach." B) "Drinking water speeds up the absorption of alcohol." C) "Drinking a carbonated beverage speeds up absorption of alcohol." D) "Alcohol must be digested before it can be absorbed." Answer: C Explanation: A) Upon ingestion, alcohol consumed with a meal remains in the stomach for digestive action, where protein in the food retains the alcohol along with the food, slowing absorption. B) When alcohol is taken with water, the water decreases the concentration and slows the absorption of alcohol. C) Carbonated liquids speed up absorption because carbon dioxide acts to move everything within the stomach rapidly into the small intestine. Thus, sparkling wines and champagne have a faster onset than wine. D) Unlike food, alcohol requires no digestion and is absorbed unchanged into the bloodstream. Page Ref: 126 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Evaluation | Learning Outcome: 6.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of and the general treatment strategies for alcohol use disorder. | QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of substance use disorders.

6) The nurse in the health center on a college campus is talking to freshman students about the consequences of drinking alcohol. What response should the nurse make when a student asks how metabolism of alcohol can be increased? A) "Drinking coffee will speed up the metabolism of alcohol." B) "Exercise will speed up the metabolism of alcohol." C) "Eating a meal will speed up the metabolism of alcohol." D) "The metabolic rate of alcohol is stable and cannot be increased." Answer: D Explanation: A) Once alcohol has been absorbed, it remains in the bloodstream until it is metabolized in the liver. The metabolic process in the liver occurs when the enzyme alcohol dehydrogenase converts alcohol to acetaldehyde. In turn, acetaldehyde is rapidly converted to acetic acid by aldehyde dehydrogenase. Alcohol is removed from the body at a constant rate, depending on the activity of enzyme alcohol dehydrogenase. This metabolic rate is stable regardless of the blood alcohol concentration, exercise, or caffeine intake. B) Once alcohol has been absorbed, it remains in the bloodstream until it is metabolized in the liver. The metabolic process in the liver occurs when the enzyme alcohol dehydrogenase converts alcohol to acetaldehyde. In turn, acetaldehyde is rapidly converted to acetic acid by aldehyde dehydrogenase. Alcohol is removed from the body at a constant rate, depending on the activity of enzyme alcohol dehydrogenase. This metabolic rate is stable regardless of the blood alcohol concentration, exercise, or caffeine intake. C) Once alcohol has been absorbed, it remains in the bloodstream until it is metabolized in the liver. The metabolic process in the liver occurs when the enzyme alcohol dehydrogenase converts alcohol to acetaldehyde. In turn, acetaldehyde is rapidly converted to acetic acid by aldehyde dehydrogenase. Alcohol is removed from the body at a constant rate, depending on the activity of enzyme alcohol dehydrogenase. This metabolic rate is stable regardless of the blood alcohol concentration, exercise, or caffeine intake. D) Once alcohol has been absorbed, it remains in the bloodstream until it is metabolized in the liver. The metabolic process in the liver occurs when the enzyme alcohol dehydrogenase converts alcohol to acetaldehyde. In turn, acetaldehyde is rapidly converted to acetic acid by aldehyde dehydrogenase. Alcohol is removed from the body at a constant rate, depending on the activity of enzyme alcohol dehydrogenase. This metabolic rate is stable regardless of the blood alcohol concentration, exercise, or caffeine intake. Page Ref: 127 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 6.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of and the general treatment strategies for alcohol use disorder. | QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of substance use disorders. 6

7) The emergency department nurse is caring for a patient with a blood alcohol concentration (BAC) of 0.20. At this BAC, the nurse should be alert for: A) respiratory arrest. B) euphoria. C) nausea and vomiting. D) coma. Answer: C Explanation: A) Respiratory arrest typically occurs with a BAC of 0.40 and higher. B) Euphoria is common in BACs of less than 0.13. At BACs greater than this level, euphoria decreases and dysphoria may be experienced. C) Nausea and vomiting may occur at a BAC of 0.20 or higher. D) Coma is possible at a BAC of 0.35. Page Ref: 127 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 6.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of and the general treatment strategies for alcohol use disorder. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of substance use disorders.

8) A patient with chronic alcohol abuse tells the nurse that he is experiencing numbness and tingling of the hands and feet. After alerting the physician, which action would the nurse anticipate implementing? A) Administering thiamine (vitamin B1) B) Administering chlordiazepoxide C) Administering glucagon D) Administering hydration Answer: A Explanation: A) Chronic alcohol abuse is associated with vitamin deficiency, especially thiamine (vitamin B1), leading to peripheral neuropathy (tingling and numbness in the hands and feet). B) Chlordiazepoxide is a benzodiazepine that is used to treat withdrawal. C) Glucagon may be used to treat hypoglycemia in the unconscious patient. D) Hydration may be required if the patient is dehydrated. Page Ref: 129 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Implementation | Learning Outcome: 6.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of and the general treatment strategies for alcohol use disorder. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of substance use disorders to diagnosis and treatment.

9) Which of the following patient statements indicates that teaching about the effects of smokeless tobacco has been effective? A) "Smokeless tobacco and other compounds in tobacco are not absorbed from my mouth." B) "Smokeless tobacco is perfectly safe for me to use." C) "Smokeless tobacco can cause tooth disease." D) "Smokeless tobacco does not increase the risk of developing cancers." Answer: C Explanation: A) Smokeless tobacco products are absorbed from the mouth or nose along with other compounds in the tobacco. B) While not burned during use, these products contain potent carcinogens, including nitrosamines. The greatest concern in nonsmoked tobacco products is increased risk for cancer of the mouth, tongue, cheek, gums, pharynx, and esophagus. Other risks associated with smokeless tobacco include stomach and pancreatic cancer, leukopenia (from white sores in the mouth that can become cancer), bone loss around the roots of the teeth, tooth loss, stained and discolored teeth, and bad breath. C) While not burned during use, these products contain potent carcinogens, including nitrosamines. The greatest concern in nonsmoked tobacco products is increased risk for cancer of the mouth, tongue, cheek, gums, pharynx, and esophagus. Other risks associated with smokeless tobacco include stomach and pancreatic cancer, leukopenia (from white sores in the mouth that can become cancer), bone loss around the roots of the teeth, tooth loss, stained and discolored teeth, and bad breath. D) While not burned during use, these products contain potent carcinogens, including nitrosamines. The greatest concern in nonsmoked tobacco products is increased risk for cancer of the mouth, tongue, cheek, gums, pharynx, and esophagus. Other risks associated with smokeless tobacco include stomach and pancreatic cancer, leukopenia (from white sores in the mouth that can become cancer), bone loss around the roots of the teeth, tooth loss, stained and discolored teeth, and bad breath. Page Ref: 133 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Evaluation | Learning Outcome: 6.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of and the general treatment strategies for tobacco use disorder. | QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of substance use disorders.

10) When assessing a patient who smoked a synthetic cannabinoid, the nurse should be alert for which potential prolonged adverse effects? A) Distorted perception and difficulty thinking and problem solving B) Bradycardia, sedation, and hallucinations C) Tachycardia, agitation, sedation, and psychosis D) Poor eye contact, paranoia, and anxiety Answer: C Explanation: A) Marijuana's immediate effects include distorted perception, difficulty with thinking and problem solving, and loss of motor coordination. These effects are not prolonged adverse effects. B) Synthetic cannabinoids can produce intense, prolonged adverse effects characterized by signs and symptoms such as tachycardia, agitation, sedation, and psychosis that sometimes require hospitalization. C) Synthetic cannabinoids can produce intense, prolonged adverse effects characterized by signs and symptoms such as tachycardia, agitation, sedation, and psychosis that sometimes require hospitalization. D) Psychoactive symptoms of marijuana use may include anxiety, paranoia, poor eye contact, agitation, both grandiose and paranoid delusions, and psychosis. These effects are not prolonged adverse effects. Page Ref: 134 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 6.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of and the general treatment strategies for tobacco use disorder. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of substance use disorders.

11) A patient brought to the emergency department by ambulance reports that he has been smoking Cannabis heavily over the last few hours. An assessment reveals conjunctival injection, increased appetite, dry mouth, and tachycardia. The nurse determines that the patient is most likely experiencing: A) Cannabis intoxication. B) Cannabis withdrawal. C) Cannabis use disorder. D) Cannabis tolerance. Answer: A Explanation: A) The diagnostic criteria for Cannabis intoxication specifies that the patient experiences at least two of the following signs or symptoms within a 2-hour period of using Cannabis that cannot be attributed to any other drug or medical condition: conjunctival injection, increased appetite, dry mouth, and tachycardia. B) Cannabis withdrawal is diagnosed by the following criteria: cessation of frequent and prolonged Cannabis usage that has been daily over the period of several months along with the exhibition of three or more of the following signs and symptoms over the course of approximately 1 week: irritability, anger, or depression; nervousness or anxiety; sleep difficulty (e.g., insomnia); decreased appetite or weight loss; restlessness; depressed mood; and at least one physical symptom causing discomfort (e.g., sweating, fever, chills, headache). C) Cannabis use disorder is the significant impairment or distress in multiple areas of functionality and also development of tolerance and withdrawal to the drug over a 12-month period. D) Tolerance after repeated use of a drug occurs when the drug no longer produces the same central nervous system (CNS) effects as it did before and more of the drug is needed to achieve the desired effect. Page Ref: 134 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Diagnosis | Learning Outcome: 6.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of and the general treatment strategies for cannabis use disorder. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of substance use disorders.

12) A patient with metastatic breast cancer has been prescribed Cannabis for medical use. Which patient statement indicates that more teaching is required? A) "Cannabis will help reduce my nausea." B) "Cannabis promotes weight loss." C) "Cannabis will reduce my pain." D) "Cannabis will relieve inflammation." Answer: B Explanation: A) Medically, Cannabis is used to increase appetite and decrease nausea, to lessen the severity of seizures, and to reduce pain and inflammation. B) Medically, Cannabis is used to increase appetite and decrease nausea, to lessen the severity of seizures, and to reduce pain and inflammation. C) Medically, Cannabis is used to increase appetite and decrease nausea, to lessen the severity of seizures, and to reduce pain and inflammation. D) Medically, Cannabis is used to increase appetite and decrease nausea, to lessen the severity of seizures, and to reduce pain and inflammation. Page Ref: 135 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Evaluation | Learning Outcome: 6.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of and the general treatment strategies for Cannabis use disorder. | QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and selfcare management | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of substance use disorders to diagnosis and treatment.

13) The nurse in the employee health clinic is performing urine drug screenings on employees. In answer to an employee's question about how long cocaine is detectable in the urine, the nurse responds: A) for 1-3 days. B) for 3-5 days. C) up to 8 days. D) up to 13 days. Answer: C Explanation: A) Cocaine is metabolized primarily in the liver. The primary metabolite is benzoylecgonine, which is the metabolite found in highest concentration in urine and is detectable in the urine for up to 8 days after cocaine consumption. It is this metabolite that is measured in urine drug tests for cocaine. B) Cocaine is metabolized primarily in the liver. The primary metabolite is benzoylecgonine, which is the metabolite found in highest concentration in urine and is detectable in the urine for up to 8 days after cocaine consumption. It is this metabolite that is measured in urine drug tests for cocaine. C) Cocaine is metabolized primarily in the liver. The primary metabolite is benzoylecgonine, which is the metabolite found in highest concentration in urine and is detectable in the urine for up to 8 days after cocaine consumption. It is this metabolite that is measured in urine drug tests for cocaine. D) Cocaine is metabolized primarily in the liver. The primary metabolite is benzoylecgonine, which is the metabolite found in highest concentration in urine and is detectable in the urine for up to 8 days after cocaine consumption. It is this metabolite that is measured in urine drug tests for cocaine. Page Ref: 136 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 6.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of and the general treatment strategies for stimulant use disorder. | QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and selfcare management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of substance use disorders to diagnosis and treatment.

14) The emergency department nurse is most likely to assess which findings in a patient who has used cocaine within the last three hours? A) Drowsiness and sedation B) Bradycardia and hypotension C) Chest pain and palpitations D) Muscular hypotonia Answer: C Explanation: A) Neurologic symptoms related to cocaine intoxication include combativeness, hallucinations, confusion, violent behavior, and self-inflicted injury. B) The cardiovascular symptoms of acute cocaine intoxication include increased heart rate, blood pressure, myocardial contractility, and myocardial oxygen demand. As a result, the patient may experience chest pain, tachycardia, palpitations, hypertension, and dysrhythmias. C) The cardiovascular symptoms of acute cocaine intoxication include increased heart rate, blood pressure, myocardial contractility, and myocardial oxygen demand. As a result, the patient may experience chest pain, tachycardia, palpitations, hypertension, and dysrhythmias. D) Other neurological symptoms related to cocaine intoxication include tremors, seizures, and myoclonus (this is spasmodic contraction of groups of muscles). Page Ref: 136 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 6.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of and the general treatment strategies for stimulant use disorder. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of substance use disorders.

15) Which statement by a patient at a substance abuse clinic indicates that more teaching is needed about the use of replacement or substitute medication for treating substance abuse disorders? A) "The substitute drug will have effects similar to those of the abused drug." B) "The substitute drug will have a lower potential for abuse." C) "The substitute drug exchanges one addicting drug for another." D) "The substitute drug will allow me to take advantage of behavioral treatments." Answer: C Explanation: A) Replacement or substitute medications have been used in treating other substance use disorders. The substitute drug must have effects similar to those of the abused drug but with a lower potential for abuse, allowing the patient to take advantage of behavioral and social treatments. Opioids have been used as a substitution for heroin. However, no such medications have been approved for cocaine use disorder. B) Replacement or substitute medications have been used in treating other substance use disorders. The substitute drug must have effects similar to those of the abused drug but with a lower potential for abuse, allowing the patient to take advantage of behavioral and social treatments. Opioids have been used as a substitution for heroin. However, no such medications have been approved for cocaine use disorder. C) Replacement or substitute medications have been used in treating other substance use disorders. The substitute drug must have effects similar to those of the abused drug but with a lower potential for abuse, allowing the patient to take advantage of behavioral and social treatments. Opioids have been used as a substitution for heroin. However, no such medications have been approved for cocaine use disorder. The purpose of substitute medications is not to replace one addicting medication with another one. D) Replacement or substitute medications have been used in treating other substance use disorders. The substitute drug must have effects similar to those of the abused drug but with a lower potential for abuse, allowing the patient to take advantage of behavioral and social treatments. Opioids have been used as a substitution for heroin. However, no such medications have been approved for cocaine use disorder. Page Ref: 137 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Evaluation | Learning Outcome: 6.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of and the general treatment strategies for stimulant use disorder. | QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and selfcare management | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of substance use disorders to diagnosis and treatment.

16) Which of the following drug characteristics should the emergency department nurse keep in mind when caring for a patient who has recently orally ingested lysergic acid diethylamide (LSD)? A) Onset of action 30-90 minutes B) Peak effect 1-2 hours C) Duration of action 2-3 hours D) Flashbacks in 4-6 hours Answer: A Explanation: A) In general, hallucinogens are consumed orally and are rapidly absorbed from the gastrointestinal tract. For example, LSD has an onset of action, peak effect, and duration of action of 30-90 minutes, 3-5 hours, and 6-12 hours, respectively. B) In general, hallucinogens are consumed orally and are rapidly absorbed from the gastrointestinal tract. For example, LSD has an onset of action, peak effect, and duration of action of 30-90 minutes, 3-5 hours, and 6-12 hours, respectively. C) In general, hallucinogens are consumed orally and are rapidly absorbed from the gastrointestinal tract. For example, LSD has an onset of action, peak effect, and duration of action of 30-90 minutes, 3-5 hours, and 6-12 hours, respectively. D) Flashback refers to symptoms that occur after the acute effects have dissipated. Flashbacks can occur months and even years after the acute intoxication. Page Ref: 138 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 6.7 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of and the general treatment strategies for hallucinogenic use disorder. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of substance use disorders to diagnosis and treatment.

17) The nurse in the health center on a college campus is talking to freshman students about the dangers of opioid use. Which response by a student indicates that more teaching is needed? A) "Opioid use disorder is associated with using other people's opioid prescriptions." B) "Opioid use disorder is associated with using illegally obtained heroin." C) "Opioid use for pain control can lead to addiction unless monitored by a doctor." D) "Opioids are always safe to use if they are prescribed by a doctor." Answer: D Explanation: A) Opioids have analgesic effects and are used for pain relief; however, they have tremendous potential for abuse. Opioid use disorder can be associated with misuse of prescription opioid medications, use of opioid medications prescribed for other individuals, or use of illegally obtained heroin. B) Opioids have analgesic effects and are used for pain relief; however, they have tremendous potential for abuse. Opioid use disorder can be associated with misuse of prescription opioid medications, use of opioid medications prescribed for other individuals, or use of illegally obtained heroin. C) Opioids have analgesic effects and are used for pain relief; however, they have tremendous potential for abuse. Opioid use disorder can be associated with misuse of prescription opioid medications, use of opioid medications prescribed for other individuals, or use of illegally obtained heroin. D) Opioids have analgesic effects and are used for pain relief; however, they have tremendous potential for abuse. Opioid use disorder can be associated with misuse of prescription opioid medications, use of opioid medications prescribed for other individuals, or use of illegally obtained heroin. Page Ref: 139 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Evaluation | Learning Outcome: 6.8 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of and the general treatment strategies for opioid use disorder. | QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Examine the etiology, incidence and pathogenesis of substance use disorders.

18) Which manifestation would the nurse expect to find in a patient with chronic opioid use? A) Track marks along a vein B) Deviated septum C) Hepatitis A D) Respiratory depression Answer: A Explanation: A) Chronic clinical manifestations of intravenous opioid abuse include track marks, which are calluses that follow the track of a vein that has been frequently injected. Chronic clinical manifestations of intranasal opioid use include a perforated nasal septum. Chronic opioid use may be associated with signs and symptoms of other chronic diseases, such as HIV and hepatitis C; this is especially true of opioids that are injected intravenously. B) Chronic clinical manifestations of intravenous opioid abuse include track marks, which are calluses that follow the track of a vein that has been frequently injected. Chronic clinical manifestations of intranasal opioid use include a perforated nasal septum. Chronic opioid use may be associated with signs and symptoms of other chronic diseases, such as HIV and hepatitis C; this is especially true of opioids that are injected intravenously. C) Chronic clinical manifestations of intravenous opioid abuse include track marks, which are calluses that follow the track of a vein that has been frequently injected. Chronic clinical manifestations of intranasal opioid use include a perforated nasal septum. Chronic opioid use may be associated with signs and symptoms of other chronic diseases, such as HIV and hepatitis C; this is especially true of opioids that are injected intravenously. D) Respiratory depression is a sign of opioid toxicity, not chronic use. Page Ref: 139 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 6.8 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of and the general treatment strategies for opioid use disorder. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of substance use disorders.

19) The nurse suspects that a patient brought to the emergency department by ambulance has suffered an opioid overdose. What is the priority action by the nurse? A) Call the physician. B) Administer naloxone. C) Obtain an order for naloxone. D) Assess the patient and get a history from the family. Answer: B Explanation: A) While calling the physician would be appropriate, the priority action by the nurse would be to give naloxone to reverse the effects of an opioid overdose. B) Naloxone is an opioid antagonist that rapidly reverses the effects of an opioid overdose. Naloxone has been prescribed for use in community settings as part of overdose education and prevention programs and can be administered by families, caregivers, and emergency personnel. Most U.S. states have passed legislation authorizing healthcare providers to provide naloxone through standing orders to such individuals and protection from penalties related to practicing medicine without a license. C) Most U.S. states have passed legislation authorizing healthcare providers to provide naloxone through standing orders to such individuals and protection from penalties related to practicing medicine without a license. D) Completing an assessment and history of the patient would be appropriate after the emergency of administering naloxone to reverse the effects of an opioid overdose has passed. Page Ref: 139 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Planning | Learning Outcome: 6.8 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of and the general treatment strategies for opioid use disorder. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of substance use disorders to diagnosis and treatment.

20) According to the Centers for Disease Control and Prevention (CDC), which of the following measures to control pain should the nurse question when caring for a patient in pain? A) Review chronic opioid use every 6 months. B) Start with the lowest effective opioid dose. C) Try nonpharmacological measures to control pain. D) Begin with nonopioid therapy. Answer: A Explanation: A) The CDC's recommendations stress that nonopioid therapy is preferred for treatment of chronic pain. Opioids should be prescribed at the lowest effective dosage with careful reassessment when an increase in dosage is considered; and concurrent use of opioids and benzodiazepines should be avoided whenever possible. Additionally, clinicians should evaluate benefits and harms of chronic opioid therapy with patients every 3 months or more often. B) The CDC's recommendations stress that nonopioid therapy is preferred for treatment of chronic pain. Opioids should be prescribed at the lowest effective dosage with careful reassessment when an increase in dosage is considered; and concurrent use of opioids and benzodiazepines should be avoided whenever possible. Additionally, clinicians should evaluate benefits and harms of chronic opioid therapy with patients every 3 months or more often. C) The CDC's recommendations stress that nonopioid therapy is preferred for treatment of chronic pain. Opioids should be prescribed at the lowest effective dosage with careful reassessment when an increase in dosage is considered; and concurrent use of opioids and benzodiazepines should be avoided whenever possible. Additionally, clinicians should evaluate benefits and harms of chronic opioid therapy with patients every 3 months or more often. D) The CDC's recommendations stress that nonopioid therapy is preferred for treatment of chronic pain. Opioids should be prescribed at the lowest effective dosage with careful reassessment when an increase in dosage is considered; and concurrent use of opioids and benzodiazepines should be avoided whenever possible. Additionally, clinicians should evaluate benefits and harms of chronic opioid therapy with patients every 3 months or more often. Page Ref: 139 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Implementation | Learning Outcome: 6.8 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of and the general treatment strategies for opioid use disorder. | QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of substance use disorders to diagnosis and treatment.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 7 Risks Related to Sleep Alterations 1) A patient in the clinic tells the nurse that she has difficulty sleeping at night. When developing a plan of care for this patient, which of the following would the nurse consider? A) Melatonin is released in response to darkness. B) Sunlight reduces the release of melatonin. C) Melatonin is released in the late afternoon. D) Melatonin secretion stops about 2 a.m. Answer: B Explanation: A) Melatonin, a sleep-inducing hormone produced by the pineal gland, is released just before a person's normal bedtime and stops about 7:00 a.m. Melatonin release drops over the course of the sleep period. Exposure to light causes melatonin release to lessen. B) Melatonin, a sleep-inducing hormone produced by the pineal gland, is released just before a person's normal bedtime and stops about 7:00 a.m. Melatonin release drops over the course of the sleep period. Exposure to light causes melatonin release to lessen. C) Melatonin, a sleep-inducing hormone produced by the pineal gland, is released just before a person's normal bedtime and stops about 7:00 a.m. Melatonin release drops over the course of the sleep period. Exposure to light causes melatonin release to lessen. D) Melatonin, a sleep-inducing hormone produced by the pineal gland, is released just before a person's normal bedtime and stops about 7:00 a.m. Melatonin release drops over the course of the sleep period. Exposure to light causes melatonin release to lessen. Page Ref: 147 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 7.2 Discuss the characteristics of normal sleep and the regulation of body rhythms and sleep | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Relate the neurobiology of the brain and how it relates to sleep.

2) Which assessment by the nurse indicates that a patient who has just fallen to sleep is in stage 1 of sleep? A) Slow rolling eye movements B) Breathing slows down C) Rapid eye movement D) Drop in blood pressure Answer: A Explanation: A) N1, or stage 1, is sometimes called light sleep. The individual drifts from the awake state into sleep, and slow rolling movements of the eye may be observed. B) In stage 2 (N2) and stage 3 (N3), the respiratory rate slows down. C) In rapid eye movement sleep (REM sleep), the eyes move back and forth rapidly. The first REM period begins about 90 minutes after sleep onset. D) A drop in blood pressure occurs in stage 3 (N3) of sleep. Page Ref: 148 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 7.2 Discuss the characteristics of normal sleep and the regulation of body rhythms and sleep | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Relate the neurobiology of the brain and how it relates to sleep.

3) When assessing a patient's sleep-wake pattern, the nurse keeps in mind circadian body patterns. Which assessment data would indicate that the client follows normal circadian sleepwake patterns? A) Highest level of alertness at 4 p.m. (1600 hours) B) Best coordination at 2:30 p.m. (1430 hours) C) Fastest reaction time at 10:00 a.m. (1000 hours) D) Greatest muscle strength at 12 noon (1200 hours) Answer: B Explanation: A) In a normal sleep-wake cycle, a high level of alertness occurs at 10:00 a.m. (1000 hours), best coordination at 2:30 p.m. (1430 hours), fastest reaction time at 3:30 p.m. (1530 hours), and greatest muscle strength at 5:00 p.m. (1700 hours) B) In a normal sleep-wake cycle, a high level of alertness occurs at 10:00 a.m. (1000 hours), best coordination at 2:30 p.m. (1430 hours), fastest reaction time at 3:30 p.m. (1530 hours), and greatest muscle strength at 5:00 p.m. (1700 hours) C) In a normal sleep-wake cycle, a high level of alertness occurs at 10:00 a.m. (1000 hours), best coordination at 2:30 p.m. (1430 hours), fastest reaction time at 3:30 p.m. (1530 hours), and greatest muscle strength at 5:00 p.m. (1700 hours) D) In a normal sleep-wake cycle, a high level of alertness occurs at 10:00 a.m. (1000 hours), best coordination at 2:30 p.m. (1430 hours), fastest reaction time at 3:30 p.m. (1530 hours), and greatest muscle strength at 5:00 p.m. (1700 hours) Page Ref: 148 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 7.2 Discuss the characteristics of normal sleep and the regulation of body rhythms and sleep | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Relate the neurobiology of the brain and how it relates to sleep.

4) When taking a healthy patient's vital signs, the nurse would expect the highest body temperature to occur at what time of day? A) 6 a.m. (0600 hours) B) 12 noon (1200 hours) C) 7 p.m. (1900 hours) D) 2 a.m. (0200 hours) Answer: C Explanation: A) The highest body temperature typically occurs at 7 p.m. (1900 hours) B) The highest body temperature typically occurs at 7 p.m. (1900 hours) C) The highest body temperature typically occurs at 7 p.m. (1900 hours) D) The highest body temperature typically occurs at 7 p.m. (1900 hours) Page Ref: 148 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 7.2 Discuss the characteristics of normal sleep and the regulation of body rhythms and sleep | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Relate the neurobiology of the brain and how it relates to sleep.

5) A gerontology nurse is speaking to adults in a senior center about healthy sleep patterns. Which sleep pattern does the nurse describe as normal for this age group? A) Taking a shorter time to fall asleep B) Having longer sleep cycles C) Taking more naps D) Spending more time in REM sleep Answer: C Explanation: A) Older adults have shorter sleep cycles and spend a smaller proportion of their sleep time in N3 and REM sleep. They also take longer to fall asleep, tend to wake up during their sleep more frequently and to stay awake longer when they do, and typically nap more than younger adults do. B) Older adults have shorter sleep cycles and spend a smaller proportion of their sleep time in N3 and REM sleep. They also take longer to fall asleep, tend to wake up during their sleep more frequently and to stay awake longer when they do, and typically nap more than younger adults do. C) Older adults have shorter sleep cycles and spend a smaller proportion of their sleep time in N3 and REM sleep. They also take longer to fall asleep, tend to wake up during their sleep more frequently and to stay awake longer when they do, and typically nap more than younger adults do. D) Older adults have shorter sleep cycles and spend a smaller proportion of their sleep time in N3 and REM sleep. They also take longer to fall asleep, tend to wake up during their sleep more frequently and to stay awake longer when they do, and typically nap more than younger adults do. Page Ref: 148 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 7.2 Discuss the characteristics of normal sleep and the regulation of body rhythms and sleep | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Relate the neurobiology of the brain and how it relates to sleep.

6) When assessing a patient with sleep deprivation, the nurse would expect the patient to report: A) weight loss. B) reduced peripheral vision. C) slow speech. D) irritability. Answer: D Explanation: A) Sleep deprivation leads to psychologic and physiologic problems. Psychologic problems include memory loss, irritability, inattention, delusions, labile emotions, slurred speech, slowed reaction time, and decreased coordination. Physiologic problems include blurred vision, dysfunctional hormone secretion, increased energy expenditure, weight gain, impaired blood cell function, and impaired immune system function. B) Sleep deprivation leads to psychologic and physiologic problems. Psychologic problems include memory loss, irritability, inattention, delusions, labile emotions, slurred speech, slowed reaction time, and decreased coordination. Physiologic problems include blurred vision, dysfunctional hormone secretion, increased energy expenditure, weight gain, impaired blood cell function, and impaired immune system function. C) Sleep deprivation leads to psychologic and physiologic problems. Psychologic problems include memory loss, irritability, inattention, delusions, labile emotions, slurred speech, slowed reaction time, and decreased coordination. Physiologic problems include blurred vision, dysfunctional hormone secretion, increased energy expenditure, weight gain, impaired blood cell function, and impaired immune system function. D) Sleep deprivation leads to psychologic and physiologic problems. Psychologic problems include memory loss, irritability, inattention, delusions, labile emotions, slurred speech, slowed reaction time, and decreased coordination. Physiologic problems include blurred vision, dysfunctional hormone secretion, increased energy expenditure, weight gain, impaired blood cell function, and impaired immune system function. Page Ref: 150 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Assessment | Learning Outcome: 7.2 Discuss the characteristics of normal sleep and the regulation of body rhythms and sleep | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of sleep alterations.

7) Which statement by a patient undergoing polysomnography indicates that more teaching is needed? A) "An EEG is performed during the sleep study in order to detect any seizure activity." B) "An EMG is performed during the sleep study to record muscle tension and relaxation." C) "An EOG is performed during the sleep study to record eye movements." D) "A nasal thermistor is used during the sleep study to measure nasal air flow." Answer: A Explanation: A) While an EEG can detect seizure activity, in a sleep study or polysomnogram, it is performed to detect brain waves to identify sleep stages. B) An EMG is done during a sleep study or polysomnogram to record muscle tension and relaxation. C) An EOG is done during a sleep study or polysomnogram to record eye movement and is used to identify REM sleep. D) A nasal thermistor is used during a sleep study or polysomnogram in order to measure nasal air flow to determine respirations. Page Ref: 151 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Assessment | Learning Outcome: 7.3 Explain what measures are used to assess sleep and its outcomes | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of sleep alterations to diagnosis and treatment.

8) To reduce jet lag in a patient traveling from the United States to Europe, what recommendation should the nurse make? A) Spend time outside during daylight at the destination. B) Take melatonin in the morning until adjusted to time. C) Drink caffeinated coffee in the early evening to overcome tiredness. D) Take a long-acting hypnotic at bedtime. Answer: A Explanation: A) Because exposure to sunlight is the strongest zeitgeber (environmental cue), it is advisable to spend time outside during daylight at the destination to reduce jet lag. Taking melatonin or a melatonin agonist, such as ramelteon (Rozerem), about 5-30 minutes before going to bed at the destination can help, as can using a short-acting hypnotic, such as zolpidem (Ambien) or zaleplon (Sonata). Stimulants such as caffeine, modafinil (Provigil), or armodafinil (Nuvigil) may help during the day. Taking a stimulant close to bedtime may, however, adversely affect sleep at night. B) Because exposure to sunlight is the strongest zeitgeber (environmental cue), it is advisable to spend time outside during daylight at the destination to reduce jet lag. Taking melatonin or a melatonin agonist, such as ramelteon (Rozerem), about 5-30 minutes before going to bed at the destination can help, as can using a short-acting hypnotic, such as zolpidem (Ambien) or zaleplon (Sonata). Stimulants such as caffeine, modafinil (Provigil), or armodafinil (Nuvigil) may help during the day. Taking a stimulant close to bedtime may, however, adversely affect sleep at night. C) Because exposure to sunlight is the strongest zeitgeber (environmental cue), it is advisable to spend time outside during daylight at the destination to reduce jet lag. Taking melatonin or a melatonin agonist, such as ramelteon (Rozerem), about 5-30 minutes before going to bed at the destination can help, as can using a short-acting hypnotic, such as zolpidem (Ambien) or zaleplon (Sonata). Stimulants such as caffeine, modafinil (Provigil), or armodafinil (Nuvigil) may help during the day. Taking a stimulant close to bedtime may, however, adversely affect sleep at night. D) Because exposure to sunlight is the strongest zeitgeber (environmental cue), it is advisable to spend time outside during daylight at the destination to reduce jet lag. Taking melatonin or a melatonin agonist, such as ramelteon (Rozerem), about 5-30 minutes before going to bed at the destination can help, as can using a short-acting hypnotic, such as zolpidem (Ambien) or zaleplon (Sonata). Stimulants such as caffeine, modafinil (Provigil), or armodafinil (Nuvigil) may help during the day. Taking a stimulant close to bedtime may, however, adversely affect sleep at night. Page Ref: 153 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 7.4 List physiologic, psychologic, and sociologic consequences of insufficient and disturbed sleep | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care 8

MNL Learning Outcome: LO 4: Consider the pathophysiology of sleep alterations to diagnosis and treatment. 9) Which assessment data is a precipitating factor for insomnia? A) Frequent worrying B) Loss of a job C) Inadequate coping skills D) Hyperarousal Answer: B Explanation: A) Predisposing factors relate to the individual's tendency to have difficulty sleeping, such as hyperarousal or frequently worrying. Precipitating factors, such as loss of a job, a death in the family, or other stressful event, trigger a period of poor sleep. Perpetuating factors include inadequate coping skills or poor sleep habits, which contribute to prolongation of insomnia and may last over a month, becoming chronic. B) Predisposing factors relate to the individual's tendency to have difficulty sleeping, such as hyperarousal or frequently worrying. Precipitating factors, such as loss of a job, a death in the family, or other stressful event, trigger a period of poor sleep. Perpetuating factors include inadequate coping skills or poor sleep habits, which contribute to prolongation of insomnia and may last over a month, becoming chronic. C) Predisposing factors relate to the individual's tendency to have difficulty sleeping, such as hyperarousal or frequently worrying. Precipitating factors, such as loss of a job, a death in the family, or other stressful event, trigger a period of poor sleep. Perpetuating factors include inadequate coping skills or poor sleep habits, which contribute to prolongation of insomnia and may last over a month, becoming chronic. D) Predisposing factors relate to the individual's tendency to have difficulty sleeping, such as hyperarousal or frequently worrying. Precipitating factors, such as loss of a job, a death in the family, or other stressful event, trigger a period of poor sleep. Perpetuating factors include inadequate coping skills or poor sleep habits, which contribute to prolongation of insomnia and may last over a month, becoming chronic. Page Ref: 153 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 7.5 Describe factors leading to insomnia and how it is diagnosed and treated | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of sleep alterations.

10) A patient is being seen in the clinic for insomnia. The nurse explains that the best diagnostic indicator of insomnia is: A) the patient's report of insomnia. B) results of polysomnography. C) completing the Pittsburgh Sleep Quality Index. D) results of actigraphy. Answer: A Explanation: A) Diagnosis of insomnia is based on patient report. Polysomnography is not performed to evaluate insomnia, but it may be used to rule out other sleep disorders as the cause of the poor sleep. Additionally, examination of a 2-week sleep diary is necessary. Use of a subjective tool to measure sleep quality, such as the Pittsburgh Sleep Quality Index aids in the diagnosis. Actigraphy can be used as an objective measure and to validate the information on the sleep diary. B) Diagnosis of insomnia is based on patient report. Polysomnography is not performed to evaluate insomnia, but it may be used to rule out other sleep disorders as the cause of the poor sleep. Additionally, examination of a 2-week sleep diary is necessary. Use of a subjective tool to measure sleep quality, such as the Pittsburgh Sleep Quality Index aids in the diagnosis. Actigraphy can be used as an objective measure and to validate the information on the sleep diary. C) Diagnosis of insomnia is based on patient report. Polysomnography is not performed to evaluate insomnia, but it may be used to rule out other sleep disorders as the cause of the poor sleep. Additionally, examination of a 2-week sleep diary is necessary. Use of a subjective tool to measure sleep quality, such as the Pittsburgh Sleep Quality Index aids in the diagnosis. Actigraphy can be used as an objective measure and to validate the information on the sleep diary. D) Diagnosis of insomnia is based on patient report. Polysomnography is not performed to evaluate insomnia, but it may be used to rule out other sleep disorders as the cause of the poor sleep. Additionally, examination of a 2-week sleep diary is necessary. Use of a subjective tool to measure sleep quality, such as the Pittsburgh Sleep Quality Index aids in the diagnosis. Actigraphy can be used as an objective measure and to validate the information on the sleep diary. Page Ref: 154 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 7.5 Describe factors leading to insomnia and how it is diagnosed and treated | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of sleep alterations to diagnosis and treatment.

11) During sleep apnea, the nurse can anticipate which laboratory values? A) A rise in blood CO2, a drop in blood O2 B) A rise in blood CO2, a rise in blood O2 C) A drop in blood CO2, a rise in blood O2 D) A drop in blood CO2, a drop in blood O2 Answer: A Explanation: A) The rise in blood CO2 (hypercapnia) and drop in blood O2 (desaturation) cause the individual to momentarily arouse, and airway muscle tone returns. The individual then takes a breath and falls back asleep, and the cycle begins again. B) The rise in blood CO2 (hypercapnia) and drop in blood O2 (desaturation) cause the individual to momentarily arouse, and airway muscle tone returns. The individual then takes a breath and falls back asleep, and the cycle begins again. C) The rise in blood CO2 (hypercapnia) and drop in blood O2 (desaturation) cause the individual to momentarily arouse, and airway muscle tone returns. The individual then takes a breath and falls back asleep, and the cycle begins again. D) The rise in blood CO2 (hypercapnia) and drop in blood O2 (desaturation) cause the individual to momentarily arouse, and airway muscle tone returns. The individual then takes a breath and falls back asleep, and the cycle begins again. Page Ref: 156 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 7.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of sleep-disordered breathing and approaches to diagnosis and treatment of these conditions across the lifespan | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of sleep alterations to diagnosis and treatment.

12) The nurse is counseling a pregnant woman with sleep obstructive sleep apnea (OSA). Which statement by the woman indicates that she does not understand what the nurse has taught? A) "My baby may have poor fetal growth due to OSA." B) "OSA may lead to a small placenta." C) "My baby may be small for gestational age at birth." D) "OSA will not affect my baby." Answer: D Explanation: A) Because of apnea-induced hypoxia, untreated OSA can lead to poor fetal growth, small placenta, and babies that are small for gestational age at birth. B) Because of apnea-induced hypoxia, untreated OSA can lead to poor fetal growth, small placenta, and babies that are small for gestational age at birth. C) Because of apnea-induced hypoxia, untreated OSA can lead to poor fetal growth, small placenta, and babies that are small for gestational age at birth. D) Because of apnea-induced hypoxia, untreated OSA can lead to poor fetal growth, small placenta, and babies that are small for gestational age at birth. Page Ref: 157 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 7.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of sleep-disordered breathing and approaches to diagnosis and treatment of these conditions across the lifespan | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of sleep alterations to diagnosis and treatment.

13) When observing a patient with central sleep apnea during sleep, the nurse is most likely to observe: A) respiratory efforts seen during periods with no airflow. B) absence of respiratory efforts during periods of no airflow. C) paradoxical chest and abdomen movements during desaturation. D) absence of desaturation. Answer: B Explanation: A) In obstructive sleep apnea, chest and abdominal movements continue through periods of desaturation with paradoxical movements often noted (chest and abdomen expand and contract oppositely). However, in central sleep apnea, chest and abdominal movements are absent during the apnea event. B) In central sleep apnea, chest and abdominal movement are absent during periods of apnea. C) In obstructive sleep apnea, chest and abdominal movements continue through periods of desaturation with paradoxical movements often noted (chest and abdomen expand and contract oppositely). However, in central sleep apnea, chest and abdominal movements are absent during the apnea event. D) In central sleep apnea, periods of desaturation may be observed via oximetry assessment. Page Ref: 157 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 7.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of sleep-disordered breathing and approaches to diagnosis and treatment of these conditions across the lifespan | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of sleep alterations.

14) Which statement is typical of a patient who is newly diagnosed with narcolepsy? A) "I gradually drift off to sleep during the day." B) "I sleep well at night." C) "I have periods where I collapse." D) "I have daytime sleepiness and fatigue." Answer: D Explanation: A) Narcolepsy is marked by sudden inappropriate bouts of sleep, not a gradual drift to sleep. B) People with narcolepsy sleep poorly at night and may complain of insomnia. C) Cataplexy generally appears within 5 years of the initial symptoms. It can range from a feeling of weakness to complete muscular collapse. D) Excessive daytime sleepiness and fatigue are the first symptoms of narcolepsy, usually appearing in adolescence. Page Ref: 160 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 7.7 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of narcolepsy and approaches to diagnosis and treatment of this condition across the lifespan | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of sleep alterations.

15) When developing a care plan for a patient with narcolepsy, the nursing diagnosis with the highest priority is: A) risk for injury. B) insomnia. C) deficient knowledge. D) disturbed body image. Answer: A Explanation: A) While all these nursing diagnoses may be appropriate for the patient with narcolepsy, the highest priority is given to safety. Affected people should not drive or engage in other activities in which sudden sleep or loss of motor control could lead to accident or serious injury. B) While all these nursing diagnoses may be appropriate for the patient with narcolepsy, the highest priority is given to safety. Affected people should not drive or engage in other activities in which sudden sleep or loss of motor control could lead to accident or serious injury. C) While all these nursing diagnoses may be appropriate for the patient with narcolepsy, the highest priority is given to safety. Affected people should not drive or engage in other activities in which sudden sleep or loss of motor control could lead to accident or serious injury. D) While all these nursing diagnoses may be appropriate for the patient with narcolepsy, the highest priority is given to safety. Affected people should not drive or engage in other activities in which sudden sleep or loss of motor control could lead to accident or serious injury. Page Ref: 160 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 7.7 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of narcolepsy and approaches to diagnosis and treatment of this condition across the lifespan | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of sleep alterations to diagnosis and treatment.

16) When evaluating the effectiveness of the stimulant drug methylphenidate in the patient with narcolepsy, the nurse should expect the patient to have: A) less attacks of sleep paralysis. B) less cataplexy attacks. C) reduced daytime sleepiness. D) uninterrupted nighttime sleep. Answer: C Explanation: A) Methylphenidate does not affect sleep paralysis. B) Methylphenidate does not affect cataplexy. C) Medication is used to manage symptoms. Stimulants such as, modafinil (Provigil®), armodafinil (Nuvigil®), amphetamines, and methylphenidate (Ritalin®) are used to manage daytime sleepiness. D) Methylphenidate does not lead to uninterrupted nighttime sleep. Page Ref: 161 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Evaluation | Learning Outcome: 7.7 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of narcolepsy and approaches to diagnosis and treatment of this condition across the lifespan | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of sleep alterations to diagnosis and treatment.

17) Which patient statement is typical of data collected from patients with a diagnosis of restless leg syndrome? A) "The urge to move my legs subsides when resting." B) "My leg restless subsides with movement." C) "The restlessness subsides in the evening." D) "My symptoms get better at night." Answer: B Explanation: A) For a diagnosis of restless leg syndrome, four symptoms must be present. They can be remembered by using the mnemonic URGE: Urge to move legs, usually accompanied by unpleasant sensations. Rest provokes symptoms. Getting active (moving) relieves symptoms. Evening and night worsen symptoms. B) For a diagnosis of restless leg syndrome, four symptoms must be present. They can be remembered by using the mnemonic URGE: Urge to move legs, usually accompanied by unpleasant sensations. Rest provokes symptoms. Getting active (moving) relieves symptoms. Evening and night worsen symptoms. C) For a diagnosis of restless leg syndrome, four symptoms must be present. They can be remembered by using the mnemonic URGE: Urge to move legs, usually accompanied by unpleasant sensations. Rest provokes symptoms. Getting active (moving) relieves symptoms. Evening and night worsen symptoms. D) For a diagnosis of restless leg syndrome, four symptoms must be present. They can be remembered by using the mnemonic URGE: Urge to move legs, usually accompanied by unpleasant sensations. Rest provokes symptoms. Getting active (moving) relieves symptoms. Evening and night worsen symptoms. Page Ref: 161 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 7.8 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of restless legs syndrome and approaches to diagnosis and treatment of this condition across the lifespan | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of sleep alterations.

18) Which instruction should the nurse give to a patient undergoing a Suggested Immobility Test for possible restless leg syndrome? A) "You will be asked to lie quietly in bed." B) "This test takes place at night." C) "Do not fall asleep." D) "You may move around if your legs feel restless." Answer: C Explanation: A) The Suggested Immobility Test is performed during waking hours. The person is seated in chair in a quiet darkened room with legs outstretched. Several EEG sensors are placed on the scalp to monitor alertness, and EMG sensors are attached to the legs. The person is then told to stay awake and not to move the legs. Subjective rating of leg sensations and objective measurements of leg movements and muscle tension confirm the diagnosis. B) The Suggested Immobility Test is performed during waking hours. The person is seated in chair in a quiet darkened room with legs outstretched. Several EEG sensors are placed on the scalp to monitor alertness, and EMG sensors are attached to the legs. The person is then told to stay awake and not to move the legs. Subjective rating of leg sensations and objective measurements of leg movements and muscle tension confirm the diagnosis. C) The Suggested Immobility Test is performed during waking hours. The person is seated in chair in a quiet darkened room with legs outstretched. Several EEG sensors are placed on the scalp to monitor alertness, and EMG sensors are attached to the legs. The person is then told to stay awake and not to move the legs. Subjective rating of leg sensations and objective measurements of leg movements and muscle tension confirm the diagnosis. D) The Suggested Immobility Test is performed during waking hours. The person is seated in chair in a quiet darkened room with legs outstretched. Several EEG sensors are placed on the scalp to monitor alertness, and EMG sensors are attached to the legs. The person is then told to stay awake and not to move the legs. Subjective rating of leg sensations and objective measurements of leg movements and muscle tension confirm the diagnosis. Page Ref: 162 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 7.8 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of restless legs syndrome and approaches to diagnosis and treatment of this condition across the lifespan | QSEN Competencies: I.C.10. Value active partnership with patients or designated surrogates in planning, implementation, and evaluation of care | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of sleep alterations.

19) A parent tells the nurse that her child woke up terrified, with eyes opened and cried out. The child did not recall the event in the morning. The nurse explains that this event is called: A) night terrors. B) somnambulism. C) enuresis. D) bruxism. Answer: A Explanation: A) During a night terror the child seems to wake from NREM sleep terrified, sits up with open eyes, cries out, may speak incoherently, and is unresponsive to outside stimuli. The child remains asleep and does not remember the night terror the following morning. This is one of the parasomnias. B) Parasomnias include bruxism (grinding one's teeth during sleep), somnambulism (sleep walking), nightmares, enuresis (bedwetting), sleep paralysis, REM sleep behavior disorder, night terrors (also called sleep terrors), and other phenomena. C) Parasomnias include bruxism (grinding one's teeth during sleep), somnambulism (sleep walking), nightmares, enuresis (bedwetting), sleep paralysis, REM sleep behavior disorder, night terrors (also called sleep terrors), and other phenomena. D) Parasomnias include bruxism (grinding one's teeth during sleep), somnambulism (sleep walking), nightmares, enuresis (bedwetting), sleep paralysis, REM sleep behavior disorder, night terrors (also called sleep terrors), and other phenomena. Page Ref: 162 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 7.9 Identify and define selected parasomnias, and describe the causes, pathogenesis, and clinical manifestations of these conditions and approaches to their diagnosis and treatment across the lifespan | QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of sleep alterations to diagnosis and treatment.

20) Which nursing diagnosis has the highest priority in the patient with somnambulism? A) Risk for injury B) Insomnia C) Deficient knowledge D) Disturbed body image Answer: A Explanation: A) The nursing diagnosis with the highest priority in the patient with somnambulism or sleep walking is safety. Care should be taken for the safety of known sleepwalkers, including locking doors and windows and blocking stairways. B) The nursing diagnosis with the highest priority in the patient with somnambulism or sleep walking is safety. Care should be taken for the safety of known sleepwalkers, including locking doors and windows and blocking stairways. C) The nursing diagnosis with the highest priority in the patient with somnambulism or sleep walking is safety. Care should be taken for the safety of known sleepwalkers, including locking doors and windows and blocking stairways. D) The nursing diagnosis with the highest priority in the patient with somnambulism or sleep walking is safety. Care should be taken for the safety of known sleepwalkers, including locking doors and windows and blocking stairways. Page Ref: 163 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 7.9 Identify and define selected parasomnias, and describe the causes, pathogenesis, and clinical manifestations of these conditions and approaches to their diagnosis and treatment across the lifespan | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of sleep alterations to diagnosis and treatment.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 8 Fluid and Electrolyte Imbalances 1) When assessing a patient with metabolic acidosis, which concept should the nurse keep in mind? A) The kidney response is to retain HCO3-. B) The kidney response is to excrete HCO3- or conserve H+. C) The kidney response is to decrease acid excretion in the urine and decrease HCO3production. D) The kidney response is to Increase CO2. Answer: A Explanation: A) In metabolic acidosis the response of the kidneys is to retain HCO3-. B) In metabolic alkalosis the response of the kidneys is to excrete HCO3- or conserve H+. C) In respiratory alkalosis the response of the kidneys is to decrease acid excretion in the urine and decrease HCO3- production. D) In respiratory acidosis the response of the lungs is to increase CO2. Page Ref: 172 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 8.1 Describe the normal fluid and electrolyte balance, the results of inappropriate fluid and electrolyte imbalance, and concepts related to fluids and electrolytes. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of electrolyte disorders.

2) When reviewing the laboratory values of a patient, which value would prompt the nurse to notify the physician? A) Serum sodium 140 mEq/L B) Serum chloride 100 mEq/L C) Serum potassium 3.0 mEq/L D) Serum phosphorous 2.0 mEq/L Answer: C Explanation: A) A normal serum sodium value is 135-145 mEq/L. B) A normal serum chloride value is 95-105 mEq/L. C) A normal serum potassium value is 3.5-5.3 mEq/L. D) A normal serum phosphorous value is 1.7-2.6 mEq/L. Page Ref: 173 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 8.2 Outline the distribution, composition, movement, and regulation of body fluids and the regulation of electrolytes. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of electrolyte disorders.

3) During an assessment, the nurse notes that a patient has 2 mm pitting edema in his ankles. In the medical record, the nurse grades this edema as: A) 1+ B) 2+ C) 3+ D) 4+ Answer: A Explanation: A) In the extremities, edema is more readily notable and palpable. This palpable quality is then graded on a scale of 1-4, the higher score indicating more serious and enduring edema (2 mm pitting when palpated is graded as 1+ pitting edema; 4 mm is considered 2+ pitting edema; 6 mm is 3+ pitting edema; and 8 mm is considered 4+ pitting edema). B) In the extremities, edema is more readily notable and palpable. This palpable quality is then graded on a scale of 1-4, the higher score indicating more serious and enduring edema (2 mm pitting when palpated is graded as 1+ pitting edema; 4 mm is considered 2+ pitting edema; 6 mm is 3+ pitting edema; and 8 mm is considered 4+ pitting edema). C) In the extremities, edema is more readily notable and palpable. This palpable quality is then graded on a scale of 1-4, the higher score indicating more serious and enduring edema (2 mm pitting when palpated is graded as 1+ pitting edema; 4 mm is considered 2+ pitting edema; 6 mm is 3+ pitting edema; and 8 mm is considered 4+ pitting edema). D) In the extremities, edema is more readily notable and palpable. This palpable quality is then graded on a scale of 1-4, the higher score indicating more serious and enduring edema (2 mm pitting when palpated is graded as 1+ pitting edema; 4 mm is considered 2+ pitting edema; 6 mm is 3+ pitting edema; and 8 mm is considered 4+ pitting edema). Page Ref: 175-176 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 8.2 Outline the distribution, composition, movement, and regulation of body fluids and the regulation of electrolytes. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of electrolyte disorders.

4) Which manifestation would the nurse expect in a 3-month-old with diarrhea? A) Bulging fontanels B) Swollen tongue C) Dry diaper for 2 hours D) No tears when crying Answer: D Explanation: A) Signs of dehydration in infants and children include dry mouth and tongue, a lack of tears when crying, no wet diapers for 3 hours, sunken eyes and cheeks, sunken fontanels, listlessness, and irritability. B) Signs of dehydration in infants and children include dry mouth and tongue, a lack of tears when crying, no wet diapers for 3 hours, sunken eyes and cheeks, sunken fontanels, listlessness, and irritability. C) Signs of dehydration in infants and children include dry mouth and tongue, a lack of tears when crying, no wet diapers for 3 hours, sunken eyes and cheeks, sunken fontanels, listlessness, and irritability. D) Signs of dehydration in infants and children include dry mouth and tongue, a lack of tears when crying, no wet diapers for 3 hours, sunken eyes and cheeks, sunken fontanels, listlessness, and irritability. Page Ref: 175 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 8.2 Outline the distribution, composition, movement, and regulation of body fluids and the regulation of electrolytes. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of electrolyte disorders.

5) Which manifestation would the nurse expect to find in a patient with fluid volume deficit? A) Postural hypotension B) Taut skin C) Low urine specific gravity D) Weight gain Answer: A Explanation: A) Clinical manifestations of fluid volume deficit include decreased systolic blood pressure, postural hypotension, increased heart rate, decreased pulse amplitude, flat jugular veins, lack of edema, poor skin turgor, low urine output, concentrated urine, high urine specific gravity, and weight loss. B) Clinical manifestations of fluid volume deficit include decreased systolic blood pressure, postural hypotension, increased heart rate, decreased pulse amplitude, flat jugular veins, lack of edema, poor skin turgor, low urine output, concentrated urine, high urine specific gravity, and weight loss. C) Clinical manifestations of fluid volume deficit include decreased systolic blood pressure, postural hypotension, increased heart rate, decreased pulse amplitude, flat jugular veins, lack of edema, poor skin turgor, low urine output, concentrated urine, high urine specific gravity, and weight loss. D) Clinical manifestations of fluid volume deficit include decreased systolic blood pressure, postural hypotension, increased heart rate, decreased pulse amplitude, flat jugular veins, lack of edema, poor skin turgor, low urine output, concentrated urine, high urine specific gravity, and weight loss. Page Ref: 179 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 8.2 Outline the distribution, composition, movement, and regulation of body fluids and the regulation of electrolytes. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of electrolyte disorders.

6) Which nursing intervention would the nurse expect to implement in a patient with isotonic fluid excess? A) Provide a 2- to 4-gram sodium diet. B) Encourage fluid intake. C) Monitor intake and output. D) Position the patient flat in bed. Answer: C Explanation: A) Treatment is aimed at restricting fluid intake and correcting the underlying etiology. Loop diuretics such as furosemide may be indicated to promote the excretion of sodium and fluid. A fluid restriction as well as limiting of sodium intake may also be necessary to prevent the need for ongoing fluid replacement. Optimal nursing care of the patient with isotonic fluid excess includes monitoring fluid intake and output, weighing the patient daily, assessing respirations to listen for crackles or rales, assessing skin for peripheral edema, monitoring responses to medication therapy with diuretics, promoting rest, and utilizing semi-Fowler positioning for orthopnea in symptomatic patients. B) Treatment is aimed at restricting fluid intake and correcting the underlying etiology. Loop diuretics such as furosemide may be indicated to promote the excretion of sodium and fluid. A fluid restriction as well as limiting of sodium intake may also be necessary to prevent the need for ongoing fluid replacement. Optimal nursing care of the patient with isotonic fluid excess includes monitoring fluid intake and output, weighing the patient daily, assessing respirations to listen for crackles or rales, assessing skin for peripheral edema, monitoring responses to medication therapy with diuretics, promoting rest, and utilizing semi-Fowler positioning for orthopnea in symptomatic patients. C) Treatment is aimed at restricting fluid intake and correcting the underlying etiology. Loop diuretics such as furosemide may be indicated to promote the excretion of sodium and fluid. A fluid restriction as well as limiting of sodium intake may also be necessary to prevent the need for ongoing fluid replacement. Optimal nursing care of the patient with isotonic fluid excess includes monitoring fluid intake and output, weighing the patient daily, assessing respirations to listen for crackles or rales, assessing skin for peripheral edema, monitoring responses to medication therapy with diuretics, promoting rest, and utilizing semi-Fowler positioning for orthopnea in symptomatic patients. D) Treatment is aimed at restricting fluid intake and correcting the underlying etiology. Loop diuretics such as furosemide may be indicated to promote the excretion of sodium and fluid. A fluid restriction as well as limiting of sodium intake may also be necessary to prevent the need for ongoing fluid replacement. Optimal nursing care of the patient with isotonic fluid excess includes monitoring fluid intake and output, weighing the patient daily, assessing respirations to listen for crackles or rales, assessing skin for peripheral edema, monitoring responses to medication therapy with diuretics, promoting rest, and utilizing semi-Fowler positioning for orthopnea in symptomatic patients. Page Ref: 180 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential

Standards: Nursing Process: Implementation | Learning Outcome: 8.2 Outline the distribution, composition, movement, and regulation of body fluids and the regulation of electrolytes. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of electrolyte imbalances to diagnosis and treatment. 7) When assessing the cardiovascular status of a patient with hypernatremia, the nurse would expect which manifestation? A) Bradycardia B) Flat jugular veins C) Hypertension D) Peripheral edema Answer: B Explanation: A) Clinical presentation of hypernatremia includes thirst, fever, dry membranes, hypotension, tachycardia, low JVP, and restlessness. B) Clinical presentation of hypernatremia includes thirst, fever, dry membranes, hypotension, tachycardia, low JVP, and restlessness. C) Clinical presentation of hypernatremia includes thirst, fever, dry membranes, hypotension, tachycardia, low JVP, and restlessness. D) Clinical presentation of hypernatremia includes thirst, fever, dry membranes, hypotension, tachycardia, low JVP, and restlessness. Page Ref: 183 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 8.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of water and sodium imbalances and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of electrolyte disorders.

8) When a patient with hypoparathyroidism reports numbness and tingling, the nurse should suspect which electrolyte imbalance? A) Hyperchloremia B) Hypernatremia C) Hypophosphatemia D) Hypocalcemia Answer: D Explanation: A) In hypoparathyroidism or parathyroid gland removal, low to undetectable levels of calcium can be found on laboratory studies. Corresponding hypomagnesemia and hyperphosphatemia can occur as well. Signs and symptoms of hypocalcemia include numbness and tingling, muscle cramping, hyperactive reflexes, tetany, laryngeal spasms, positive Chvostek and Trousseau signs, decreased blood pressure, ventricular dysrhythmias, bone pain, and fractures. B) In hypoparathyroidism or parathyroid gland removal, low to undetectable levels of calcium can be found on laboratory studies. Corresponding hypomagnesemia and hyperphosphatemia can occur as well. Signs and symptoms of hypocalcemia include numbness and tingling, muscle cramping, hyperactive reflexes, tetany, laryngeal spasms, positive Chvostek and Trousseau signs, decreased blood pressure, ventricular dysrhythmias, bone pain, and fractures. C) In hypoparathyroidism or parathyroid gland removal, low to undetectable levels of calcium can be found on laboratory studies. Corresponding hypomagnesemia and hyperphosphatemia can occur as well. Signs and symptoms of hypocalcemia include numbness and tingling, muscle cramping, hyperactive reflexes, tetany, laryngeal spasms, positive Chvostek and Trousseau signs, decreased blood pressure, ventricular dysrhythmias, bone pain, and fractures. D) In hypoparathyroidism or parathyroid gland removal, low to undetectable levels of calcium can be found on laboratory studies. Corresponding hypomagnesemia and hyperphosphatemia can occur as well. Signs and symptoms of hypocalcemia include numbness and tingling, muscle cramping, hyperactive reflexes, tetany, laryngeal spasms, positive Chvostek and Trousseau signs, decreased blood pressure, ventricular dysrhythmias, bone pain, and fractures. Page Ref: 189-190 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Diagnosing | Learning Outcome: 8.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of calcium imbalances and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of electrolyte disorders.

9) Which assessment finding would alert the nurse that a patient who is vomiting has developed hypochloremia? A) Slow, shallow respirations B) Polydipsia C) Poor skin turgor D) Decreased urine output Answer: A Explanation: A) Acute fluid volume excess associated with dilutional hypochloremia can lead to cerebral edema with altered mental status, confusion, and convulsions. Other findings may include sweating, headache, weakness, nausea, tetany, weight gain, increased urine output, muscle weakness, and slow, shallow respirations. B) Acute fluid volume excess associated with dilutional hypochloremia can lead to cerebral edema with altered mental status, confusion, and convulsions. Other findings may include sweating, headache, weakness, nausea, tetany, weight gain, increased urine output, muscle weakness, and slow, shallow respirations. C) Acute fluid volume excess associated with dilutional hypochloremia can lead to cerebral edema with altered mental status, confusion, and convulsions. Other findings may include sweating, headache, weakness, nausea, tetany, weight gain, increased urine output, muscle weakness, and slow, shallow respirations. D) Acute fluid volume excess associated with dilutional hypochloremia can lead to cerebral edema with altered mental status, confusion, and convulsions. Other findings may include sweating, headache, weakness, nausea, tetany, weight gain, increased urine output, muscle weakness, and slow, shallow respirations. Page Ref: 185 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessing | Learning Outcome: 8.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of chloride imbalances and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of electrolyte disorders.

10) Which nursing intervention should be included in the nursing plan of care for a patient with hepatic impairment and hypochloremia? A) Administer ammonium chloride. B) Discontinue a loop diuretic and change to another class of drug. C) Infuse a hypotonic saline solution. D) Encourage intake of low-chloride foods. Answer: B Explanation: A) Ammonium chloride can be given to a patient with metabolic acidosis. However, this medication should be avoided for patients with hepatic or renal impairment. B) Changing the patient from a loop diuretic therapy to another class of drugs may be beneficial in preventing further hypochloremia. Loop diuretics act on the ascending portion of the loop of Henle, which prevents sodium, potassium, and chloride resorption, therefore contributing to hypochloremia. C) Depending on the etiology, the treatment plan may consist of isotonic saline or hypertonic saline as well as replacement with oral sodium chloride. D) Chloride-rich foods such as tomato juice, bananas, dates, eggs, cheese, milk, salty broth, canned vegetables, and processed meals can help correct hypochloremia. Page Ref: 186 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Planning | Learning Outcome: 8.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of chloride imbalances and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of electrolyte imbalances to diagnosis and treatment.

11) Which statement by a patient receiving a thiazide diuretic indicates to the nurse that the patient needs more instruction? A) "I may need to take a potassium supplement." B) "I should avoid foods high in potassium." C) "I will need to have my potassium level checked periodically." D) "I should report any undue weakness or fatigue." Answer: B Explanation: A) Patients who are taking a loop or thiazide diuretic are at risk for hypokalemia. If dietary intake of potassium is not sufficient, the patient may need to take a potassium supplement. B) Patients who are taking a loop or thiazide diuretic are at risk for hypokalemia. If dietary intake of potassium is not sufficient, the patient may need to take a potassium supplement. C) Patients who are taking a loop or thiazide diuretic are at risk for hypokalemia, therefore, the patient's serum potassium level should be monitored regularly. D) Weakness and fatigue are symptoms of hypokalemia and should be reported to the healthcare provider. Page Ref: 188 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Evaluation | Learning Outcome: 8.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of potassium imbalances and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of electrolyte imbalances to diagnosis and treatment.

12) Which response should the nurse make when a patient receiving intravenous potassium complains of burning at the infusion site? A) "Let me check the IV site and make sure there are no complications." B) "Don't worry, the burning goes away with time." C) "It's normal for the insertion site to be red and warm." D) "I'll check back with you in 2 hours and see if it still burns." Answer: A Explanation: A) The intravenous access site should be monitored for burning and pain; potassium is irritating to the tissues around the intravenous access point and can cause infiltration and discomfort. B) The intravenous access site should be monitored for burning and pain; potassium is irritating to the tissues around the intravenous access point and can cause infiltration and discomfort. C) The intravenous access site should be monitored for burning and pain; potassium is irritating to the tissues around the intravenous access point and can cause infiltration and discomfort. D) The intravenous access site should be monitored for burning and pain; potassium is irritating to the tissues around the intravenous access point and can cause infiltration and discomfort. Page Ref: 188 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Implementation | Learning Outcome: 8.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of potassium imbalances and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.C.10 Value active partnership with patients or designated surrogates in planning, implementation, and evaluation of care | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of electrolyte imbalances to diagnosis and treatment.

13) The nurse is administering intravenous (IV) magnesium to a patient with hypomagnesemia. Which action should the nurse take to prevent the development of complications? A) Observe the cardiac telemetry monitor for ventricular arrhythmias. B) Keep calcium gluconate on hand. C) Infuse the IV magnesium slowly. D) Administer loop diuretics. Answer: C Explanation: A) A danger of IV magnesium infusion is the development of hypermagnesemia. Cardiac arrhythmias associated with hypermagnesemia include bradyarrhythmias, tall T wave, widened QRS, prolonged QT interval, atrioventricular blocks, and finally, cardiac arrest. Ventricular tachycardia, ventricular fibrillation, and torsades de pointes may occur with hypomagnesemia. Observing the cardiac monitor, however, will not prevent complications. B) Calcium gluconate should be kept on hand to treat hypermagnesemia stemming from overreplacement and/or rapid replacement. It does not, however, prevent complications during IV magnesium infusion. C) Slow administration of intravenous magnesium reduces the risk of cardiac arrhythmias or conduction abnormalities such as heart blockade or asystole. D) Loop diuretics with either sodium chloride or lactated Ringer's will help to promote excretion of magnesium in patients with hypermagnesemia and adequate renal function. It will not preventcomplications of IV infusion of magnesium. Page Ref: 192 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Planning | Learning Outcome: 8.8 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of magnesium imbalances and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of electrolyte imbalances to diagnosis and treatment.

14) The nurse would expect to assess which finding in the patient with hypermagnesemia? A) Increased deep tendon reflexes B) Respiratory depression C) Hypertension D) Tachyarrhythmias Answer: B Explanation: A) Magnesium has sedating effects on the various systems of the body. Hypermagnesemia produces respiratory depression, decreased deep tendon reflexes, decreased level of consciousness, bradyarrhythmias, and hypotension. Hypomagnesemia causes the opposite symptoms: increased deep tendon reflexes, hypertension, and tachyarrhythmias. B) Magnesium has sedating effects on the various systems of the body. Hypermagnesemia produces respiratory depression, decreased deep tendon reflexes, decreased level of consciousness, bradyarrhythmias, and hypotension. Hypomagnesemia causes the opposite symptoms: increased deep tendon reflexes, hypertension, and tachyarrhythmias. C) Magnesium has sedating effects on the various systems of the body. Hypermagnesemia produces respiratory depression, decreased deep tendon reflexes, decreased level of consciousness, bradyarrhythmias, and hypotension. Hypomagnesemia causes the opposite symptoms: increased deep tendon reflexes, hypertension, and tachyarrhythmias. D) Magnesium has sedating effects on the various systems of the body. Hypermagnesemia produces respiratory depression, decreased deep tendon reflexes, decreased level of consciousness, bradyarrhythmias, and hypotension. Hypomagnesemia causes the opposite symptoms: increased deep tendon reflexes, hypertension, and tachyarrhythmias. Page Ref: 192 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 8.8 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of magnesium imbalances and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of electrolyte disorders.

15) Which question should the nurse ask during the admission history of a patient with hypomagnesemia? A) "Do you use magnesium-containing laxatives?" B) "How much alcohol do you drink?" C) "Are you taking lithium?" D) "Do you have renal failure?" Answer: B Explanation: A) Hypermagnesemia often results from renal failure and is more pronounced if magnesium-containing antacids are consumed. The use of laxatives may contribute to hypermagnesemia, as can increased dietary intake, diabetic ketoacidosis, lithium toxicity, burns, trauma, and shock. A common iatrogenic cause of hypermagnesemia is an overreplacement with supplements or overuse of magnesium-containing laxatives, which can be exacerbated in patients with renal failure. B) The most common cause of hypomagnesemia is excessive alcohol intake. Hypomagnesemia in patients who abuse alcohol is typically due to malabsorption. C) Hypermagnesemia often results from renal failure and is more pronounced if magnesiumcontaining antacids are consumed. The use of laxatives may contribute to hypermagnesemia, as can increased dietary intake, diabetic ketoacidosis, lithium toxicity, burns, trauma, and shock. A common iatrogenic cause of hypermagnesemia is an overreplacement with supplements or overuse of magnesium-containing laxatives, which can be exacerbated in patients with renal failure. D) Hypermagnesemia often results from renal failure and is more pronounced if magnesiumcontaining antacids are consumed. The use of laxatives may contribute to hypermagnesemia, as can increased dietary intake, diabetic ketoacidosis, lithium toxicity, burns, trauma, and shock. A common iatrogenic cause of hypermagnesemia is an overreplacement with supplements or overuse of magnesium-containing laxatives, which can be exacerbated in patients with renal failure. Page Ref: 192 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 8.8 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of magnesium imbalances and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of electrolyte imbalances to diagnosis and treatment.

16) The nurse notes that a patient's serum phosphorus level is 6.1 mg/dL. Which disorder is most likely responsible for this phosphorous level? A) Respiratory alkalosis B) Hypercalcemia C) Hyperparathyroidism D) Chronic renal failure Answer: D Explanation: A) The most common etiology of hyperphosphatemia in both primary and acute care is chronic renal failure. Other causes of hyperphosphatemia include respiratory acidosis, metabolic acidosis, hypocalcemia (coincides hyperphosphatemia in chronic renal failure), vitamin D excess, and chemotherapy (hyperphosphatemia from tumor lysis). B) The most common etiology of hyperphosphatemia in both primary and acute care is chronic renal failure. Other causes of hyperphosphatemia include respiratory acidosis, metabolic acidosis, hypocalcemia (coincides hyperphosphatemia in chronic renal failure), vitamin D excess, and chemotherapy (hyperphosphatemia from tumor lysis). C) Hyperparathyroidism is a cause of hypophosphatemia. D) The normal range for phosphorus is between 2.5 and 4.5 mg/dL. The most common etiology of hyperphosphatemia is chronic renal failure. Page Ref: 190 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Diagnosing | Learning Outcome: 8.7 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of phosphorus imbalances and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of electrolyte imbalances to diagnosis and treatment.

17) Which electrocardiogram findings would the nurse expect to observe on the rhythm strip of a patient with hypercalcemia? A) Shortened QT interval B) Prolonged ST segment C) Sinus bradycardia D) ST segment depression Answer: A Explanation: A) Electrocardiogram findings in the patient with hypercalcemia can include a shortened QT interval, a shortened ST segment, or various tachyarrhythmias. B) Electrocardiogram findings in the patient with hypercalcemia can include a shortened QT interval, a shortened ST segment, or various tachyarrhythmias. C) Electrocardiogram findings in the patient with hypercalcemia can include a shortened QT interval, a shortened ST segment, or various tachyarrhythmias. D) Electrocardiogram findings in the patient with hypercalcemia can include a shortened QT interval, a shortened ST segment, or various tachyarrhythmias. Page Ref: 189 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 8.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of calcium imbalances and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of electrolyte disorders.

18) Which response by a patient with hypoparathyroidism would indicate a positive Chvostek sign? A) A twitch of the lip on the ipsilateral side B) A twitch of the lip on the contralateral side C) A lack of twitching of the lip D) Bilateral twitching of the lip Answer: A Explanation: A) A positive Chvostek sign indicates neuromuscular involvement in hypocalcemia. Tapping on the facial nerve below the temple can elicit a twitch or spasm of the nose or lip on the ipsilateral side of tapping; this action is known as the Chvostek sign. B) A positive Chvostek sign indicates neuromuscular involvement in hypocalcemia. Tapping on the facial nerve below the temple can elicit a twitch or spasm of the nose or lip on the ipsilateralside of tapping; this action is known as the Chvostek sign. C) A positive Chvostek sign indicates neuromuscular involvement in hypocalcemia. Tapping on the facial nerve below the temple can elicit a twitch or spasm of the nose or lip on the ipsilateralside of tapping; this action is known as the Chvostek sign. D) A positive Chvostek sign indicates neuromuscular involvement in hypocalcemia. Tapping on the facial nerve below the temple can elicit a twitch or spasm of the nose or lip on the ipsilateral side of tapping; this action is known as the Chvostek sign. Page Ref: 190 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 8.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of calcium imbalances and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of electrolyte disorders.

19) During report, the nurse learns that a patient has a Trousseau sign. The nurse would also expect this patient to exhibit: A) muscle weakness. B) hypertension. C) hypoactive bowel sounds. D) tetany. Answer: D Explanation: A) Marked CNS and neuromuscular excitability are major implications of hypocalcemia. Tingling, spasms, tetany, and possibly convulsions in extreme hypocalcemia may occur. Two clinical signs of neuromuscular excitability are the Chvostek sign and Trousseau sign. Other clinical manifestations of hypocalcemia are ECG changes (such as prolonged QT interval leading to ventricular arrhythmias and cardiac arrest), tetany (manifesting as laryngospasm), intestinal cramping, hyperactive bowel sounds, hypotension, and osteoporosis with or without pathologic fractures. B) Marked CNS and neuromuscular excitability are major implications of hypocalcemia. Tingling, spasms, tetany, and possibly convulsions in extreme hypocalcemia may occur. Two clinical signs of neuromuscular excitability are the Chvostek sign and Trousseau sign. Other clinical manifestations of hypocalcemia are ECG changes (such as prolonged QT interval leading to ventricular arrhythmias and cardiac arrest), tetany (manifesting as laryngospasm), intestinal cramping, hyperactive bowel sounds, hypotension, and osteoporosis with or without pathologic fractures. C) Marked CNS and neuromuscular excitability are major implications of hypocalcemia. Tingling, spasms, tetany, and possibly convulsions in extreme hypocalcemia may occur. Two clinical signs of neuromuscular excitability are the Chvostek sign and Trousseau sign. Other clinical manifestations of hypocalcemia are ECG changes (such as prolonged QT interval leading to ventricular arrhythmias and cardiac arrest), tetany (manifesting as laryngospasm), intestinal cramping, hyperactive bowel sounds, hypotension, and osteoporosis with or without pathologic fractures. D) Marked CNS and neuromuscular excitability are major implications of hypocalcemia. Tingling, spasms, tetany, and possibly convulsions in extreme hypocalcemia may occur. Two clinical signs of neuromuscular excitability are the Chvostek sign and Trousseau sign. Other clinical manifestations of hypocalcemia are ECG changes (such as prolonged QT interval leading to ventricular arrhythmias and cardiac arrest), tetany (manifesting as laryngospasm), intestinal cramping, hyperactive bowel sounds, hypotension, and osteoporosis with or without pathologic fractures. Page Ref: 189-190 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 8.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of calcium imbalances and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of electrolyte disorders.

20) When assessing a patient with hypophosphatemia, the nurse should keep in mind that the clinical manifestations of this disorder correlate with those of: A) hypercalcemia. B) hypocalcemia. C) hypermagnesemia. D) hypomagnesemia. Answer: A Explanation: A) Clinical manifestations of hypophosphatemia correlate with those of hypercalcemia. B) Clinical manifestations of hypophosphatemia correlate with those of hypercalcemia. C) Clinical manifestations of hypophosphatemia correlate with those of hypercalcemia. D) Clinical manifestations of hypophosphatemia correlate with those of hypercalcemia. Page Ref: 191 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 8.7 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of phosphorus imbalances and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of electrolyte disorders.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 9 Acid-Base Imbalances 1) The nurse is caring for a client with acute respiratory acidosis and notes the client's rate and depth of breathing are increased. What is the nurse's understanding of the cause of this finding? A) Respiratory muscles increase the force of contraction with excess hydrogen levels in the blood. B) The diaphragm weakens with excess hydrogen levels in the blood. C) As the pH increases, the respiratory rate increases. D) As the carbon dioxide level decreases, the respiratory rate increases. Answer: A Explanation: A) Respiratory acidosis occurs with excess hydrogen levels in the blood, making the pH acidic. In response, the body attempts to compensate for the acid-base imbalance through increased force of respiratory muscle contraction, increasing the rate and depth of breathing in an effort to remove the excess acid. B) Respiratory acidosis occurs with excess hydrogen levels in the blood, making the pH acidic. In response, the body attempts to compensate for the acid-base imbalance through increased force of respiratory muscle contraction, including the diaphragm, increasing the rate and depth of breathing in an effort to remove the excess acid. The increased rate and depth of breathing does not mean that the diaphragm is weak. C) Respiratory acidosis occurs with excess hydrogen levels in the blood, making the pH acidic. In response, the body attempts to compensate by increasing the rate and depth of breathing in an effort to remove the excess acid. An increased pH is an alkalotic state, not acidotic. D) Respiratory acidosis manifests with increased carbon dioxide levels, not decreased. Page Ref: 203 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 9.7 Differentiate the causes, underlying pathogenesis, and clinical manifestations of respiratory acidosis and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: I. 7. Integrate the knowledge and methods of a variety of disciplines to inform decision making NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of each type of acid-base imbalance to diagnosis and treatment.

2) The nurse reviews arterial blood gas results and notes the client has a metabolic acidosis. Which organ does the nurse expect will compensate for the client's acid-base imbalance? A) Kidneys B) Lungs C) Liver D) Brain Answer: B Explanation: A) The kidneys compensate for respiratory acidosis, not metabolic acidosis. B) The lungs compensate for the acid-base imbalance of metabolic acidosis by increasing the rate and depth of breathing to make the pH more alkalotic. C) The liver and brain do not directly compensate for metabolic acidosis. D) The liver and brain do not directly compensate for metabolic acidosis. Page Ref: 203 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 9.4 Compare the roles and limitations of chemical buffers, the kidneys, and the lungs in the maintenance of acid-base balance in the extracellular fluid, and explain the regulation of intracellular pH. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: I. 7. Integrate the knowledge and methods of a variety of disciplines to inform decision making NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of each type of acid-base imbalance to diagnosis and treatment.

3) A client with renal impairment presents with an acid-base imbalance. Which mechanisms does the nurse recognize may be impaired? Select all that apply. A) Resorption of bicarbonate from the renal tubule into the blood. B) Secretion of bicarbonate into the urine. C) Resorption of hydrogen from the nephron into the blood. D) Excretion of hydrogen buffered by ammonia. E) Secretion of hydrogen into the urine. Answer: A, D, E Explanation: A) The kidneys contribute to acid-base balance by three mechanisms that take place along the tubules of the nephron: resorption of bicarbonate from the renal tubule into the blood, excretion of hydrogen buffered by ammonia, and secretion of hydrogen into the urine. Impairment of the kidneys may impair one or all of these processes. Impairment of the kidneys may lead to impaired secretion of hydrogen into the urine, not bicarbonate. B) The kidneys contribute to acid-base balance by three mechanisms that take place along the tubules of the nephron: resorption of bicarbonate from the renal tubule into the blood, excretion of hydrogen buffered by ammonia, and secretion of hydrogen into the urine. Impairment of the kidneys may impair one or all of these processes. Impairment of the kidneys may lead to impaired secretion of hydrogen into the urine, not bicarbonate. C) The kidneys contribute to acid-base balance by three mechanisms that take place along the tubules of the nephron: resorption of bicarbonate from the renal tubule into the blood, excretion of hydrogen buffered by ammonia, and secretion of hydrogen into the urine. Impairment of the kidneys may impair one or all of these processes. Impairment of the kidneys may lead to impaired secretion of hydrogen into the urine, not bicarbonate. D) The kidneys contribute to acid-base balance by three mechanisms that take place along the tubules of the nephron: resorption of bicarbonate from the renal tubule into the blood, excretion of hydrogen buffered by ammonia, and secretion of hydrogen into the urine. Impairment of the kidneys may impair one or all of these processes. Impairment of the kidneys may lead to impaired secretion of hydrogen into the urine, not bicarbonate. E) The kidneys contribute to acid-base balance by three mechanisms that take place along the tubules of the nephron: resorption of bicarbonate from the renal tubule into the blood, excretion of hydrogen buffered by ammonia, and secretion of hydrogen into the urine. Impairment of the kidneys may impair one or all of these processes. Impairment of the kidneys may lead to impaired secretion of hydrogen into the urine, not bicarbonate. Page Ref: 203 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 9.4 Compare the roles and limitations of chemical buffers, the kidneys, and the lungs in the maintenance of acid-base balance in the extracellular fluid, and explain the regulation of intracellular pH. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: I. 7. Integrate the knowledge and methods of a variety of disciplines to inform decision making NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of each type of acid-base imbalance to diagnosis and treatment. 3

4) The nurse cares for a client with acute respiratory acidosis. Which central nervous system (CNS) manifestation will the nurse likely find? A) Parasthesias B) Dizziness C) Anxiety D) Papilledema Answer: D Explanation: A) Paresthesia's, dizziness, and anxiety are not manifestations of respiratory acidosis. B) Paresthesia's, dizziness, and anxiety are not manifestations of respiratory acidosis. C) Paresthesia's, dizziness, and anxiety are not manifestations of respiratory acidosis. D) CNS manifestations of acidosis may include: confusion, headache, seizures, and coma. These symptoms are also the result of vasodilation-induced increased cerebral blood flow, which can increase intracranial pressure and result in manifestations such as papilledema (swelling of the optic disc). Page Ref: 209-210 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 9.5 Describe the four types of simple acid-base imbalances, and explain the basis for the clinical manifestations of acidosis and alkalosis. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of each type of acid-base imbalance to diagnosis and treatment.

5) The nurse cares for a client with metabolic acidosis and hyperphosphatemia. What pathophysiological process does the nurse recognize is the reason for the client's phosphate abnormality? A) Depression of glycolysis B) Ionized calcium is decreased C) Hydrogen ions move out of the cells D) Positive and negative ions enter the cells Answer: A Explanation: A) In acidosis, there is an increase in serum phosphate because glycolysis is depressed during acidosis, and there is decreased utilization of phosphate in metabolic reactions. B) Ionized calcium level is increased in acidosis and decreased in alkalosis. C) In acidosis, hydrogen ions enter the cells and do not move out of the cells. In acidosis, some of the excess hydrogen ions enter the cells in exchange for the movement of potassium ions out of the cell. D) In acidosis, there is an increase in serum phosphate because glycolysis is depressed during acidosis, and there is decreased utilization of phosphate in metabolic reactions. Ionized calcium level is increased in acidosis and decreased in alkalosis. In acidosis, Hydrogen enters the cells and does not move out of the cells. In acidosis, some of the excess of the excess hydrogen ions enter the cells in exchange for the movement of potassium ions out of the cell. Page Ref: 210 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 9.9 Differentiate the causes, underlying pathogenesis, and clinical manifestations of metabolic acidosis and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: I. 7. Integrate the knowledge and methods of a variety of disciplines to inform decision making NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of each type of acid-base imbalance to diagnosis and treatment.

6) The nurse cares for a client experiencing prolonged vomiting resulting in metabolic alkalosis. Which physiologic effect of alkalosis does the nurse recognize? A) Movement of potassium out of the cells in exchange for hydrogen into the cells. B) Increased level of free calcium blocking sodium channels. C) Increased glycolysis and utilization of phosphate. D) Decreased cardiac contractility. Answer: C Explanation: A) In metabolic alkalosis, there is increased glycolysis and utilization of phosphate. The movement of potassium out of the cells in exchange for hydrogen into the cells, increased level of free calcium blocking sodium channels, and decreased cardiac contractility are all associated with acidosis, not alkalosis. B) In metabolic alkalosis, there is increased glycolysis and utilization of phosphate. The movement of potassium out of the cells in exchange for hydrogen into the cells, increased level of free calcium blocking sodium channels, and decreased cardiac contractility are all associated with acidosis, not alkalosis. C) In metabolic alkalosis, there is increased glycolysis and utilization of phosphate. The movement of potassium out of the cells in exchange for hydrogen into the cells, increased level of free calcium blocking sodium channels, and decreased cardiac contractility are all associated with acidosis, not alkalosis. D) In metabolic alkalosis, there is increased glycolysis and utilization of phosphate. The movement of potassium out of the cells in exchange for hydrogen into the cells, increased level of free calcium blocking sodium channels, and decreased cardiac contractility are all associated with acidosis, not alkalosis. Page Ref: 212 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 9.5 Describe the four types of simple acid-base imbalances, and explain the basis for the clinical manifestations of acidosis and alkalosis. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: I. 7. Integrate the knowledge and methods of a variety of disciplines to inform decision making NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of each type of acid-base imbalance to diagnosis and treatment.

7) The nurse cares for a critically ill client with a severe acid-base imbalance. When reviewing the client's anion gap, which additional laboratory value does the nurse recognize may skew the anion gap results? A) Hemoglobin B) Albumin C) PaO2 D) PaCO2 Answer: B Explanation: A) Albumin, which is an anion, makes up part of the anion gap. So if a patient has a low albumin level (hypoalbuminemia), a common finding in critically ill patients, the anion gap will be lower than normal. Hemoglobin, PaO2, and PaCO2 do not make up the anion gap. B) Albumin, which is an anion, makes up part of the anion gap. So if a patient has a low albumin level (hypoalbuminemia), a common finding in critically ill patients, the anion gap will be lower than normal. Hemoglobin, PaO2, and PaCO2 do not make up the anion gap. C) Albumin, which is an anion, makes up part of the anion gap. So if a patient has a low albumin level (hypoalbuminemia), a common finding in critically ill patients, the anion gap will be lower than normal. Hemoglobin, PaO2, and PaCO2 do not make up the anion gap. D) Albumin, which is an anion, makes up part of the anion gap. So if a patient has a low albumin level (hypoalbuminemia), a common finding in critically ill patients, the anion gap will be lower than normal. Hemoglobin, PaO2, and PaCO2 do not make up the anion gap. Page Ref: 215 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 9.6 Interpret arterial and venous blood gas results, the anion gap, and base excess values. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of each type of acid-base imbalance to diagnosis and treatment.

8) The nurse cares for a client with an acid-base imbalance. Which electrolyte imbalance will most likely cause respiratory acidosis? A) Hypokalemia B) Hyperkalemia C) Hyponatremia D) Hypernatremia Answer: A Explanation: A) Severe hypokalemia causes respiratory acidosis because low potassium in the extracellular fluid causes some potassium to move out of cells, leaving the charge inside the cell more negative and farther from its threshold potential. As a result, muscles involved in breathing such as the diaphragm will have decreased contractility, leading to hypoventilation. Hyperkalemia (increased potassium), hyponatremia (decreased sodium), and hypernatremia (increased sodium) do not directly cause respiratory acidosis. B) Severe hypokalemia causes respiratory acidosis because low potassium in the extracellular fluid causes some potassium to move out of cells, leaving the charge inside the cell more negative and farther from its threshold potential. As a result, muscles involved in breathing such as the diaphragm will have decreased contractility, leading to hypoventilation. Hyperkalemia (increased potassium), hyponatremia (decreased sodium), and hypernatremia (increased sodium) do not directly cause respiratory acidosis. C) Severe hypokalemia causes respiratory acidosis because low potassium in the extracellular fluid causes some potassium to move out of cells, leaving the charge inside the cell more negative and farther from its threshold potential. As a result, muscles involved in breathing such as the diaphragm will have decreased contractility, leading to hypoventilation. Hyperkalemia (increased potassium), hyponatremia (decreased sodium), and hypernatremia (increased sodium) do not directly cause respiratory acidosis. D) Severe hypokalemia causes respiratory acidosis because low potassium in the extracellular fluid causes some potassium to move out of cells, leaving the charge inside the cell more negative and farther from its threshold potential. As a result, muscles involved in breathing such as the diaphragm will have decreased contractility, leading to hypoventilation. Hyperkalemia (increased potassium), hyponatremia (decreased sodium), and hypernatremia (increased sodium) do not directly cause respiratory acidosis. Page Ref: 217 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 9.7 Differentiate the causes, underlying pathogenesis, and clinical manifestations of respiratory acidosis and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: I. 7: Integrate the knowledge and methods of a variety of disciplines to inform decision making NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of each type of acid-base imbalance to diagnosis and treatment.

9) A nurse cares for a client with hyperpyrexia due to pyelonephritis. Which acid-base imbalance is most likely with this client? A) Metabolic acidosis B) Metabolic alkalosis C) Respiratory alkalosis D) Respiratory acidosis Answer: C Explanation: A) Hyperpyrexia (fever) causes a hypermetabolic state, increasing respiratory rate. Increased respiratory rate "blows off" excess carbon dioxide and decreases pCO2 levels. Decreased pCO2 increases the pH, causing respiratory alkalosis. Metabolic acidosis, metabolic alkalosis, and respiratory acidosis are not the most likely acid-base imbalances the client will experience. B) Hyperpyrexia (fever) causes a hypermetabolic state, increasing respiratory rate. Increased respiratory rate "blows off" excess carbon dioxide and decreases pCO2 levels. Decreased pCO2 increases the pH, causing respiratory alkalosis. Metabolic acidosis, metabolic alkalosis, and respiratory acidosis are not the most likely acid-base imbalances the client will experience. C) Hyperpyrexia (fever) causes a hypermetabolic state, increasing respiratory rate. Increased respiratory rate "blows off" excess carbon dioxide and decreases pCO2 levels. Decreased pCO2 increases the pH, causing respiratory alkalosis. Metabolic acidosis, metabolic alkalosis, and respiratory acidosis are not the most likely acid-base imbalances the client will experience. D) Hyperpyrexia (fever) causes a hypermetabolic state, increasing respiratory rate. Increased respiratory rate "blows off" excess carbon dioxide and decreases pCO2 levels. Decreased pCO2 increases the pH, causing respiratory alkalosis. Metabolic acidosis, metabolic alkalosis, and respiratory acidosis are not the most likely acid-base imbalances the client will experience. Page Ref: 219 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 9.8 Differentiate the causes, underlying pathogenesis, and clinical manifestations of respiratory alkalosis and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: I. 7: Integrate the knowledge and methods of a variety of disciplines to inform decision making NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of each type of acid-base imbalance to diagnosis and treatment.

10) An older adult client presents to the emergency room with a severe acid-base imbalance after taking "cold medicine" for a week. The client has a history of arthritis and reports daily use of aspirin. Which late effect acid-base imbalance does the nurse suspect the client is experiencing? A) Respiratory alkalosis B) Respiratory acidosis C) Metabolic alkalosis D) Metabolic acidosis Answer: D Explanation: A) Early effect of salicylate poisoning may cause respiratory alkalosis due to stimulation of the respiratory center; however, this is not a late effect. B) Respiratory acidosis is not a late effect of salicylate poisoning. C) Metabolic alkalosis is not a late effect of salicylate poisoning. D) The highest mortality rate from salicylate overdose is among older adults who take a salicylate routinely for treatment of a medical condition, such as arthritis, and then take additional amounts or another product containing a salicylate to treat an acute problem, such as a cold or the flu.This older adult client is likely experiencing salicylate poisoning. Many clinical manifestations of salicylate poisoning are due to their ability to inhibit cell enzymes, resulting in accumulation of acids within the blood. This causes metabolic acidosis. Page Ref: 221 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 9.9 Differentiate the causes, underlying pathogenesis, and clinical manifestations of metabolic acidosis and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: I. 7: Integrate the knowledge and methods of a variety of disciplines to inform decision making NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of each type of acid-base imbalance to diagnosis and treatment.

11) The nurse cares for four clients with acid-base imbalances. Which client is most likely experiencing metabolic alkalosis? A) Adult who has had lactated Ringer's solution infusing for 72 hours. B) Adolescent with a diagnosis of diabetic ketoacidosis. C) Older adult with a diagnosis of salicylate poisoning. D) Child with severe diarrhea. Answer: A Explanation: A) Administration of a large amount of anions, such as lactate in lactated Ringer's intravenous solution, has an effect similar to the administration of bicarbonate because the liver metabolizes these anions forming bicarbonate. B) Ketoacidosis, salicylate poisoning, and severe diarrhea all cause metabolic acidosis, not alkalosis. C) Ketoacidosis, salicylate poisoning, and severe diarrhea all cause metabolic acidosis, not alkalosis. D) Ketoacidosis, salicylate poisoning, and severe diarrhea all cause metabolic acidosis, not alkalosis. Page Ref: 226 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 9.10 Differentiate the causes, underlying pathogenesis, and clinical manifestations of metabolic alkalosis and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of each type of acid-base imbalance to diagnosis and treatment.

12) A client with congestive heart failure is voiding large amounts of urine via indwelling urinary catheter. Which acid-base balance does the nurse recognize the client is at greatest risk for developing? A) Metabolic acidosis B) Metabolic alkalosis C) Respiratory acidosis D) Respiratory alkalosis Answer: B Explanation: A) Diuretic-induced loss of the cation Na+ in the urine is accompanied by an approximately equal loss of the anion Cl- in the urine. Hypovolemia caused by these diuretics stimulates aldosterone secretion. Stimulation of aldosterone causes increased renal bicarbonate resorption and an increase in H+ secretion into the urine. This leads to metabolic alkalosis (due to increased bicarbonate resorption and loss of acid). Metabolic acidosis, respiratory acidosis, and respiratory alkalosis do not occur as a result of diuretic administration. B) Diuretic-induced loss of the cation Na+ in the urine is accompanied by an approximately equal loss of the anion Cl- in the urine. Hypovolemia caused by these diuretics stimulates aldosterone secretion. Stimulation of aldosterone causes increased renal bicarbonate resorption and an increase in H+ secretion into the urine. This leads to metabolic alkalosis (due to increased bicarbonate resorption and loss of acid). C) Diuretic-induced loss of the cation Na+ in the urine is accompanied by an approximately equal loss of the anion Cl- in the urine. Hypovolemia caused by these diuretics stimulates aldosterone secretion. Stimulation of aldosterone causes increased renal bicarbonate resorption and an increase in H+ secretion into the urine. This leads to metabolic alkalosis (due to increased bicarbonate resorption and loss of acid). Metabolic acidosis, respiratory acidosis, and respiratory alkalosis do not occur as a result of diuretic administration. D) Diuretic-induced loss of the cation Na+ in the urine is accompanied by an approximately equal loss of the anion Cl- in the urine. Hypovolemia caused by these diuretics stimulates aldosterone secretion. Stimulation of aldosterone causes increased renal bicarbonate resorption and an increase in H+ secretion into the urine. This leads to metabolic alkalosis (due to increased bicarbonate resorption and loss of acid). Metabolic acidosis, respiratory acidosis, and respiratory alkalosis do not occur as a result of diuretic administration. Page Ref: 225 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 9.10 Differentiate the causes, underlying pathogenesis, and clinical manifestations of metabolic alkalosis and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: I. 7: Integrate the knowledge and methods of a variety of disciplines to inform decision making NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of each type of acid-base imbalance to diagnosis and treatment.

13) The nurse is reviewing the arterial blood gas results of a client. When comparing various components of the ABG, which statement does the nurse recognize is true? A) The higher the pH, the higher the H+ concentration. B) The higher the HCO3, the lower the pH. C) The lower the pH, the higher the H+ concentration. D) The lower the PaCO2, the lower the pH. Answer: C Explanation: A) Normal pH is 7.35-7.45. As the H+ concentration increases, the pH decreases (more acid). The other answer choices are not correct. B) Normal pH is 7.35-7.45. As the H+ concentration increases, the pH decreases (more acid). The other answer choices are not correct. C) Normal pH is 7.35-7.45. As the H+ concentration increases, the pH decreases (more acid). The other answer choices are not correct. D) Normal pH is 7.35-7.45. As the H+ concentration increases, the pH decreases (more acid). The other answer choices are not correct. Page Ref: 200 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 9.3 Explain pH and its relation to the hydrogen ion concentration. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of each type of acid-base imbalance to diagnosis and treatment.

14) The nurse is caring for a client with respiratory acidosis. Which compensatory mechanism does the nurse understand will act to normalize the client's acid-base balance? A) Kidneys excrete bicarbonate. B) Hypoventilation retains carbon dioxide. C) Hyperventilation releases carbon dioxide. D) Kidneys reabsorb bicarbonate. Answer: D Explanation: A) Respiratory acidosis occurs with an increase in H+ concentration (increased PaCO2 levels). The compensatory mechanism for respiratory acidosis is regulated by the kidneys. The kidneys will reabsorb bicarbonate in order to increase the pH (make it more alkaline). The other answer choices do not represent how the body will compensate for respiratory acidosis. B) Respiratory acidosis occurs with an increase in H+ concentration (increased PaCO2 levels). The compensatory mechanism for respiratory acidosis is regulated by the kidneys. The kidneys will reabsorb bicarbonate in order to increase the pH (make it more alkaline). The other answer choices do not represent how the body will compensate for respiratory acidosis. C) Respiratory acidosis occurs with an increase in H+ concentration (increased PaCO2 levels). The compensatory mechanism for respiratory acidosis is regulated by the kidneys. The kidneys will reabsorb bicarbonate in order to increase the pH (make it more alkaline). The other answer choices do not represent how the body will compensate for respiratory acidosis. D) Respiratory acidosis occurs with an increase in H+ concentration (increased PaCO2 levels). The compensatory mechanism for respiratory acidosis is regulated by the kidneys. The kidneys will reabsorb bicarbonate in order to increase the pH (make it more alkaline). The other answer choices do not represent how the body will compensate for respiratory acidosis. Page Ref: 228 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 9.4 Compare the roles and limitations of chemical buffers, the kidneys, and the lungs in the maintenance of acid-base balance in the extracellular fluid, and explain the regulation of intracellular pH. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: I. 7: Integrate the knowledge and methods of a variety of disciplines to inform decision making NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of each type of acid-base imbalance to diagnosis and treatment.

15) A client with liver failure is diagnosed with metabolic acidosis. What pathophysiological mechanism does the nurse recognize is the cause of the client's acid-base imbalance? A) Volume deficit and loss of gastric acid. B) Impaired clearance of hydrogen ions. C) Poor tissue perfusion and anaerobic metabolism. D) Impaired clearance of lactate. Answer: D Explanation: A) Liver failure may present as both respiratory alkalosis and metabolic acidosis. In liver failure, an impairment of lactate clearance increases the H+ concentration in the blood, increasing the acid concentration in the blood and causing metabolic acidosis. The other answer choices are not pathophysiological processes involved in liver failure. B) Liver failure may present as both respiratory alkalosis and metabolic acidosis. In liver failure, an impairment of lactate clearance increases the H+ concentration in the blood, increasing the acid concentration in the blood and causing metabolic acidosis. The other answer choices are not pathophysiological processes involved in liver failure. C) Liver failure may present as both respiratory alkalosis and metabolic acidosis. In liver failure, an impairment of lactate clearance increases the H+ concentration in the blood, increasing the acid concentration in the blood and causing metabolic acidosis. The other answer choices are not pathophysiological processes involved in liver failure. D) Liver failure may present as both respiratory alkalosis and metabolic acidosis. In liver failure, an impairment of lactate clearance increases the H+ concentration in the blood, increasing the acid concentration in the blood and causing metabolic acidosis. The other answer choices are not pathophysiological processes involved in liver failure. Page Ref: 227 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 9.11 Describe common clinical conditions that result in mixed acid-base imbalances. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: I. 7: Integrate the knowledge and methods of a variety of disciplines to inform decision making NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of each type of acid-base imbalance to diagnosis and treatment.

16) A nurse cares for a client with chronic respiratory acidosis who is placed on mechanical ventilation for an acute exacerbation of emphysema. Which acid-base abnormality will the nurse expect if the client's PaCO2 is corrected too quickly? A) pH 7.52 B) pH 7.35 C) HCO3 18 mmoL/L D) HCO3 24 mmoL/L Answer: A Explanation: A) When the PaCO2, and thus carbonic acid, is quickly lowered, for example by placing the client on mechanical ventilation, the elevated bicarbonate has less acid to buffer, resulting in metabolic alkalosis. This condition is called posthypercapneic metabolic alkalosis. Because it takes the kidneys several days to decrease the amount of bicarbonate that had been retained, it is important to avoid excessively rapid normalization of the PaCO2 in individuals with chronic respiratory acidosis. A pH of 7.52 represents alkalosis and would be most likely with this client. Metabolic alkalosis manifests as an increase in HCO3 levels. Normal HCO3 levels are 22-28 mmoL/L. A decreased HCO3 level (18 mmoL/L) indicates metabolic acidosis and a HCO3 of 24 mmoL/L indicates a normal level. A pH of 7.35 is a normal pH. B) When the PaCO2, and thus carbonic acid, is quickly lowered, for example by placing the client on mechanical ventilation, the elevated bicarbonate has less acid to buffer, resulting in metabolic alkalosis. This condition is called posthypercapneic metabolic alkalosis. Because it takes the kidneys several days to decrease the amount of bicarbonate that had been retained, it is important to avoid excessively rapid normalization of the PaCO2 in individuals with chronic respiratory acidosis. A pH of 7.52 represents alkalosis and would be most likely with this client. Metabolic alkalosis manifests as an increase in HCO3 levels. Normal HCO3 levels are 22-28 mmoL/L. A decreased HCO3 level (18 mmoL/L) indicates metabolic acidosis and a HCO3 of 24 mmoL/L indicates a normal level. A pH of 7.35 is a normal pH. C) When the PaCO2, and thus carbonic acid, is quickly lowered, for example by placing the client on mechanical ventilation, the elevated bicarbonate has less acid to buffer, resulting in metabolic alkalosis. This condition is called posthypercapneic metabolic alkalosis. Because it takes the kidneys several days to decrease the amount of bicarbonate that had been retained, it is important to avoid excessively rapid normalization of the PaCO2 in individuals with chronic respiratory acidosis. A pH of 7.52 represents alkalosis and would be most likely with this client. Metabolic alkalosis manifests as an increase in HCO3 levels. Normal HCO3 levels are 22-28 mmoL/L. A decreased HCO3 level (18 mmoL/L) indicates metabolic acidosis and a HCO3 of 24 mmoL/L indicates a normal level. A pH of 7.35 is a normal pH. D) When the PaCO2, and thus carbonic acid, is quickly lowered, for example by placing the client on mechanical ventilation, the elevated bicarbonate has less acid to buffer, resulting in metabolic alkalosis. This condition is called posthypercapneic metabolic alkalosis. Because it takes the kidneys several days to decrease the amount of bicarbonate that had been retained, it is important to avoid excessively rapid normalization of the PaCO2 in individuals with chronic respiratory acidosis. A pH of 7.52 represents alkalosis and would be most likely with this client. Metabolic alkalosis manifests as an increase in HCO3 levels. Normal HCO3 levels are 22-28 mmoL/L. A decreased HCO3 level (18 mmoL/L) indicates metabolic acidosis and a HCO3 of 24 mmoL/L indicates a normal level. A pH of 7.35 is a normal pH. Page Ref: 225 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation 16

Standards: Nursing Process: Assessment | Learning Outcome: 9.10 Differentiate the causes, underlying pathogenesis, and clinical manifestations of metabolic alkalosis and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: I. 7: Integrate the knowledge and methods of a variety of disciplines to inform decision making NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of each type of acid-base imbalance to diagnosis and treatment. 17) The nurse cares for a pediatric client who has accidentally taken an overdose of antacids. Which acid-base abnormality does the nurse anticipate the client will manifest? A) Metabolic acidosis B) Respiratory acidosis C) Metabolic alkalosis D) Respiratory alkalosis Answer: C Explanation: A) An excessive intake of over-the-counter antacids (calcium carbonate) results in hypercalcemia and metabolic alkalosis. The other answer choices would not represent the client's acid-base imbalance. B) An excessive intake of over-the-counter antacids (calcium carbonate) results in hypercalcemia and metabolic alkalosis. The other answer choices would not represent the client's acid-base imbalance. C) An excessive intake of over-the-counter antacids (calcium carbonate) results in hypercalcemia and metabolic alkalosis. The other answer choices would not represent the client's acid-base imbalance. D) An excessive intake of over-the-counter antacids (calcium carbonate) results in hypercalcemia and metabolic alkalosis. The other answer choices would not represent the client's acid-base imbalance. Page Ref: 226 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 9.10 Differentiate the causes, underlying pathogenesis, and clinical manifestations of metabolic alkalosis and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: I. 7: Integrate the knowledge and methods of a variety of disciplines to inform decision making NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of each type of acid-base imbalance to diagnosis and treatment.

18) The nurse is caring for a client with metabolic alkalosis. The health care provider prescribes acetazolamide for the treatment of the client's condition. What is the nurse's understanding of the purpose of this treatment? A) It increases renal resorption of bicarbonate. B) It decreases carbonic acid levels in the blood. C) It decreases urinary output and hydrogen loss. D) It increases renal excretion of bicarbonate. Answer: D Explanation: A) Acetazolamide (Diamox) is used to treat metabolic alkalosis and works by increasing renal secretion of bicarbonate when added volume from infusion of a saline solution is contraindicated. Acetazolamide does not increase renal resorption of bicarbonate. Acetazolamide does not decrease urinary output or decrease carbonic acid levels in the blood. B) Acetazolamide (Diamox) is used to treat metabolic alkalosis and works by increasing renal secretion of bicarbonate when added volume from infusion of a saline solution is contraindicated. Acetazolamide does not increase renal resorption of bicarbonate. Acetazolamide does not decrease urinary output or decrease carbonic acid levels in the blood. C) Acetazolamide (Diamox) is used to treat metabolic alkalosis and works by increasing renal secretion of bicarbonate when added volume from infusion of a saline solution is contraindicated. Acetazolamide does not increase renal resorption of bicarbonate. Acetazolamide does not decrease urinary output or decrease carbonic acid levels in the blood. D) Acetazolamide (Diamox) is used to treat metabolic alkalosis and works by increasing renal secretion of bicarbonate when added volume from infusion of a saline solution is contraindicated. Acetazolamide does not increase renal resorption of bicarbonate. Acetazolamide does not decrease urinary output or decrease carbonic acid levels in the blood. Page Ref: 226 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Assessment | Learning Outcome: 9.10 Differentiate the causes, underlying pathogenesis, and clinical manifestations of metabolic alkalosis and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of each type of acid-base imbalance to diagnosis and treatment.

19) The nurse is caring for a client with uncompensated respiratory acidosis. Which acid-base findings will the nurse anticipate? Select all that apply. A) pH 7.29 B) HCO3 23 mmoL/L C) HCO3 18 mmoL/L D) pH 7.48 E) PaCO2 50 mmHg Answer: A, B, E Explanation: A) Uncompensated respiratory acidosis presents with a decreased pH (below 7.35), elevated PaCO2 (above 45 mmHg), and a normal HCO3 (22-26 mmoL/L). A decreased HCO3 and increased pH do not represent uncompensated respiratory acidosis. B) Uncompensated respiratory acidosis presents with a decreased pH (below 7.35), elevated PaCO2 (above 45 mmHg), and a normal HCO3 (22-26 mmoL/L). A decreased HCO3 and increased pH do not represent uncompensated respiratory acidosis. C) Uncompensated respiratory acidosis presents with a decreased pH (below 7.35), elevated PaCO2 (above 45 mmHg), and a normal HCO3 (22-26 mmoL/L). A decreased HCO3 and increased pH do not represent uncompensated respiratory acidosis. D) Uncompensated respiratory acidosis presents with a decreased pH (below 7.35), elevated PaCO2 (above 45 mmHg), and a normal HCO3 (22-26 mmoL/L). A decreased HCO3 and increased pH do not represent uncompensated respiratory acidosis. E) Uncompensated respiratory acidosis presents with a decreased pH (below 7.35), elevated PaCO2 (above 45 mmHg), and a normal HCO3 (22-26 mmoL/L). A decreased HCO3 and increased pH do not represent uncompensated respiratory acidosis. Page Ref: 218 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 9.7 Differentiate the causes, underlying pathogenesis, and clinical manifestations of respiratory acidosis and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: I. 7: Integrate the knowledge and methods of a variety of disciplines to inform decision making NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of each type of acid-base imbalance to diagnosis and treatment.

20) The nurse is caring for a client with an acid-base imbalance. The nurse recognizes that the client has an alteration in protein function due to the imbalance. Proteins are components of which pathophysiological concept or process? Select all that apply. A) Receptors B) Ion channels C) Ion pumps D) Metabolic reaction catalysts E) Production of cellular energy Answer: A, B, C Explanation: A) A disruption in acid-base balance interferes with the function of proteins that are components of receptors, ion channels, and ion pumps. Enzymes, not proteins, act as catalysts for metabolic reactions and production of cellular energy. B) A disruption in acid-base balance interferes with the function of proteins that are components of receptors, ion channels, and ion pumps. Enzymes, not proteins, act as catalysts for metabolic reactions and production of cellular energy. C) A disruption in acid-base balance interferes with the function of proteins that are components of receptors, ion channels, and ion pumps. Enzymes, not proteins, act as catalysts for metabolic reactions and production of cellular energy. D) A disruption in acid-base balance interferes with the function of proteins that are components of receptors, ion channels, and ion pumps. Enzymes, not proteins, act as catalysts for metabolic reactions and production of cellular energy. E) A disruption in acid-base balance interferes with the function of proteins that are components of receptors, ion channels, and ion pumps. Enzymes, not proteins, act as catalysts for metabolic reactions and production of cellular energy. Page Ref: 198 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 9.2 Differentiate the characteristics of acids and bases and their sources in the body. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: I. 7: Integrate the knowledge and methods of a variety of disciplines to inform decision making NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of each type of acid-base imbalance to diagnosis and treatment.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 10 Mechanisms of Cell Injury and Aging 1) A community health nurse is teaching a class on the effects of heart injury. Which statement from class attendees indicates an appropriate understanding of the course material? A) "When my heart cells are deprived of oxygen, irreversible damage occurs." B) "My heart cells may fully recover if blood supply returns within 15 minutes." C) "When my heart cells sustain an injury, they can no longer function normally." D) "Even if my heart cells die, the damage to my heart is still reversible." Answer: B Explanation: A) Myocardial cells have the ability to fully recover, even if their blood supply is restricted, as long as blood supply is not compromised for longer than 10 to 15 minutes. Irreversible damage does not occur when myocardial cells are deprived of oxygen for a shorter duration of time. When heart cells sustain an injury, irreversible damage does not occur unless sustained oxidative stress occurs. If myocardial cells die, the damage to the heart is irreversible. B) Myocardial cells have the ability to fully recover, even if their blood supply is restricted, as long as blood supply is not compromised for longer than 10 to 15 minutes. Irreversible damage does not occur when myocardial cells are deprived of oxygen for a shorter duration of time. When heart cells sustain an injury, irreversible damage does not occur unless sustained oxidative stress occurs. If myocardial cells die, the damage to the heart is irreversible. C) Myocardial cells have the ability to fully recover, even if their blood supply is restricted, as long as blood supply is not compromised for longer than 10 to 15 minutes. Irreversible damage does not occur when myocardial cells are deprived of oxygen for a shorter duration of time. When heart cells sustain an injury, irreversible damage does not occur unless sustained oxidative stress occurs. If myocardial cells die, the damage to the heart is irreversible. D) Myocardial cells have the ability to fully recover, even if their blood supply is restricted, as long as blood supply is not compromised for longer than 10 to 15 minutes. Irreversible damage does not occur when myocardial cells are deprived of oxygen for a shorter duration of time. When heart cells sustain an injury, irreversible damage does not occur unless sustained oxidative stress occurs. If myocardial cells die, the damage to the heart is irreversible. Page Ref: 239 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 10.1 Differentiate reversible from nonreversible cell injury, cellular adaptation, and concepts related to cell injury and aging. | QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the impact of cellular injury, its response to injury, and cellular aging.

2) A nurse is caring for a client with a diagnosis of nephrogenic diabetes insipidus. Which statement will the nurse include when teaching the client about the condition? A) "You have a condition resulting from renal channelopathy." B) "You have an inflammatory condition affecting calcium transport in airway smooth muscle cells." C) "Your condition is the result of a defect in the chloride channel, resulting in increased sodium and water resorption." D) "Your condition is the result of acquired channelopathy caused by the immune system." Answer: A Explanation: A) Nephrogenic diabetes insipidus is a condition resulting from renal channelopathy, which results in decreased responsiveness to antidiuretic hormone. B) Asthma is a condition involving airway inflammation and the involvement of calcium transport in airway smooth muscle cells. C) Cystic fibrosis is a result of a defect in the chloride channel, resulting in increased sodium and water resorption. D) Myasthenia gravis is an example of acquired channelopathy caused by the immune destruction of ion channels responding to the neurotransmitter acetylcholine. Page Ref: 241-242 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 10.2 Summarize cell structures and functions, and describe the consequences of injury to the cell membrane and organelles. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the impact of cellular injury, its response to injury, and cellular aging.

3) A nurse is caring for a number of clients. Based on the site of injury, which client is at the most immediate risk for hypoxia-induced cell injury? A) A client admitted with an injury to the right great toe. B) A client admitted with a chest wall injury. C) A client admitted with a traumatic brain injury. D) A client admitted for a right femoral head fracture. Answer: C Explanation: A) Brain tissue has a survival time of less than three minutes during hypoxia. Based on the location of the injury, the client admitted for a traumatic brain injury is at the most immediate risk for hypoxia-induced cell injury. Skeletal muscle, such as that involved with the clients with injuries to the chest wall, right great toe, and right femoral head respectively, has a survival time of 60 to 90 minutes during hypoxia. Vascular smooth muscle, such as that involved with the clients with injuries to the chest wall, right great toe, and right femoral head respectively, has a survival time of 24 to 72 hours. B) Brain tissue has a survival time of less than three minutes during hypoxia. Based on the location of the injury, the client admitted for a traumatic brain injury is at the most immediate risk for hypoxia-induced cell injury. Skeletal muscle, such as that involved with the clients with injuries to the chest wall, right great toe, and right femoral head respectively, has a survival time of 60 to 90 minutes during hypoxia. Vascular smooth muscle, such as that involved with the clients with injuries to the chest wall, right great toe, and right femoral head respectively, has a survival time of 24 to 72 hours. C) Brain tissue has a survival time of less than three minutes during hypoxia. Based on the location of the injury, the client admitted for a traumatic brain injury is at the most immediate risk for hypoxia-induced cell injury. Skeletal muscle, such as that involved with the clients with injuries to the chest wall, right great toe, and right femoral head respectively, has a survival time of 60 to 90 minutes during hypoxia. Vascular smooth muscle, such as that involved with the clients with injuries to the chest wall, right great toe, and right femoral head respectively, has a survival time of 24 to 72 hours. D) Brain tissue has a survival time of less than three minutes during hypoxia. Based on the location of the injury, the client admitted for a traumatic brain injury is at the most immediate risk for hypoxia-induced cell injury. Skeletal muscle, such as that involved with the clients with injuries to the chest wall, right great toe, and right femoral head respectively, has a survival time of 60 to 90 minutes during hypoxia. Vascular smooth muscle, such as that involved with the clients with injuries to the chest wall, right great toe, and right femoral head respectively, has a survival time of 24 to 72 hours. Page Ref: 247 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 10.3 Explain the common causes of cellular injury. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care 3

MNL Learning Outcome: LO 4: Consider the impact of cellular injury, its response to injury, and cellular aging. 4) A nurse is educating a group of clients on the health risks of air pollution. Which client is at the greatest risk of exposure to air pollution? A) A client who lives in a remote, rural community. B) A client who works as a bookkeeper in a busy office environment. C) A client with a family history of asthma. D) A client who regularly engages in outdoor activities. Answer: D Explanation: A) A client who lives in a remote, rural community is at lower risk of exposure to air pollution than individuals living in areas with heavy motor vehicle traffic. B) A client who works indoors as a bookkeeper is at lower risk of exposure to air pollution than an individual working outdoors. C) A client's family history of asthma does not affect his or her risk of exposure to air pollution. D) Individuals who engage in physical activity outdoors, which is associated with deeper and faster breathing, are at higher risk for inhaling any pollutants present in the air. Page Ref: 249 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 10.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of cell injury caused by environmental factors and approaches to diagnosis and treatment of these injuries across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII.1 Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities and populations NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the impact of cellular injury, its response to injury, and cellular aging.

5) A nurse is assessing the medical history of a client presenting for an office visit. Which assessment finding is most likely to indicate a possible injury to endothelial cells? A) A healing abrasion on the client's arm. B) A tick removal procedure completed two weeks ago. C) A raised, blistering rash on the client's leg caused by poison ivy. D) A 20 pack-year history of smoking. Answer: D Explanation: A) Abrasions, parasites, and surface exposure to irritant chemicals are more likely to cause injury to epithelial cells. B) Abrasions, parasites, and surface exposure to irritant chemicals are more likely to cause injury to epithelial cells. C) Abrasions, parasites, and surface exposure to irritant chemicals are more likely to cause injury to epithelial cells. D) Environmental irritants such as tobacco products can result in injury to endothelial cells. Page Ref: 256 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 10.5 Describe the impact of injury on endothelial and epithelial cells in various organs. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the impact of cellular injury, its response to injury, and cellular aging.

6) A nurse is providing dietary education for a client. Which statement by the client indicates an understanding of dietary antioxidants? A) "Vitamin E is one of the most important dietary lipid-soluble antioxidants." B) "Antioxidants are only found in healthy, whole foods." C) "Vitamin C is a dietary, fat-soluble antioxidant." D) "Dietary vitamins are an example of enzymatic antioxidants." Answer: A Explanation: A) Vitamin E is one of the most important dietary, fat-soluble antioxidants. B) Antioxidants are found in healthy, whole foods, but can also be found in some medications. C) Vitamin C is an example of a dietary, water-soluble antioxidant. D) Both Vitamin C and Vitamin E are examples of nonenzymatic antioxidants. Page Ref: 249 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Evaluation | Learning Outcome: 10.3 Explain the common causes of cellular injury. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the impact of cellular injury, its response to injury, and cellular aging.

7) A nurse is educating a client with cervical dysplasia diagnosed by Papanicolaou (Pap) smear. Which statement by the client requires further follow up by the nurse? A) "This condition may be reversible." B) "I have cervical cancer." C) "This is an abnormal condition." D) "My cervical cells have grown in a deranged manner." Answer: B Explanation: A) Cervical dysplasia is an abnormal condition defined by deranged cellular growth. Dysplasia is a condition that may be reversible once the irritant causing the dysplasia is treated or removed. B) Dysplasia can be a precursor to cancer, but does not indicate a diagnosis of cancer by itself; therefore this statement requires further follow up by the nurse. C) Cervical dysplasia is an abnormal condition defined by deranged cellular growth. Dysplasia is a condition that may be reversible once the irritant causing the dysplasia is treated or removed. D) Cervical dysplasia is an abnormal condition defined by deranged cellular growth. Dysplasia is a condition that may be reversible once the irritant causing the dysplasia is treated or removed. Page Ref: 259 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 10.6 Summarize the cellular responses to injury and the cellular repair process. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the impact of cellular injury, its response to injury, and cellular aging.

8) A nurse is caring for a client with gangrene present on the client's leg. What is the nurse's understanding of the client's condition? Select all that apply. A) There are two types of gangrene: wet and dry. B) Gangrene describes a mass of necrotic tissue. C) The client has a form of coagulation necrosis. D) Gangrene is caused by cell injury culminating in apoptosis. E) The client has an active infection. Answer: A, B, C Explanation: A) Gangrene describes a mass of necrotic tissue, which is caused by a form of coagulation necrosis. There are two types of gangrene: wet and dry. Wet gangrene describes the presence of an infection, whereas an infection may or may not be present in dry gangrene. B) Gangrene describes a mass of necrotic tissue, which is caused by a form of coagulation necrosis. C) Gangrene describes a mass of necrotic tissue, which is caused by a form of coagulation necrosis. D) Apoptosis refers to programmed cell death, which is distinct from necrosis. E) There are two types of gangrene: wet and dry. Wet gangrene describes the presence of an infection, whereas an infection may or may not be present in dry gangrene. Page Ref: 263 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 10.7 Compare and contrast the causes and effects of cell death due to necrosis and cell death due to apoptosis. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the impact of cellular injury, its response to injury, and cellular aging.

9) A nurse is performing an assessment on a client, and notes findings consistent with hypoxemia. Which manifestation suggest this diagnosis? A) Tachypnea B) Bradycardia C) Hyperthermia D) Hemiparesis Answer: A Explanation: A) Tachypnea is a symptom suggestive of hypoxemia. B) Tachycardia, not bradycardia, is a symptom suggestive of hypoxemia. C) Hyperthermia is not a symptom suggestive of hypoxemia. D) Hemiparesis is not a symptom suggestive of hypoxemia. Page Ref: 245 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 10.7 Compare and contrast the causes and effects of cell death due to necrosis and cell death due to apoptosis. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the impact of cellular injury, its response to injury, and cellular aging.

10) A nurse is performing follow up education for a client who recently underwent a punch biopsy procedure for suspected melanoma. Which statement by the client indicates appropriate understanding of melanin? A) "Melanin an example of an external pigment." B) "Melanin is a yellow-brown pigment composed of fats." C) "Melanin protects certain cells from UV light." D) "Melanin is composed of hemoglobin, a blood component." Answer: C Explanation: A) Melanin is an endogenous, nonhemoglobin pigment that is brown-black in appearance and protects the nuclei of basal epidermal cells from UV light. B) Melanin is an endogenous, nonhemoglobin pigment that is brown-black in appearance and protects the nuclei of basal epidermal cells from UV light. Melanin is distinct from lipofuscin, which is a granular yellow-brown pigment composed of lipid-containing residues of lysosomal digestion. C) Melanin is an endogenous, nonhemoglobin pigment that is brown-black in appearance and protects the nuclei of basal epidermal cells from UV light. Melanin is distinct from Lipofuscin, which is a granular yellow-brown pigment composed of lipid-containing residues of lysosomal digestion. D) Melanin is an endogenous, nonhemoglobin pigment that is brown-black in appearance and protects the nuclei of basal epidermal cells from UV light. Page Ref: 261 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 10.6 Summarize the cellular responses to injury and the cellular repair process. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the impact of cellular injury, its response to injury, and cellular aging.

11) A nurse is caring for a premature newborn who has experienced oxidative stress when transitioning from fetal circulation to newborn circulation. Which conditions is the newborn at risk for developing? Select all that apply. A) Respiratory distress syndrome (RDS) B) Necrotizing enterocolitis C) Intravascular hemorrhage D) Gestational diabetes mellitus E) Retinopathy of prematurity Answer: A, B, C, E Explanation: A) The major complications associated with oxidative stress in premature newborns include respiratory distress syndrome, necrotizing enterocolitis, chronic lung disease, retinopathy of prematurity, and intravascular hemorrhage. Oxidative stress during premature delivery does not cause gestational diabetes mellitus, but rather gestational diabetes mellitus can be a contributing factor to premature delivery. B) The major complications associated with oxidative stress in premature newborns include respiratory distress syndrome, necrotizing enterocolitis, chronic lung disease, retinopathy of prematurity, and intravascular hemorrhage. Oxidative stress during premature delivery does not cause gestational diabetes mellitus, but rather gestational diabetes mellitus can be a contributing factor to premature delivery. C) The major complications associated with oxidative stress in premature newborns include respiratory distress syndrome, necrotizing enterocolitis, chronic lung disease, retinopathy of prematurity, and intravascular hemorrhage. Oxidative stress during premature delivery does not cause gestational diabetes mellitus, but rather gestational diabetes mellitus can be a contributing factor to premature delivery. D) The major complications associated with oxidative stress in premature newborns include respiratory distress syndrome, necrotizing enterocolitis, chronic lung disease, retinopathy of prematurity, and intravascular hemorrhage. Oxidative stress during premature delivery does not cause gestational diabetes mellitus, but rather gestational diabetes mellitus can be a contributing factor to premature delivery. E) The major complications associated with oxidative stress in premature newborns include respiratory distress syndrome, necrotizing enterocolitis, chronic lung disease, retinopathy of prematurity, and intravascular hemorrhage. Oxidative stress during premature delivery does not cause gestational diabetes mellitus, but rather gestational diabetes mellitus can be a contributing factor to premature delivery. Page Ref: 248 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 10.3 Explain the common causes of cellular injury. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the impact of cellular injury, its response to injury, and cellular aging. 11

12) A nurse is caring for an older adult client in a long-term care facility. What is the nurse's understanding of replicative senescence? A) It refers to the brain's ability to recall memories. B) It is the limitation of the number of times a cell can divide. C) It is the body's ability to repair cells damaged by reactive oxygen species (ROS). D) It is caused by decreased caloric intake. Answer: B Explanation: A) Replicative senescence is not defined by the brain's ability to recall memories or decreased caloric intake. B) Replicative senescence refers to the limitation of the number of times the body's cells can divide. C) Replicative senescence refers to the limitation of the number of times the body's cells can divide. The damage caused by reactive oxygen species (ROS) is counteracted by antioxidants, and is not directly related to the concept of replicative senescence. Replicative senescence is not defined by the brain's ability to recall memories or decreased caloric intake. D) Replicative senescence is not defined by the brain's ability to recall memories or decreased caloric intake. Page Ref: 265 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 10.8 Describe the normal lifespan, the molecular basis of aging, and the changes that occur with aging in the human body. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the impact of cellular injury, its response to injury, and cellular aging.

13) A nurse is caring for a client with endometrial hyperplasia. What is the nurse's understanding of the condition of the client's endometrial cells? A) The cells have increased in size. B) The cells have increased intracellular protein. C) The cells have increased in number. D) The cells have increased motility. Answer: C Explanation: A) Hyperplasia refers to an increase in the number of cells in an organ or tissue. Hypertrophy refers to when cells are increased in size. Hyperplasia is not defined by an increase in intracellular protein or motility. B) Hyperplasia refers to an increase in the number of cells in an organ or tissue. Hypertrophy refers to when cells are increased in size. Hyperplasia is not defined by an increase in intracellular protein or motility. C) Hyperplasia refers to an increase in the number of cells in an organ or tissue. Hypertrophy refers to when cells are increased in size. Hyperplasia is not defined by an increase in intracellular protein or motility. D) Hyperplasia refers to an increase in the number of cells in an organ or tissue. Hypertrophy refers to when cells are increased in size. Hyperplasia is not defined by an increase in intracellular protein or motility. Page Ref: 259 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 10.6 Summarize the cellular responses to injury and the cellular repair process. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the impact of cellular injury, its response to injury, and cellular aging.

14) A nurse is reviewing a client's pathology report which notes the presence of intracellular hyaline. What condition does the nurse identify as an example where intracellular hyaline may be present? A) Scar tissue B) Arteriosclerosis C) Decreased vascularity D) Tumor Answer: D Explanation: A) Scar tissue, arteriosclerosis, and decreased vascularity are all examples of conditions with extracellular hyaline present. A tumor has intracellular hyaline. B) Scar tissue, arteriosclerosis, and decreased vascularity are all examples of conditions with extracellular hyaline present. A tumor has intracellular hyaline. C) Scar tissue, arteriosclerosis, and decreased vascularity are all examples of conditions with extracellular hyaline present. A tumor has intracellular hyaline. D) Tumor cells may have intracellular hyaline globules present. A tumor has intracellular hyaline. Page Ref: 261 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 10.6 Summarize the cellular responses to injury and the cellular repair process. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the impact of cellular injury, its response to injury, and cellular aging.

15) A nurse is performing an assessment on a client with acute ionizing radiation exposure. Which assessment findings does the nurse anticipate? Select all that apply. A) Nausea B) Fatigue C) Vomiting D) Constipation E) Hypercoagulability Answer: A, B, C Explanation: A) Nausea, fatigue, vomiting, diarrhea, and hemorrhage are examples of symptoms an individuals can exhibit when exposed to high levels of ionizing radiation. B) Nausea, fatigue, vomiting, diarrhea, and hemorrhage are examples of symptoms an individuals can exhibit when exposed to high levels of ionizing radiation. C) Nausea, fatigue, vomiting, diarrhea, and hemorrhage are examples of symptoms an individuals can exhibit when exposed to high levels of ionizing radiation. D) Constipation and hypercoagulability are not symptoms of acute ionizing radiation exposure E) Constipation and hypercoagulability are not symptoms of acute ionizing radiation exposure Page Ref: 255 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 10.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of cell injury caused by environmental factors and approaches to diagnosis and treatment of these injuries across the lifespan. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the impact of cellular injury, its response to injury, and cellular aging.

16) A nurse is teaching a community health class about the causes of cancer. Which statement will the nurse include when teaching about the formation of cancer? A) "When cellular death is altered, cancer may occur." B) "When cells do not divide enough, a tumor may form." C) "Tumors form when enzymes cause the uncontrolled destruction of cell components." D) "When cellular contents leak out through altered cell walls, cancer may occur." Answer: A Explanation: A) Apoptosis is also referred to as programmed cell death, and the interference of this process contributes to carcinogenesis, the formation of cancer. B) Replicative senescence refers to the limited number of times a cell can divide. Replicative senescence protects the cell from cancer, it does not cause it. C) Necrosis is the unregulated enzymatic destruction of cell components, which leads to cell death through a different process than apoptosis. D) Inflammation refers to cellular contents leaking out through the cell's damaged plasma membrane. Page Ref: 264-265 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 10.7 Compare and contrast the causes and effects of cell death due to necrosis and cell death due to apoptosis. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and wellbeing, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the impact of cellular injury, its response to injury, and cellular aging.

17) A nurse is educating a client who asks, "Why don't I get sick every time my body's cells are stressed?" How will the nurse respond? A) "When cells are exposed to stressors, they focus exclusively on specialized functions." B) "The body's cells are not at risk for injury under stressors alone." C) "To avoid injury, cells generally adapt to stressors by expending more resources." D) "Changes can occur in the body's cells that favor cellular survival." Answer: D Explanation: A) When the body's cells are exposed to stressors, they can undergo changes that favor cellular survival. Cells under stress generally focus exclusively on functions related to survival and cease to perform differentiated functions. Stressors, even on their own, can lead to cell injury. To avoid injury, cells generally conserve resources. B) When the body's cells are exposed to stressors, they can undergo changes that favor cellular survival. Cells under stress generally focus exclusively on functions related to survival and cease to perform differentiated functions. Stressors, even on their own, can lead to cell injury. To avoid injury, cells generally conserve resources. C) When the body's cells are exposed to stressors, they can undergo changes that favor cellular survival. Cells under stress generally focus exclusively on functions related to survival and cease to perform differentiated functions. Stressors, even on their own, can lead to cell injury. To avoid injury, cells generally conserve resources. D) When the body's cells are exposed to stressors, they can undergo changes that favor cellular survival. Cells under stress generally focus exclusively on functions related to survival and cease to perform differentiated functions. Stressors, even on their own, can lead to cell injury. To avoid injury, cells generally conserve resources. Page Ref: 239 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 10.1 Differentiate reversible from nonreversible cell injury, cellular adaptation, and concepts related to cell injury and aging. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the impact of cellular injury, its response to injury, and cellular aging.

18) A nurse educator is providing review of material to staff nurses regarding the process of inflammation. Which statement by the nurse indicates an understanding of the material? Select all that apply. A) "Inflammation is a temporary cell-to-cell interaction,." B) "Inflammation requires the immune cells to talk to each other." C) "Inflammation occurs between closely knit cell pathways." D) "Inflammation is critical for the development of the body." E) "Inflammation regulates the behavior of cells." Answer: A, B Explanation: A) Inflammation is a transient or temporary cell-to-cell interaction that occurs between cells of the immune system. It is a process that utilizes cell signaling systems, that require the immune cells to communicate with each other. Inflammation does not occur between cell junctions or pathways. Inflammation is critical to body's ability to rid itself of harmful substances; however, inflammation is not critical to the development of the body. The extracellular matrix plays a substantial role in regulating the behavior of cells in multicellular organisms, not inflammation. B) Inflammation is a transient or temporary cell-to-cell interaction that occurs between cells of the immune system. It is a process that utilizes cell signaling systems, that require the immune cells to communicate with each other. Inflammation does not occur between cell junctions or pathways. Inflammation is critical to body's ability to rid itself of harmful substances; however, inflammation is not critical to the development of the body. The extracellular matrix plays a substantial role in regulating the behavior of cells in multicellular organisms, not inflammation. C) Inflammation is a transient or temporary cell-to-cell interaction that occurs between cells of the immune system. It is a process that utilizes cell signaling systems, that require the immune cells to communicate with each other. Inflammation does not occur between cell junctions or pathways. Inflammation is critical to body's ability to rid itself of harmful substances; however, inflammation is not critical to the development of the body. The extracellular matrix plays a substantial role in regulating the behavior of cells in multicellular organisms, not inflammation. D) Inflammation is a transient or temporary cell-to-cell interaction that occurs between cells of the immune system. It is a process that utilizes cell signaling systems, that require the immune cells to communicate with each other. Inflammation does not occur between cell junctions or pathways. Inflammation is critical to body's ability to rid itself of harmful substances; however, inflammation is not critical to the development of the body. The extracellular matrix plays a substantial role in regulating the behavior of cells in multicellular organisms, not inflammation. E) Inflammation is a transient or temporary cell-to-cell interaction that occurs between cells of the immune system. It is a process that utilizes cell signaling systems, that require the immune cells to communicate with each other. Inflammation does not occur between cell junctions or pathways. Inflammation is critical to body's ability to rid itself of harmful substances; however, inflammation is not critical to the development of the body. The extracellular matrix plays a substantial role in regulating the behavior of cells in multicellular organisms, not inflammation. Page Ref: 243 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation

Standards: Nursing Process: Evaluation | Learning Outcome: 10.2 Summarize cell structures and functions, and describe the consequences of injury to the cell membrane and organelles. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the impact of cellular injury, its response to injury, and cellular aging. 19) A nurse is performing an assessment on a client diagnosed with carbon monoxide (CO) poisoning. Which assessment findings would the nurse anticipate? Select all that apply. A) Headache B) Bradycardia C) Dyspnea D) Hypertension E) Syncope Answer: A, C, E Explanation: A) A client diagnosed with carbon monoxide (CO) poisoning may exhibit symptoms including headache, tachycardia, dyspnea, hypotension, and syncope. B) A client diagnosed with carbon monoxide (CO) poisoning may exhibit symptoms including headache, tachycardia, dyspnea, hypotension, and syncope. C) A client diagnosed with carbon monoxide (CO) poisoning may exhibit symptoms including headache, tachycardia, dyspnea, hypotension, and syncope. D) A client diagnosed with carbon monoxide (CO) poisoning may exhibit symptoms including headache, tachycardia, dyspnea, hypotension, and syncope. E) A client diagnosed with carbon monoxide (CO) poisoning may exhibit symptoms including headache, tachycardia, dyspnea, hypotension, and syncope. Page Ref: 252 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 10.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of cell injury caused by environmental factors and approaches to diagnosis and treatment of these injuries across the lifespan. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the impact of cellular injury, its response to injury, and cellular aging.

20) A nurse is caring for a client with a 15% carboxyhemoglobin level. Which clinical manifestations will the nurse expect to find in the client? Select all that apply. A) Headache B) Exertional dyspnea C) Dizziness D) Confusion E) Tachycardia Answer: A, B, C Explanation: A) Low levels of carbon monoxide (CO) are normally present in the body because CO is the by product of some metabolic reactions. Carboxyhemoglobin levels of 1-2% is normal in non-smokers and up to 10% in individuals who smoke. Carboxyhemoglobin of 10-30% causes headache, exertional dyspnea, dizziness, nausea, and fatigue. Confusion occurs at levels of 3050% and tachycardia occurs at levels of 50-60%. B) Low levels of carbon monoxide (CO) are normally present in the body because CO is the by product of some metabolic reactions. Carboxyhemoglobin levels of 1-2% is normal in nonsmokers and up to 10% in individuals who smoke. Carboxyhemoglobin of 10-30% causes headache, exertional dyspnea, dizziness, nausea, and fatigue. Confusion occurs at levels of 3050% and tachycardia occurs at levels of 50-60%. C) Low levels of carbon monoxide (CO) are normally present in the body because CO is the by product of some metabolic reactions. Carboxyhemoglobin levels of 1-2% is normal in nonsmokers and up to 10% in individuals who smoke. Carboxyhemoglobin of 10-30% causes headache, exertional dyspnea, dizziness, nausea, and fatigue. Confusion occurs at levels of 3050% and tachycardia occurs at levels of 50-60%. D) Low levels of carbon monoxide (CO) are normally present in the body because CO is the by product of some metabolic reactions. Carboxyhemoglobin levels of 1-2% is normal in nonsmokers and up to 10% in individuals who smoke. Carboxyhemoglobin of 10-30% causes headache, exertional dyspnea, dizziness, nausea, and fatigue. Confusion occurs at levels of 3050% and tachycardia occurs at levels of 50-60%. E) Low levels of carbon monoxide (CO) are normally present in the body because CO is the by product of some metabolic reactions. Carboxyhemoglobin levels of 1-2% is normal in nonsmokers and up to 10% in individuals who smoke. Carboxyhemoglobin of 10-30% causes headache, exertional dyspnea, dizziness, nausea, and fatigue. Confusion occurs at levels of 3050% and tachycardia occurs at levels of 50-60%. Page Ref: 252 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 10.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of cell injury caused by environmental factors and approaches to diagnosis and treatment of these injuries across the lifespan. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the impact of cellular injury, its response to injury, and cellular aging. 20

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 11 Inflammation 1) Lab results for a client are consistent with inflammation. What is the nurse's understanding of inflammation? Select all that apply. A) It is defined as a protective tissue response. B) It is a response to tissue injury. C) It involves the destruction of tissue. D) It indicates the presence of an infection. E) It begins the process of tissue repair. Answer: A, B, C, E Explanation: A) Inflammation is a protective tissue response that involves the destruction of damaged tissue, and begins the process of tissue repair. B) Inflammation is a protective tissue response that involves the destruction of damaged tissue, and begins the process of tissue repair. C) Inflammation is a protective tissue response that involves the destruction of damaged tissue, and begins the process of tissue repair. D) Inflammation does not necessarily indicate the presence of an infection. E) Inflammation is a protective tissue response that involves the destruction of damaged tissue, and begins the process of tissue repair. Page Ref: 272 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 11.1 Recognize the complex role that inflammation plays in defending the body from injury and promoting healing. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Relate chronic inflammation to associated disorders.

2) The nurse is providing education for a client with Crohn disease. Which statement will the nurse include when teaching the client about the disease? A) "Crohn disease is an active allergic response." B) "Crohn disease is the result of an acute inflammatory response." C) "Crohn disease is a chronic inflammatory disorder." D) Crohn disease is a chronic inflammatory disorder caused by the immune system targeting healthy tissues of the digestive tract. The cause of Crohn disease is understood to be multifactorial, but is not the result of an allergic response, nor an acute inflammatory response. Crohn disease is not caused by the immune system targeting diseased tissue. Answer: C Explanation: A) Crohn disease is a chronic inflammatory disorder caused by the immune system targeting healthy tissues of the digestive tract. The cause of Crohn disease is understood to be multifactorial, but is not the result of an allergic response, nor an acute inflammatory response. Crohn disease is not caused by the immune system targeting diseased tissue. B) Crohn disease is a chronic inflammatory disorder caused by the immune system targeting healthy tissues of the digestive tract. The cause of Crohn disease is understood to be multifactorial, but is not the result of an allergic response, nor an acute inflammatory response. Crohn disease is not caused by the immune system targeting diseased tissue. C) Crohn disease is a chronic inflammatory disorder caused by the immune system targeting healthy tissues of the digestive tract. The cause of Crohn disease is understood to be multifactorial, but is not the result of an allergic response, nor an acute inflammatory response. Crohn disease is not caused by the immune system targeting diseased tissue. D) "Crohn disease is a condition caused by the immune system targeting diseased tissue." Page Ref: 272 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 11.1 Recognize the complex role that inflammation plays in defending the body from injury and promoting healing. | QSEN Competencies: I.B.1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care | AACN Essential Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Relate chronic inflammation to associated disorders.

3) The nurse is providing education to the parent of an infant about innate immunity. Which statement by the parent indicates an understanding of the material? A) "Innate immunity is a delayed response of the immune system." B) "Innate immunity responds to a specific antigen to prevent illness." C) "Innate immunity is the basis for vaccinations." D) "Innate immunity is the body's first line of defense." Answer: D Explanation: A) Innate immunity is the immune system's initial, nonspecific response to antigens in general, and is the body's first line of defense against potentially harmful foreign material. In contrast, acquired immunity is a delayed response to a specific antigen, and is the basis for receiving vaccinations. B) Innate immunity is the immune system's initial, nonspecific response to antigens in general, and is the body's first line of defense against potentially harmful foreign material. In contrast, acquired immunity is a delayed response to a specific antigen, and is the basis for receiving vaccinations. C) Innate immunity is the immune system's initial, nonspecific response to antigens in general, and is the body's first line of defense against potentially harmful foreign material. In contrast, acquired immunity is a delayed response to a specific antigen, and is the basis for receiving vaccinations. D) Innate immunity is the immune system's initial, nonspecific response to antigens in general, and is the body's first line of defense against potentially harmful foreign material. In contrast, acquired immunity is a delayed response to a specific antigen, and is the basis for receiving vaccinations. Page Ref: 274 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 11.2 Describe the inflammatory response as a key component of the body's defense system. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Relate chronic inflammation to associated disorders.

4) The nurse is assessing a client with local cellulitis due to an insect bite. Which symptoms will the nurse anticipate? A) Swelling B) Chills C) Redness D) Heat E) Pain Answer: A, C, D, E Explanation: A) Swelling, redness, heat, and pain are all symptoms of acute, local inflammation. B) Chills are a symptom of systemic inflammation. C) Swelling, redness, heat, and pain are all symptoms of acute, local inflammation. D) Swelling, redness, heat, and pain are all symptoms of acute, local inflammation. E) Swelling, redness, heat, and pain are all symptoms of acute, local inflammation. Page Ref: 274 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 11.2 Describe the inflammatory response as a key component of the body's defense system. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Relate chronic inflammation to associated disorders.

5) The nurse is caring for a client with acute inflammation of the right knee resulting from a bacterial infection. Which vascular events are occurring as a result of the inflammation? Select all that apply. A) Vascular permeability B) Cellular infiltration C) Prolonged vasoconstriction D) Thrombosis E) Release of chemical mediators Answer: A, B, D Explanation: A) When acute inflammation occurs as a result of a bacterial infection, chemical mediators are released which result in the following vascular events: vasodilation, vascular permeability, cellular infiltration, and thrombosis formation. While there is a brief period of vasoconstriction after the initial tissue insult, it is followed by a prolonged period of vasodilation. B) When acute inflammation occurs as a result of a bacterial infection, chemical mediators are released which result in the following vascular events: vasodilation, vascular permeability, cellular infiltration, and thrombosis formation. While there is a brief period of vasoconstriction after the initial tissue insult, it is followed by a prolonged period of vasodilation. C) When acute inflammation occurs as a result of a bacterial infection, chemical mediators are released which result in the following vascular events: vasodilation, vascular permeability, cellular infiltration, and thrombosis formation. While there is a brief period of vasoconstriction after the initial tissue insult, it is followed by a prolonged period of vasodilation. D) When acute inflammation occurs as a result of a bacterial infection, chemical mediators are released which result in the following vascular events: vasodilation, vascular permeability, cellular infiltration, and thrombosis formation. While there is a brief period of vasoconstriction after the initial tissue insult, it is followed by a prolonged period of vasodilation. E) When acute inflammation occurs as a result of a bacterial infection, chemical mediators are released which result in the following vascular events: vasodilation, vascular permeability, cellular infiltration, and thrombosis formation. While there is a brief period of vasoconstriction after the initial tissue insult, it is followed by a prolonged period of vasodilation. Page Ref: 276 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 11.3 Discriminate the characteristics of the acute inflammatory response. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Relate chronic inflammation to associated disorders.

6) A client with a burn injury asks, "Why does swelling happen after a burn?" What is the nurse's best initial response? A) "Swelling occurs because the vessels dilate, which slows the flow of blood." B) "Swelling occurs because the vessels leak fluid into the surrounding tissue." C) "Swelling occurs because of the release of chemicals that impact the vessels." D) "Swelling occurs in order to prepare the injured area for healing." Answer: D Explanation: A) The nurse's best response is to answer the question by responding first with the general reason that the body induces swelling after a burn injury. With a burn injury, the vessels dilate, slowing the velocity of blood flow; however, there is an increase of blood flow to the injured site. While the other responses are correct, they do not specifically address the client's question about the purpose of swelling after a burn injury. B) The nurse's best response is to answer the question by responding first with the general reason that the body induces swelling after a burn injury. With a burn injury, the vessels dilate, slowing the velocity of blood flow; however, there is an increase of blood flow to the injured site. While the other responses are correct, they do not specifically address the client's question about the purpose of swelling after a burn injury. C) The nurse's best response is to answer the question by responding first with the general reason that the body induces swelling after a burn injury. With a burn injury, the vessels dilate, slowing the velocity of blood flow; however, there is an increase of blood flow to the injured site. While the other responses are correct, they do not specifically address the client's question about the purpose of swelling after a burn injury. D) The nurse's best response is to answer the question by responding first with the general reason that the body induces swelling after a burn injury. With a burn injury, the vessels dilate, slowing the velocity of blood flow; however, there is an increase of blood flow to the injured site. While the other responses are correct, they do not specifically address the client's question about the purpose of swelling after a burn injury. Page Ref: 277 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 11.3 Discriminate the characteristics of the acute inflammatory response. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Relate chronic inflammation to associated disorders.

7) The nurse is caring for a client with a healing surgical incision. Which organs does the nurse understand are integral to regulating the client's inflammation? Select all that apply. A) Skin B) Spleen C) Thymus D) Kidneys E) Appendix Answer: B, C Explanation: A) The skin, kidneys, and appendix are not integral to regulating the client's inflammation. B) The sympathetic nervous system innervates lymph node-related organs such as the spleen, thymus, bone marrow, and lymph nodes, which are integral to regulating the inflammatory response. C) The sympathetic nervous system innervates lymph node-related organs such as the spleen, thymus, bone marrow, and lymph nodes, which are integral to regulating the inflammatory response. D) The skin, kidneys, and appendix are not integral to regulating the client's inflammation. E) The skin, kidneys, and appendix are not integral to regulating the client's inflammation. Page Ref: 281 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 11.4 Explain the regulation and resolution of the acute inflammatory process. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Relate chronic inflammation to associated disorders.

8) The nurse prepares to administer a glucocorticoid agent to a client with an inflammatory disorder. What is the nurse's understanding of the purpose of glucocorticoids in the hypothalamic-pituitary-adrenal (HPA) axis? A) Glucocorticoids cause the release of cytokines that downregulate the inflammatory response. B) Glucocorticoids increase the number of active immune cells in the body. C) Glucocorticoids stimulate the pituitary, decreasing inflammation. D) Glucorticoids act with cytokines to decrease the inflammatory response. Answer: D Explanation: A) Cortisol is produced by the adrenal glands, and affects the immune cells, pituitary, and hypothalamus. The release of anti-inflammatory cytokines act with the release of glucocorticoids to attenuate the inflammatory response. Additionally, while the interaction between cortisol, the hypothalamus, and the pituitary attenuate inflammation, it is the hypothalamus which stimulates the pituitary to release adrenocorticotropic hormone, and not vise versa. B) Cortisol is produced by the adrenal glands, and affects the immune cells, pituitary, and hypothalamus. The release of anti-inflammatory cytokines act with the release of glucocorticoids to attenuate the inflammatory response. Additionally, while the interaction between cortisol, the hypothalamus, and the pituitary attenuate inflammation, it is the hypothalamus which stimulates the pituitary to release adrenocorticotropic hormone, and not vise versa. C) Cortisol is produced by the adrenal glands, and affects the immune cells, pituitary, and hypothalamus. The release of anti-inflammatory cytokines act with the release of glucocorticoids to attenuate the inflammatory response. Additionally, while the interaction between cortisol, the hypothalamus, and the pituitary attenuate inflammation, it is the hypothalamus which stimulates the pituitary to release adrenocorticotropic hormone, and not vise versa. D) Cortisol is produced by the adrenal glands, and affects the immune cells, pituitary, and hypothalamus. The release of anti-inflammatory cytokines act with the release of glucocorticoids to attenuate the inflammatory response. Additionally, while the interaction between cortisol, the hypothalamus, and the pituitary attenuate inflammation, it is the hypothalamus which stimulates the pituitary to release adrenocorticotropic hormone, and not vise versa. Page Ref: 281 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 11.4 Explain the regulation and resolution of the acute inflammatory process. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Relate chronic inflammation to associated disorders.

9) The nurse is caring for a client diagnosed with appendicitis. The nurse understands that this is an example of which type of inflammation? A) Serous inflammation B) Purulent inflammation C) Fibrinous inflammation D) Ulceration Answer: B Explanation: A) Serous inflammation is fluid accumulation as a result of tissue injury that does not contain many cells. B) Purulent (suppurative) inflammation is the formation of pus, which contains many neutrophils, cellular debris, and edema fluid. Appendicitis and suppurative tonsillitis are examples of suppurative inflammation. C) Fibrinous inflammation is the result of increased vascular permeability that allows fluid with large proteins to leak out of the vessels into the surrounding tissue. D) Ulceration results from very severe inflammation and is a local defect caused by necrosis of cells and sloughing of necrotic tissue. Page Ref: 282 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 11.5 Discuss the primary morphologic types of acute inflammation and the four possible outcomes of acute inflammation. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: I.7. Integrate the knowledge and methods of a variety of disciplines to inform decision making NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Relate chronic inflammation to associated disorders.

10) The nurse is caring for a client with acute inflammation. What possible outcomes of acute inflammation does the nurse anticipate while caring for the client? Select all that apply. A) Fibrosis formation B) Abscess formation C) Chronic inflammation D) Serous inflammation E) Resolution Answer: A, B, C, E Explanation: A) The possible outcomes of acute inflammation are resolution, fibrosis, abscess formation, and chronic inflammation. Acute inflammation can progress to chronic inflammation if the cause is not eradicated, but serous inflammation is a fluid accumulation as a result of tissue injury. Serous inflammation is not a classification of an outcome of acute inflammation. B) The possible outcomes of acute inflammation are resolution, fibrosis, abscess formation, and chronic inflammation. Acute inflammation can progress to chronic inflammation if the cause is not eradicated, but serous inflammation is a fluid accumulation as a result of tissue injury. Serous inflammation is not a classification of an outcome of acute inflammation. C) The possible outcomes of acute inflammation are resolution, fibrosis, abscess formation, and chronic inflammation. Acute inflammation can progress to chronic inflammation if the cause is not eradicated, but serous inflammation is a fluid accumulation as a result of tissue injury. Serous inflammation is not a classification of an outcome of acute inflammation. D) The possible outcomes of acute inflammation are resolution, fibrosis, abscess formation, and chronic inflammation. Acute inflammation can progress to chronic inflammation if the cause is not eradicated, but serous inflammation is a fluid accumulation as a result of tissue injury. Serous inflammation is not a classification of an outcome of acute inflammation. E) The possible outcomes of acute inflammation are resolution, fibrosis, abscess formation, and chronic inflammation. Acute inflammation can progress to chronic inflammation if the cause is not eradicated, but serous inflammation is a fluid accumulation as a result of tissue injury. Serous inflammation is not a classification of an outcome of acute inflammation. Page Ref: 282 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 11.5 Discuss the primary morphologic types of acute inflammation and the four possible outcomes of acute inflammation. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Relate chronic inflammation to associated disorders.

11) A client's laboratory results are consistent with chronic inflammation. Which potential causes of chronic inflammation does the nurse suspect? Select all that apply. A) Malnutrition B) Autoimmune diseases C) Poor blood supply D) Prolonged exposure to irritants E) Unresolved or repeated acute infections Answer: B, D, E Explanation: A) Autoimmune diseases, prolonged exposure to irritants, and unresolved or repeated acute infections are understood to be causative factors for chronic inflammation. Malnutrition and a poor blood supply are understood to be risk factors, not causative factors for chronic inflammation. B) Autoimmune diseases, prolonged exposure to irritants, and unresolved or repeated acute infections are understood to be causative factors, not causative factors for chronic inflammation. Malnutrition and a poor blood supply are understood to be risk factors for chronic inflammation. C) Autoimmune diseases, prolonged exposure to irritants, and unresolved or repeated acute infections are understood to be causative factors, not causative factors for chronic inflammation. Malnutrition and a poor blood supply are understood to be risk factors for chronic inflammation. D) Autoimmune diseases, prolonged exposure to irritants, and unresolved or repeated acute infections are understood to be causative factors, not causative factors for chronic inflammation. Malnutrition and a poor blood supply are understood to be risk factors for chronic inflammation. E) Autoimmune diseases, prolonged exposure to irritants, and unresolved or repeated acute infections are understood to be causative factors, not causative factors for chronic inflammation. Malnutrition and a poor blood supply are understood to be risk factors for chronic inflammation. Page Ref: 283 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 11.6 Identify the conditions under which chronic inflammation may arise, and explain the process of chronic inflammation and its possible outcomes. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Relate chronic inflammation to associated disorders.

12) A nurse cares for a client experiencing an acute-phase inflammatory response. Which clinical manifestation does the nurse expect upon physical assessment? A) Leukopenia B) Decreased serum proteins C) Pyrexia D) Decreased erythrocytes Answer: C Explanation: A) An acute-phase inflammatory response occurs due to the release of chemical mediators (cytokines), causing systemic effects. Effects include fever (pyrexia), increased serum proteins, and leukocytosis (not leukopenia). Decreased erythrocytes (RBCs) is not a result of an acute-phase inflammatory response. B) An acute-phase inflammatory response occurs due to the release of chemical mediators (cytokines), causing systemic effects. Effects include fever (pyrexia), increased serum proteins, and leukocytosis (not leukopenia). Decreased erythrocytes (RBCs) is not a result of an acutephase inflammatory response. C) An acute-phase inflammatory response occurs due to the release of chemical mediators (cytokines), causing systemic effects. Effects include fever (pyrexia), increased serum proteins, and leukocytosis (not leukopenia). Decreased erythrocytes (RBCs) is not a result of an acutephase inflammatory response. D) An acute-phase inflammatory response occurs due to the release of chemical mediators (cytokines), causing systemic effects. Effects include fever (pyrexia), increased serum proteins, and leukocytosis (not leukopenia). Decreased erythrocytes (RBCs) is not a result of an acutephase inflammatory response. Page Ref: 284 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 11.6 Identify the conditions under which chronic inflammation may arise, and explain the process of chronic inflammation and its possible outcomes. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Relate chronic inflammation to associated disorders.

13) The nurse is caring for a client with systemic inflammatory response syndrome (SIRS). Which assessment finding would the nurse anticipate? Select all that apply. A) A white blood cell (WBC) count less than 3,000 cells/mm3 or greater than 10,000 cells/mm3 B) A heart rate of greater than 90 beats per minute C) A respiratory rate of greater than 16 respirations per minute D) A body temperature of less than 36°C or greater than 38°C E) The presence of greater than 20% immature neutrophils Answer: A, B, D Explanation: A) In adults, two of the following criteria must be met for the diagnosis of systemic inflammatory response syndrome (SIRS): (1) body temperature less than 36°C or greater than 38°C; (2) heart rate greater than 90 beats per minute; (3) respiratory rate greater than 20 breaths per minute or arterial partial pressure of carbon dioxide less than 32 mmHg; and (4) white blood cell (WBC count less than 4,000 cells/mm3 or greater than 12,000 cells/mm3) or the presence of greater than 10% immature neutrophils. B) In adults, two of the following criteria must be met for the diagnosis of systemic inflammatory response syndrome (SIRS): (1) body temperature less than 36°C or greater than 38°C; (2) heart rate greater than 90 beats per minute; (3) respiratory rate greater than 20 breaths per minute or arterial partial pressure of carbon dioxide less than 32 mmHg; and (4) white blood cell (WBC count less than 4,000 cells/mm3 or greater than 12,000 cells/mm3 or the presence of greater than 10% immature neutrophils. C) In adults, two of the following criteria must be met for the diagnosis of systemic inflammatory response syndrome (SIRS): (1) body temperature less than 36°C or greater than 38°C; (2) heart rate greater than 90 beats per minute; (3) respiratory rate greater than 20 breaths per minute or arterial partial pressure of carbon dioxide less than 32 mmHg; and (4) white blood cell (WBC count less than 4,000 cells/mm3 or greater than 12,000 cells/mm3 or the presence of greater than 10% immature neutrophils. D) In adults, two of the following criteria must be met for the diagnosis of systemic inflammatory response syndrome (SIRS): (1) body temperature less than 36°C or greater than 38°C; (2) heart rate greater than 90 beats per minute; (3) respiratory rate greater than 20 breaths per minute or arterial partial pressure of carbon dioxide less than 32 mmHg; and (4) white blood cell (WBC count less than 4,000 cells/mm3 or greater than 12,000 cells/mm3 or the presence of greater than 10% immature neutrophils. E) In adults, two of the following criteria must be met for the diagnosis of systemic inflammatory response syndrome (SIRS): (1) body temperature less than 36°C or greater than 38°C; (2) heart rate greater than 90 beats per minute; (3) respiratory rate greater than 20 breaths per minute or arterial partial pressure of carbon dioxide less than 32 mmHg; and (4) white blood cell (WBC count less than 4,000 cells/mm3 or greater than 12,000 cells/mm3 or the presence of greater than 10% immature neutrophils. Page Ref: 284 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation

Standards: Nursing Process: Assessment | Learning Outcome: 11.7 Describe the causes and processes associated with systemic inflammation. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Relate chronic inflammation to associated disorders. 14) A nurse is caring for a client with lymphocytosis. Which possible causes of this finding does the nurse identify? Select all that apply. A) Parasitic infections B) Lymphoma C) Inflammatory bowel disease D) Tuberculosis E) Myelogenous leukemia Answer: B, D Explanation: A) Parasitic infections can be a cause of eosinophilia. B) Acute viral infections (e.g. chicken pox), certain bacterial infections (e.g. pertussis and tuberculosis), and lymphoma are examples of causes of lymphocytosis. C) Inflammatory bowel disease and myelogenous leukemia can be causes of monocytosis. D) Acute viral infections (e.g. chicken pox), certain bacterial infections (e.g. pertussis and tuberculosis), and lymphoma are examples of causes of lymphocytosis. E) Inflammatory bowel disease and myelogenous leukemia can be causes of monocytosis. Page Ref: 285 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 11.7 Describe the causes and processes associated with systemic inflammation. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Relate chronic inflammation to associated disorders.

15) A nurse is providing education to a client with alopecia areata. Which statement by the client indicates an understanding of this condition? A) "My condition is a tissue-specific autoimmune disease." B) "My condition is due to my body perceiving my skin as foreign." C) "My condition is caused by initiating an inflammatory response to diseased tissue." D) "My condition is caused by anti-inflammatory cytokines." Answer: A Explanation: A) Alopecia areata is a tissue-specific, not an organ-specific, autoimmune disease in which the immune system initiates an inflammatory response to normal tissue. B) Alopecia areata is a tissue-specific, not an organ-specific, autoimmune disease in which the immune system initiates an inflammatory response to normal tissue. C) Alopecia areata is a tissue-specific, not an organ-specific, autoimmune disease in which the immune system initiates an inflammatory response to normal tissue. D) Pro-inflammatory cytokines are a key factor in the mechanism of the disease. Page Ref: 286 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 11.8 Discuss the potential causes and consequences of impaired and excessive inflammation. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Relate chronic inflammation to associated disorders.

16) The nurse is providing education for a client diagnosed with systemic lupus erythematosus (SLE). Which statement will the nurse include in the teaching material? A) "Excessive inflammation occurs when you have less white blood cells." B) "Removal of dead cells in your body causes an immune response." C) "Your body is in a state of imbalance due to problems removing dead cells." D) "Excessive inflammation occurs when you have abnormally-shaped cells." Answer: C Explanation: A) Removal of dead cells is necessary to maintain homeostasis, and is impaired in a client with systemic lupus erythematosus (SLE). Excessive inflammation is characterized by overexpression of leukocyte adhesion molecules, not leukopenia. Removal of dead cells by phagocytosis does not cause an immune response in SLE. If dead cells are not cleared, they may leak intracellular antigens, resulting in inflammation. Abnormally-shaped cells are not a characteristic of SLE and will not be included in the client teaching. B) Removal of dead cells is necessary to maintain homeostasis, and is impaired in a client with systemic lupus erythematosus (SLE). Excessive inflammation is characterized by overexpression of leukocyte adhesion molecules, not leukopenia. Removal of dead cells by phagocytosis does not cause an immune response in SLE. If dead cells are not cleared, they may leak intracellular antigens, resulting in inflammation. Abnormally-shaped cells are not a characteristic of SLE and will not be included in the client teaching. C) Removal of dead cells is necessary to maintain homeostasis, and is impaired in a client with systemic lupus erythematosus (SLE). Excessive inflammation is characterized by overexpression of leukocyte adhesion molecules, not leukopenia. Removal of dead cells by phagocytosis does not cause an immune response in SLE. If dead cells are not cleared, they may leak intracellular antigens, resulting in inflammation. Abnormally-shaped cells are not a characteristic of SLE and will not be included in the client teaching. D) Removal of dead cells is necessary to maintain homeostasis, and is impaired in a client with systemic lupus erythematosus (SLE). Excessive inflammation is characterized by overexpression of leukocyte adhesion molecules, not leukopenia. Removal of dead cells by phagocytosis does not cause an immune response in SLE. If dead cells are not cleared, they may leak intracellular antigens, resulting in inflammation. Abnormally-shaped cells are not a characteristic of SLE and will not be included in the client teaching. Page Ref: 286 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 11.8 Discuss the potential causes and consequences of impaired and excessive inflammation. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Relate chronic inflammation to associated disorders.

17) The nurse is caring for a group of clients with conditions involving inflammation. Which condition is most closely related to the concept of immunity? A) Asthma B) Frostbite C) Colon cancer D) Hypersensitivity reaction Answer: D Explanation: A) The client with the condition most closely related to immunity is the client with a hypersensitivity reaction. Asthma is most closely related to the concept of oxygenation Frostbite is a condition related to the concept of thermoregulation, and colon cancer is more closely related to the concept of cellular regulation. B) The client with the condition most closely related to immunity is the client with a hypersensitivity reaction. Asthma is most closely related to the concept of oxygenation Frostbite is a condition related to the concept of thermoregulation, and colon cancer is more closely related to the concept of cellular regulation. C) The client with the condition most closely related to immunity is the client with a hypersensitivity reaction. Asthma is most closely related to the concept of oxygenation Frostbite is a condition related to the concept of thermoregulation, and colon cancer is more closely related to the concept of cellular regulation. D) The client with the condition most closely related to immunity is the client with a hypersensitivity reaction. Asthma is most closely related to the concept of oxygenation Frostbite is a condition related to the concept of thermoregulation, and colon cancer is more closely related to the concept of cellular regulation. Page Ref: 286 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 11.9 Recognize key disorders in which inflammation is an important contributing factor. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Relate chronic inflammation to associated disorders.

18) A nurse is caring for a group of clients. Which clients have disorders associated with chronic inflammation? Select all that apply. A) A client with a knee replacement B) A client with osteoporosis C) A client with bacterial meningitis D) A client with major depression E) A client with advanced Alzheimer disease (AD) Answer: D, E Explanation: A) Both major depression and Alzheimer disease (AD) are associated with chronic inflammation. Other conditions associated with chronic inflammation include asthma, atherosclerosis, diabetes mellitus, and obesity. B) Both major depression and Alzheimer disease (AD) are associated with chronic inflammation. Other conditions associated with chronic inflammation include asthma, atherosclerosis, diabetes mellitus, and obesity. C) Both major depression and Alzheimer disease (AD) are associated with chronic inflammation. Other conditions associated with chronic inflammation include asthma, atherosclerosis, diabetes mellitus, and obesity. D) Both major depression and Alzheimer disease (AD) are associated with chronic inflammation. Other conditions associated with chronic inflammation include asthma, atherosclerosis, diabetes mellitus, and obesity. E) Both major depression and Alzheimer disease (AD) are associated with chronic inflammation. Other conditions associated with chronic inflammation include asthma, atherosclerosis, diabetes mellitus, and obesity. Page Ref: 287 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 11.9 Recognize key disorders in which inflammation is an important contributing factor. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Relate chronic inflammation to associated disorders.

19) The nurse is preparing to administer prednisone to a client with an inflammatory condition. Which statement by the client requires further follow up by the nurse? A) "I will elevate the affected area." B) "I can anticipate that my swelling will decrease." C) "I will take the medication to treat the cause of my inflammation." D) "Applying ice to the affected area may not be helpful." Answer: C Explanation: A) A common treatment for inflammation related to injury for many years was the RICE protocol, which consists of rest, ice, compression, and elevation (RICE). B) It is important to note that steroidal anti-inflammatory drugs such as prednisone do not treat the underlying cause of inflammation. Instead, prednisone treats the symptoms related to inflammation, such as redness, heat, swelling, and loss of function. A common treatment for inflammation related to injury for many years was the RICE protocol, which consists of Rest, Ice, Compression, and Elevation (RICE). C) It is important to note that steroidal anti-inflammatory drugs such as prednisone do not treat the underlying cause of inflammation. Instead, prednisone treats the symptoms related to inflammation, such as redness, heat, swelling, and loss of function. D) A common treatment for inflammation related to injury for many years was the RICE protocol, which consists of rest, ice, compression, and elevation (RICE). However, recent research has brought into question the effectiveness of applying ice to an injured area. Page Ref: 287 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Evaluation | Learning Outcome: 11.10 Identify primary treatments for inflammation. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Relate chronic inflammation to associated disorders.

20) The nurse is reviewing a client's list of medications. Which medications does the nurse understand to be anti-inflammatory in action? Select all that apply. A) Prednisone B) Aspirin C) Ibuprofen D) Acetaminophen E) Celecoxib Answer: A, B, C, E Explanation: A) Prednisone is a steroidal anti-inflammatory drug. B) Aspirin and ibuprofen are considered non-steroidal anti-inflammatory drugs (NSAIDs). C) Aspirin and ibuprofen are considered non-steroidal anti-inflammatory drugs (NSAIDs). D) Acetaminophen is an analgesic and antipyretic, but is not anti-inflammatory in action. E) Celecoxib is a cyclooxygenase inhibitor and is anti-inflammatory in action. Page Ref: 288 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Planning | Learning Outcome: 11.10 Identify primary treatments for inflammation. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Relate chronic inflammation to associated disorders.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 12 Neoplasia 1) The nurse is preparing to provide education to a client with a diagnosis of a malignant neoplasm. What is the nurse's understanding of the client's condition? A) This condition is life-threatening. B) In this condition, cells typically grow slowly. C) Malignant cells have minimal nuclear variation in size and shape. D) Malignant cells represent a range of ploidy statuses. Answer: D Explanation: A) A malignant neoplasm can be life threatening, but is not always so. B) Malignant cells represent a range of ploidy statuses, exhibit nuclear variation in size and shape, and involve the affected cells growing more rapidly than normal. C) Malignant cells represent a range of ploidy statuses, exhibit nuclear variation in size and shape, and involve the affected cells growing more rapidly than normal. D) Malignant cells represent a range of ploidy statuses, exhibit nuclear variation in size and shape, and involve the affected cells growing more rapidly than normal. Page Ref: 295 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 12.1 Define neoplasia and cancer, and discuss concepts related to the development of malignant tumors. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of neoplasia.

2) The nurse is educating a client who has breast cancer that has metastasized to the bone. Which statement by the client requires additional follow up by the nurse? A) "My cancer has spread from its primary site." B) "I have two different types of cancer." C) "Like all cancer, mine is the result of damaged DNA or RNA." D) "My cancer may have developed by nature, nurture, or a combination of the two." Answer: B Explanation: A) When cancer metastasizes, it spreads from its primary site to another location in the body. B) Although the cancer is located in more than one location in the case of metastatic cancer, the histology remains the same as the site of origin. C) All cancer is the result of damaged DNA or RNA by nature, nurture, or a combination of both. D) All cancer is the result of damaged DNA or RNA by nature, nurture, or a combination of both. Page Ref: 295-296 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 12.1 Define neoplasia and cancer, and discuss concepts related to the development of malignant tumors. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of neoplasia.

3) The nurse is caring for a client with leukemia who is experiencing a blast crisis. What is the nurse's understanding of the client's condition? Select all that apply. A) A blast crisis is the rapid proliferation of immature cells. B) The new cells resulting from the client's condition have distinct morphology and specialized functions. C) This condition occurs in early stage leukemias, such as chronic myelogenous leukemia. D) The most immature cells in the body are labeled as blast cells. E) The cells resulting from a blast crisis are found in the bone marrow and/or blood. Answer: A, D, E Explanation: A) A blast crisis is the rapid proliferation of blast cells in late stage leukemias such as chronic myelogenous leukemia. B) The new cells resulting from a blast crisis do not have a distinct morphology and are unable to perform specialized functions. C) A blast crisis is the rapid proliferation of blast cells in late stage leukemias such as chronic myelogenous leukemia. D) The most immature cells in the body are labeled as blast cells, and are found in the bone marrow and/or blood. E) The most immature cells in the body are labeled as blast cells, and are found in the bone marrow and/or blood. Page Ref: 299 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 12.2 Compare and contrast cell cycles for normal and malignant cells. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of neoplasia.

4) A nurse is caring for a client with a retinoblastoma. What aspect of the cell cycle does the nurse understand to be the cause of this client's condition? A) This condition occurs during cellular angiogenesis. B) This condition is a result of TP53 activation, which contributes to apoptosis. C) This condition developed during the DNA synthesis phase of the cell cycle. D) The presence of retinoblastoma protein is the cause of this condition. Answer: C Explanation: A) Angiogenesis refers to the growth of new blood vessels, and is a mechanism by which cancer can survive in the body, but is not related to the formation of retinoblastomas. B) The TP53 gene codes for the production of the p53 tumor suppressor protein, which has been called the guardian of the cell cycle, and is not the cause of retinoblastomas. C) The retinoblastoma protein is formed during the DNA synthesis phase of the cell cycle. The retinoblastoma protein is so named because if both of the alleles of the retinoblastoma gene are mutated, it results in retinoblastoma, a tumor of the retina in the eye. D) The retinoblastoma protein is formed during the DNA synthesis phase of the cell cycle. The retinoblastoma protein is so named because if both of the alleles of the retinoblastoma gene are mutated, it results in retinoblastoma, a tumor of the retina in the eye. Page Ref: 298 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 12.2 Compare and contrast cell cycles for normal and malignant cells. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of neoplasia.

5) The nurse is teaching a community course about cancer prevention. Which contributing factors to malignancy will the nurse include in the teaching? Select all that apply. A) Lifestyle factors B) Hormonal influences C) Environmental variables D) Acute inflammation E) Oxidative stress Answer: A, B, C, E Explanation: A) Environmental variables, oxidative stress, hormonal influences, lifestyle factors, and chronic inflammation (not acute inflammation) are factors that occur outside the cell and can alter the gene products (proteins) of the body's cells, and therefore change the activity and function of the cell or tissue, contributing to the initiation of cancer at the genetic level. B) Environmental variables, oxidative stress, hormonal influences, lifestyle factors, and chronic inflammation (not acute inflammation) are factors that occur outside the cell and can alter the gene products (proteins) of the body's cells, and therefore change the activity and function of the cell or tissue, contributing to the initiation of cancer at the genetic level. C) Environmental variables, oxidative stress, hormonal influences, lifestyle factors, and chronic inflammation (not acute inflammation) are factors that occur outside the cell and can alter the gene products (proteins) of the body's cells, and therefore change the activity and function of the cell or tissue, contributing to the initiation of cancer at the genetic level. D) Environmental variables, oxidative stress, hormonal influences, lifestyle factors, and chronic inflammation (not acute inflammation) are factors that occur outside the cell and can alter the gene products (proteins) of the body's cells, and therefore change the activity and function of the cell or tissue, contributing to the initiation of cancer at the genetic level. E) Environmental variables, oxidative stress, hormonal influences, lifestyle factors, and chronic inflammation (not acute inflammation) are factors that occur outside the cell and can alter the gene products (proteins) of the body's cells, and therefore change the activity and function of the cell or tissue, contributing to the initiation of cancer at the genetic level. Page Ref: 299 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 12.3 Identify how genetic factors interact to affect the molecular changes associated with a malignancy. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of neoplasia.

6) The nurse is providing education for a client diagnosed with HER2/neu positive breast cancer. What will the nurse include in the teaching about this condition? A) "HER2/neu positivity is a result of gene amplification in your condition." B) "Your children may be at a higher risk for the development of cancer." C) "Your condition is less likely to be poorly differentiated." D) "You are at greater risk for developing Burkitt lymphoma." Answer: A Explanation: A) The client's diagnosis is a result of the amplification of the HER2/neu gene in the client's breast cancer. B) The client's diagnosis is a result of the amplification of the HER2/neu gene in the client's breast cancer. HER2/neu status is not related to the heredity of the client's cancer, the grades of cellular differentiation, or the development of Burkitt lymphoma. C) The client's diagnosis is a result of the amplification of the HER2/neu gene in the client's breast cancer. HER2/neu status is not related to the heredity of the client's cancer, the grades of cellular differentiation, or the development of Burkitt lymphoma. D) The client's diagnosis is a result of the amplification of the HER2/neu gene in the client's breast cancer. HER2/neu status is not related to the heredity of the client's cancer, the grades of cellular differentiation, or the development of Burkitt lymphoma. Page Ref: 301 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 12.3 Identify how genetic factors interact to affect the molecular changes associated with a malignancy. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of neoplasia.

7) The nurse is reviewing discharge instructions with a client whose colon cancer exhibits VEGF overexpression. Which statement regarding the client's condition is true? A) Angiogenesis only occurs in VEGF overexpressing tumors. B) VEGF causes the growth of new vessels, forming a microcirculatory system. C) ATP production is inhibited by the presence of VEGF. D) VEGF positive tumor cells do not require glycolysis to generate energy for growth. Answer: B Explanation: A) Angiogenesis may occur in tumors that do not overexpress VEGF. B) Vascular endothelial growth factor (VEGF) causes the growth of new vessels, forming a microcirculatory system to and within a tumor. C) Vascular endothelial growth factor (VEGF) causes the growth of new vessels, forming a microcirculatory system to and within a tumor. The increased blood flow to the tumor increases ATP production and growth of the tumor, which requires glycolysis. D) Vascular endothelial growth factor (VEGF) causes the growth of new vessels, forming a microcirculatory system to and within a tumor. The increased blood flow to the tumor increases ATP production and growth of the tumor, which requires glycolysis. Page Ref: 303 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 12.4 Explain the multistep process of carcinogenesis, incorporating angiogenesis, mechanisms of altered cellular differentiation, and cancer growth rates. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: . IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of neoplasia.

8) The nurse preceptor on a cancer ward is educating a novice nurse about the theory of carcinogenesis. Which statements by the novice nurse requires additional follow up by the nurse preceptor? A) "During step 2, promotion, a cancer-causing agent damages DNA." B) "Vitamins may modify how carcinogens can affect my body's cells." C) "Step 3, progression, involves the accumulation of mutations in my body's cells." D) "Promoters are characterized by their ability to initiate carcinogenesis." Answer: A Explanation: A) The first step of carcinogenesis, initiation, is when a cancer-causing agent damages cellular DNA. B) Vitamins may modify how carcinogens can affect the body's cells. C) Step 3 of carcinogenesis, progression, involves the accumulation of mutations in the body's cells. D) Promoters are substances with the ability to initiate carcinogenesis both after cells are exposed to an initiating factor, or can be initiating factors in and of themselves. Page Ref: 305 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 12.4 Explain the multistep process of carcinogenesis, incorporating angiogenesis, mechanisms of altered cellular differentiation, and cancer growth rates. | QSEN Competencies: II. B. 9 Communicate with team members, adapting own style of communicating to needs of the team and situation | AACN Essential Competencies: I.9 Value the ideal of lifelong learning to support excellence in nursing practice NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of neoplasia.

9) A nurse is caring for a client with non-small cell lung cancer (NSCLC) that has metastasized to the brain. What changes in the client's cells have occurred to allow metastasis? Select all that apply. A) Alterations in lectin binding allow cancer cells to avoid sticking to leukocytes and platelets. B) Human leukocyte antigen (HLA) may be present, allowing malignant cells to escape detection by the immune system. C) The cytoskeleton loses rigidity, making cells more amenable to proliferation. D) Further growth is inhibited at the primary site, encouraging cells to spread to other sites in the body. E) Altered cytoskeletal control leads to the loss of internal and external cellular functions. Answer: C, E Explanation: A) Changes occurring in cancer cells that allow the cells to metastasize include alterations in lectin binding, which allow cancer cells to stick to leukocytes and platelets to avoid detection by the immune system. B) Human leukocyte antigen (HLA) may be absent, which is another means by which malignant cells escape detection by the immune system. C) The cytoskeleton loses rigidity, making cancer cells more amenable to proliferation. D) Further growth becomes possible at the primary site, and malignant cells are more able to spread to other sites in the body. E) Altered cytoskeletal control leads to the loss of internal and external cellular functions. Page Ref: 306 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 12.5 Analyze how the mechanisms of cancer invasion and metastasis affect the patterns of spread of cancer cells. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of neoplasia.

10) The nurse is caring for a client with a diagnosis of metastatic cancer with a pathogenic bone fracture. The nurse understands that this condition occurs by which mechanism? A) Increased osteoblastic growth factors (ObGFs) results in a fragile bony structure. B) Increased osteoclast activating factors (OcAFs) result in increased pressure in the bone, resulting in pathogenic fracture. C) Pathogenic fractures occur by either increased pressure in the bone, or breakdown of the bony matrix. D) Pathogenic fractures occur due to the breakdown of the bone network and loss of the bony matrix. Answer: C Explanation: A) The same type of cancer can cause pathogenic fractures by different mechanisms. The two mechanisms by which pathogenic fractures occur involve increased osteoblastic growth factors (ObGFs) resulting in increased pressure in the bone, and increased osteoclast activating factors (OcAFs) resulting in loss of bony matrix and a fragile bone structure. B) The same type of cancer can cause pathogenic fractures by different mechanisms. The two mechanisms by which pathogenic fractures occur involve increased osteoblastic growth factors (ObGFs) resulting in increased pressure in the bone, and increased osteoclast activating factors (OcAFs) resulting in loss of bony matrix and a fragile bone structure. C) The same type of cancer can cause pathogenic fractures by different mechanisms. The two mechanisms by which pathogenic fractures occur involve increased osteoblastic growth factors (ObGFs) resulting in increased pressure in the bone, and increased osteoclast activating factors (OcAFs) resulting in loss of bony matrix and a fragile bone structure. D) The same type of cancer can cause pathogenic fractures by different mechanisms. The two mechanisms by which pathogenic fractures occur involve increased osteoblastic growth factors (ObGFs) resulting in increased pressure in the bone, and increased osteoclast activating factors (OcAFs) resulting in loss of bony matrix and a fragile bone structure. Page Ref: 307 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 12.5 Analyze how the mechanisms of cancer invasion and metastasis affect the patterns of spread of cancer cells. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of neoplasia.

11) The nurse is teaching a community health class about the epidemiology of cancer. Which statement should the nurse include in the teaching? A) "Cancer is the leading cause of death in developing countries." B) "Racial disparities in cancer incidence are affected by healthcare accessibility." C) "Because of intensive antismoking campaigns, lung cancer no longer has the highest death rate among cancers." D) "Brain tumors are the least commonly diagnosed malignancies in children." Answer: B Explanation: A) Cancer remains the leading cause of death in developed countries, with lung cancer having the highest death rate among cancer diagnoses despite intensive antismoking campaigns. B) Racial disparities in cancer incidence exist due to limited healthcare accessibility in minority groups. C) Cancer remains the leading cause of death in developed countries, with lung cancer having the highest death rate among cancer diagnoses despite intensive antismoking campaigns. D) Brain tumors are the second most diagnosed malignancies in children. Page Ref: 308 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 12.6 Determine the epidemiology of cancer and how factors such as age, gender, race/ethnicity, and the effect of geographic location affect the incidence of different cancers. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and selfcare management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of neoplasia.

12) The nurse is preparing to administer a human papilloma virus (HPV) vaccine to a client. What does the nurse understand about infections and cancer incidence? A) The HPV vaccine is effective for preventing all types of HPV infections. B) HPV vaccination is effective for the treatment of cervical cancer. C) Many of the leading cancers in the world are due to infections like HPV. D) Screening for cervical cancer is no longer necessary after receiving the HPV vaccine. Answer: C Explanation: A) HPV vaccination is 70% effective for the prevention of cervical cancer, and is effective for preventing HPV types 16 and 18, but not types 6 and 11. Because the vaccine does not provide complete immunity to all types of HPV, screening for cervical cancer remains important after receiving the HPV vaccine. B) HPV vaccination is 70% effective for the prevention of cervical cancer, and is effective for preventing HPV types 16 and 18, but not types 6 and 11. Because the vaccine does not provide complete immunity to all types of HPV, screening for cervical cancer remains important after receiving the HPV vaccine. Many of the leading cancers in the world are due to infections like HPV. HPV vaccination is not considered a treatment for cervical cancer. C) Many of the leading cancers in the world are due to infections like HPV. D) Because the vaccine does not provide complete immunity to all types of HPV, screening for cervical cancer remains important after receiving the HPV vaccine. Page Ref: 308 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 12.6 Determine the epidemiology of cancer and how factors such as age, gender, race/ethnicity, and the effect of geographic location affect the incidence of different cancers. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and selfcare management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of neoplasia.

13) The nurse is assessing a client for signs and symptoms of cancer. Which assessment findings does the nurse understand may indicate the presence of cancer? Select all that apply. A) A change in bowel or bladder habits B) Abdominal pain C) Thickening or a lump in any part of the body D) The recent development of a fever E) An obvious change in a mole Answer: A, C, E Explanation: A) The American Cancer Society developed the acronym CAUTION to assist the public in remembering common signs and symptoms of cancer. These include a Change in bowel or bladder habits, A sore that does not heal, Unusual bleeding or discharge, Thickening or lump in the breast or any part of the body, Indigestion or difficulty swallowing, Obvious change in a mole, and/or Nagging cough or hoarseness. A common misconception is that cancer will be painful, and therefore obvious to patients and healthcare providers. B) A common misconception is that a cancer will be painful, and therefore obvious to patients and healthcare providers. C) The American Cancer Society developed the acronym CAUTION to assist the public in remembering common signs and symptoms of cancer. These include a Change in bowel or bladder habits, A sore that does not heal, Unusual bleeding or discharge, Thickening or lump in the breast or any part of the body, Indigestion or difficulty swallowing, Obvious change in a mole, and/or Nagging cough or hoarseness. D) A recent development of a fever is not a sign of cancer. E) The American Cancer Society developed the acronym CAUTION to assist the public in remembering common signs and symptoms of cancer These include a Change in bowel or bladder habits, A sore that does not heal, Unusual bleeding or discharge, Thickening or lump in the breast or any part of the body, Indigestion or difficulty swallowing, Obvious change in a mole, and/or Nagging cough or hoarseness. Page Ref: 311 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 12.7 Identify clinical manifestations commonly associated with different forms of cancer. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of neoplasia.

14) The nurse is assessing a client diagnosed with an early stage malignancy. What does the nurse understand about the local effects of cancer? A) A new lump or tissue thickening will determine the extent of the cancer. B) Lymphadenopathy means the cancer is progressing. C) A growing tumor is not likely to exert pressure on the surrounding tissue. D) Assessment findings are likely to be linked to the tissue source of the tumor. Answer: D Explanation: A) The extent of a malignancy is determined by a combination of radiographic and pathologic testing to determine the cancer's stage. B) Lymphadenopathy may or may not mean that the cancer is progressing, and could be due to another cause. C) Assessment findings in an early stage malignancy are most likely to be linked to the tissue A growing tumor is likely to exert pressure on the surrounding tissue, which results in the associated assessment findings. D) Assessment findings in an early stage malignancy are most likely to be linked to the tissue source of the tumor. Page Ref: 312 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 12.7 Identify clinical manifestations commonly associated with different forms of cancer. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of neoplasia.

15) The oncology nurse is preparing to administer pembrolizumab, a targeted cancer treatment, to a client with non-small cell lung cancer (NSCLC). What is the nurse's understanding of targeted cancer treatment? A) Targeted therapy has a higher degree of toxicity than standard chemotherapy. B) In targeted therapy, a normal gene is inserted to replace an abnormal gene. C) Targeted therapy is only available through clinical trials. D) Targeted therapy is known as personalized medicine. Answer: D Explanation: A) Targeted therapy is also referred to as personalized medicine. Several targeted therapies are currently approved by the FDA for the treatment of cancer. Targeted therapies inhibit or block a receptor or pathway involved in the mechanism by which the cancer grows and spreads, which is distinct from gene therapy, in which a normal gene is inserted to replace an abnormal gene. Gene therapy is currently only available through clinical trials. Targeted therapy is, at times, preferred over standard chemotherapy because it is associated with a lower degree of toxicity. B) Targeted therapy is also referred to as personalized medicine. Several targeted therapies are currently approved by the FDA for the treatment of cancer. Targeted therapies inhibit or block a receptor or pathway involved in the mechanism by which the cancer grows and spreads, which is distinct from gene therapy, in which a normal gene is inserted to replace an abnormal gene. C) Targeted therapy is also referred to as personalized medicine. Several targeted therapies are currently approved by the FDA for the treatment of cancer. Gene therapy is currently only available through clinical trials. D) Targeted therapy is also referred to as personalized medicine. Targeted therapies inhibit or block a receptor or pathway involved in the mechanism by which the cancer grows and spreads Page Ref: 317 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Planning | Learning Outcome: 12.8 Explain the link between the pathophysiology of cancer and the different treatment modalities across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of neoplasia.

16) The nurse is providing education to a client about to undergo an allogeneic hematopoietic stem cell transplant (HSCT). What statement by the client indicates the need for additional follow up by the nurse? A) "I can expect a full recovery with a low risk for complications." B) "I will require radiation treatment to my brain, since most chemo doesn't cross the blood-brain barrier." C) "I will receive multiple types of cancer treatment to promote a better outcome." D) "I have discussed all of my concerns related to fertility and sexuality." Answer: A Explanation: A) Allogeneic hematopoietic stem cell transplantation (HSCT) is a cancer treatment that utilizes multiple cancer treatment modalities to promote better outcomes for clients, including radiation to the brain. Multiple early and long-term complications can occur with HSCT including nausea, vomiting, diarrhea mucositis, myelosuppression, liver and renal toxicity, and graft-versus-host disease (GVHD). B) Allogeneic hematopoietic stem cell transplantation (HSCT) is a cancer treatment that utilizes multiple cancer treatment modalities to promote better outcomes for clients, including radiation to the brain. C) Allogeneic hematopoietic stem cell transplantation (HSCT) is a cancer treatment that utilizes multiple cancer treatment modalities to promote better outcomes for clients, including radiation to the brain. D) It is important for patients to discuss concerns related to fertility and sexuality prior to beginning treatment, as these may be affected by treatment. Page Ref: 318 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 12.8 Explain the link between the pathophysiology of cancer and the different treatment modalities across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of neoplasia.

17) The nurse is providing education for a client diagnosed with an adenoma. Which statement by the client requires further follow up by the nurse? A) "This is a well-differentiated neoplasm." B) "This is a malignancy of the mesenchymal tissue." C) "This means that the affected cells were encapsulated." D) "This is a slow-growing condition." Answer: B Explanation: A) An adenoma is a benign, well-differentiated, slow-growing neoplasm in which the affected cells remain encapsulated. B) This response is wrong because an adenoma is benign, not malignant. C) An adenoma is a benign, well-differentiated, slow-growing neoplasm in which the affected cells remain encapsulated. D) An adenoma is a benign, well-differentiated, slow-growing neoplasm in which the affected cells remain encapsulated. Page Ref: 295 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 12.1 Define neoplasia and cancer, and discuss concepts related to the development of malignant tumors. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of neoplasia.

18) The nurse is caring for a client recently discovered to have grade 2 colon cancer. Which statement by the client is consistent with the client's continuum of care? A) "I am in the middle of cancer treatment." B) "I am due for a survivorship follow up visit." C) "I have just completed chemoradiation therapy." D) "I am still discussing my diagnosis with my providers." Answer: D Explanation: A) Grading of differentiation is important to determine prior to cancer treatment. B) Grading of differentiation is important to determine prior to cancer treatment. C) Grading of differentiation is important to determine prior to cancer treatment. D) Cancer grade involves a histological analysis of cancer cells and, in the continuum of care, typically occurs while diagnosis discussions are taking place. Grading of differentiation is important to determine prior to cancer treatment. Page Ref: 299 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 12.2 Compare and contrast cell cycles for normal and malignant cells. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of neoplasia.

19) The nurse is reviewing laboratory results for a patient who is BRCA1 and BRCA2 positive. The nurse understands that the client and the client's immediate family may be at increased riskfor which malignancies? Select all that apply. A) Prostate B) Multiple Myeloma C) Ovarian D) Pancreatic E) Melanoma Answer: A, C, D, E Explanation: A) BRCA1 and BRCA2 are genes associated with inherited breast, ovarian, pancreatic, prostate, and melanoma cancers, but not multiple myeloma. B) BRCA1 and BRCA2 are genes associated with inherited breast, ovarian, pancreatic, prostate, and melanoma cancers, but not multiple myeloma. C) BRCA1 and BRCA2 are genes associated with inherited breast, ovarian, pancreatic, prostate, and melanoma cancers, but not multiple myeloma. D) BRCA1 and BRCA2 are genes associated with inherited breast, ovarian, pancreatic, prostate, and melanoma cancers, but not multiple myeloma. E) BRCA1 and BRCA2 are genes associated with inherited breast, ovarian, pancreatic, prostate, and melanoma cancers, but not multiple myeloma. Page Ref: 300 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 12.3 Identify how genetic factors interact to affect the molecular changes associated with a malignancy. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of neoplasia.

20) The nurse is caring for a client with T1N0MX cancer. What is the nurse's understanding of the client's cancer staging? Select all that apply. A) The client has no regional lymph node spread. B) The client has carcinoma in situ. C) The client's primary tumor cannot be evaluated. D) The client has innumerable distant metastases. E) The client has not been evaluated for distant metastases. Answer: A, E Explanation: A) N0 indicates no regional lymph node involvement. B) Carcinoma in situ is designated as Tis. C) According to the AJCC Cancer Staging Manual, T1-4 determines the size and/or extent of the primary tumor. A primary tumor that cannot be evaluated is designated as TX. D) MX indicates that evaluation for distant metastasis has not occurred. E) MX indicates that evaluation for distant metastasis has not occurred. Page Ref: 314 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 12.8 Explain the link between the pathophysiology of cancer and the different treatment modalities across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of neoplasia.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 13 Mechanisms of Infection and Host Protection 1) When planning a program to discuss the problem of antibiotic drug resistance in the community, the nurse should include which of the following directions? A) Avoid the use of antibiotics unless they are necessary. B) Take antibiotics only until the symptoms are gone. C) Treat influenza immediately with antibiotics. D) Take antibiotics immediately if you are feeling ill. Answer: A Explanation: A) Overuse of antimicrobials has contributed significantly to this resistance by selectively pressuring microorganisms to mutate in order to evade the lethal consequences of these drugs. B) A full course of antibiotics should be taken as prescribed, even if the symptoms have subsided. C) Viral infections should not be treated with antibiotics. D) Antibiotics should only be taken at the direction of a healthcare professional. Page Ref: 328 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 13.1 Identify factors that increase the global threat of infectious disease and explain concepts related to infection, such as immunity, inflammation, tissue integrity, environment, thermoregulation, perfusion, and oxygenation. | QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Consider the various components involved in the infectious process that lead to disease.

2) While monitoring community health trends, the public health nurse notes an emerging infectious disease. What condition would alert the nurse to such an occurrence? A) The disease occurs cyclically within a population. B) The disease is newly identified within a population. C) The disease is regularly seen in a geographic area. D) The disease occurs sporadically and has occurred before in a geographic area. Answer: B Explanation: A) An emerging infectious disease is one that is newly identified in a population or a disease that has significantly increased in incidence or geographic range. B) An emerging infectious disease is one that is newly identified in a population or a disease that has significantly increased in incidence or geographic range. C) An emerging infectious disease is one that is newly identified in a population or a disease that has significantly increased in incidence or geographic range. D) An emerging infectious disease is one that is newly identified in a population or a disease that has significantly increased in incidence or geographic range. Page Ref: 327 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 13.1 Identify factors that increase the global threat of infectious disease and explain concepts related to infection, such as immunity, inflammation, tissue integrity, environment, thermoregulation, perfusion, and oxygenation. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Consider the various components involved in the infectious process that lead to disease.

3) The staff development nurse at the hospital is teaching other nurses about the infectious process. Which statement by a nurse in the class indicates that this class participant needs further teaching about the concept of commensal microorganisms? A) "A commensal microorganism is normal flora." B) "These microorganisms can cause disease if they enter sterile tissues of the body." C) "A commensal microorganism is always damaging to the host." D) "A commensal microorganism derives benefits from the host." Answer: C Explanation: A) Commensal microorganisms make up the commensal flora or normal flora or, as they have more recently been termed, the normal microbiota of the host. B) Many of these microorganisms can cause disease if they enter the sterile organs or tissues of the body. C) Commensal microorganisms not only derive benefit from the host but also confer benefit to the host. D) Commensal microorganisms not only derive benefit from the host but also confer benefit to the host. Page Ref: 330 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 13.2 Explain the mutual beneficial relationship between the human host and commensal microorganisms. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Consider the various components involved in the infectious process that lead to disease.

4) Which strategy in the plan of care for a mechanically ventilated critically ill patient has the highest priority to reduce the risk of ventilator-associated pneumonia? A) Suction frequently. B) Provide mouth care. C) Turn and position. D) Administer antibiotics intravenously. Answer: B Explanation: A) While the patient may need to be suctioned, this intervention does not reduce the risk of ventilator-associated pneumonia. B) Research suggests that implementation of a standardized oral hygiene protocol using a toothbrush for mechanical cleaning of the teeth may significantly reduce the colonization of dental plaque with respiratory pathogens. C) All critically ill patients need to turned and positioned, but this intervention does not reduce the risk of ventilator-associated pneumonia D) Antibiotics may be needed in a critically ill patient, but this intervention does not reduce the risk of ventilator-associated pneumonia Page Ref: 331 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 13.2 Explain the mutual beneficial relationship between the human host and commensal microorganisms. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Consider the various components involved in the infectious process that lead to disease.

5) When teaching a patient about ways to prevent West Nile disease, the nurse should tell the patient to avoid which vector? A) Deer ticks B) Mosquitoes C) Cats D) Dogs Answer: B Explanation: A) Vectors are living intermediaries that convey an infectious agent from its reservoir to a susceptible host. Lyme disease is transmitted by the bite of the deer tick. B) Vectors are living intermediaries that convey an infectious agent from its reservoir to a susceptible host. West Nile disease and some forms of meningitis are transmitted by mosquitoes. C) Vectors are living intermediaries that convey an infectious agent from its reservoir to a susceptible host. Cats can spread toxoplasmosis, which can be very dangerous to pregnant women. D) Vectors are living intermediaries that convey an infectious agent from its reservoir to a susceptible host. Bites from dogs transmit diseases such as rabies. Page Ref: 331 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 13.3 Describe the series of events that allow a microbial pathogen to exit an environmental reservoir and to produce infectious disease in humans, and list examples of microbial virulence factors. | QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Examine the various bacterial and parasitic agents and their role in the pathogenesis of human diseases.

6) The school nurse is teaching parents of school-age children ways to avoid transmitting disease. Which portal of entry is involved in spreading disease by direct entry? A) Ingesting infected food B) Inhaling droplets from an infected person C) Sharing needles D) Entering through a wound in the skin Answer: D Explanation: A) Enteric pathogens enter the host by ingestion of contaminated food. Certain foods are more suitable for microbial growth, and under appropriate environmental conditions, this growth is nourished. Common cases of food poisoning occur in this manner when pathogens such as Salmonella or Escherichia coli are transmitted from eating undercooked eggs or meats or contaminated fruits or vegetables. Other bacteria, such as Clostridia botulinum, grow best in anaerobic acidic foods. B) Respiratory pathogens are commonly transmitted from droplets of fluid that are released into the environment by an infected person during activities such talking, coughing, spitting, sneezing, or even singing. The infectious agents in these droplets enter the body of another person through the eyes, nose, or mouth. C) When needles are shared, such as in IV drug use, pathogens can be injected into the bloodstream. D) Direct entry of a pathogen may occur when a wound becomes contaminated, such as with soil containing the spores of Clostridium tetani (which causes tetanus). Page Ref: 331 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 13.3 Describe the series of events that allow a microbial pathogen to exit an environmental reservoir and to produce infectious disease in humans, and list examples of microbial virulence factors. | QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Examine the various bacterial and parasitic agents and their role in the pathogenesis of human diseases.

7) When assessing a female patient with toxic shock syndrome, the nurse may suspect that the patient has recently: A) used hyperabsorbent tampons while menstruating. B) traveled to the Southwest of the United States. C) experienced a tick bite. D) eaten contaminated food. Answer: A Explanation: A) Toxic shock syndrome is linked to the use of hyperabsorbent tampons in menstruating women. B) Toxic shock syndrome is linked to the use of hyperabsorbent tampons in menstruating women. C) Toxic shock syndrome is linked to the use of hyperabsorbent tampons in menstruating women. D) Toxic shock syndrome is linked to the use of hyperabsorbent tampons in menstruating women. Page Ref: 336 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 13.3 Describe the series of events that allow a microbial pathogen to exit an environmental reservoir and to produce infectious disease in humans, and list examples of microbial virulence factors. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Consider the various components involved in the infectious process that lead to disease.

8) Which information should be included in the teaching care plan for a patient with tuberculosis (TB) in order to reduce the transmission of the disease? A) TB is spread through sexual contact. B) Transmission occurs from sharing utensils of a person with TB. C) TB is transmitted by inhaling droplets from a person with TB. D) TB can spread through breaks in the skin. Answer: C Explanation: A) The tubercle bacilli are spread from person to person by droplet nuclei released into the environment when an infected person coughs, sneezes, speaks, or sings. They are not spread through sexual contact, sharing utensils, or through breaks in the skin. B) The tubercle bacilli are spread from person to person by droplet nuclei released into the environment when an infected person coughs, sneezes, speaks, or sings. They are not spread through sexual contact, sharing utensils, or through breaks in the skin. C) The tubercle bacilli are spread from person to person by droplet nuclei released into the environment when an infected person coughs, sneezes, speaks, or sings. They are not spread through sexual contact, sharing utensils, or through breaks in the skin. D) The tubercle bacilli are spread from person to person by droplet nuclei released into the environment when an infected person coughs, sneezes, speaks, or sings. They are not spread through sexual contact, sharing utensils, or through breaks in the skin. Page Ref: 338 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Planning | Learning Outcome: 13.4 Contrast the characteristic features of bacteria, viruses, fungi, prions, protozoa, and helminths, and explain the steps of viral invasion and replication within a human host cell. | QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and wellbeing, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Examine the various bacterial and parasitic agents and their role in the pathogenesis of human diseases.

9) Which finding would the nurse expect in a patient with Salmonellosis? A) Recent ingestion of contaminated water B) Symptoms of gastroenteritis C) Symptoms lasting for 7 to 10 days D) Manifestations of systemic disease Answer: B Explanation: A) Salmonellosis is transmitted by contaminated food such as poultry and eggs. B) Salmonellosis usually presents as a gastroenteritis (nausea, vomiting, and nonbloody stools). C) The disease is usually self-limiting and lasts 2-5 days. D) In uncomplicated infection, which is the most common type, the microorganisms only invade the epithelium and do not produce systemic infection. Page Ref: 339 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 13.4 Contrast the characteristic features of bacteria, viruses, fungi, prions, protozoa, and helminths, and explain the steps of viral invasion and replication within a human host cell. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Examine the various bacterial and parasitic agents and their role in the pathogenesis of human diseases.

10) A patient is being seen in the clinic for vaccinations and medical advice prior to traveling to an underdeveloped nation for volunteer work. Which patient statement indicates that further teaching is needed regarding the transmission of typhus? A) "The disease may be transmitted by touching an infected object." B) "The disease may be transmitted through humans." C) "I should avoid drinking the water if sanitary conditions are poor." D) "I can get typhus from contaminated food." Answer: A Explanation: A) The microorganism is transmitted from a human reservoir, in the water supply (if sanitary conditions are poor), or in contaminated food. Touching an infected object does not transmit the disease, unless ingested. B) The microorganism is transmitted from a human reservoir, in the water supply (if sanitary conditions are poor), or in contaminated food. C) The microorganism is transmitted from a human reservoir, in the water supply (if sanitary conditions are poor), or in contaminated food. D) The microorganism is transmitted from a human reservoir, in the water supply (if sanitary conditions are poor), or in contaminated food. Page Ref: 339 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Evaluation | Learning Outcome: 13.4 Contrast the characteristic features of bacteria, viruses, fungi, prions, protozoa, and helminths, and explain the steps of viral invasion and replication within a human host cell. | QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and wellbeing, and self-care management | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Examine the various bacterial and parasitic agents and their role in the pathogenesis of human diseases.

11) Which statement indicates that a nurse's teaching to parents about childhood pneumococcal vaccination has been understood? A) "For children older than 15 months who have not received the vaccine, the vaccine is no longer recommended." B) "The final dose should be administered between 2 and 3 years of age." C) "The series of vaccinations starts at 6 months." D) "This is a series of four vaccinations." Answer: D Explanation: A) For children, a pneumococcal vaccine is recommended for administration in a series of four doses beginning at the age of 2 months, with the final dose administered between 12 and 15 months of age. If the child has not received the vaccine by age 15 months, it is still recommended. B) For children, a pneumococcal vaccine is recommended for administration in a series of four doses beginning at the age of 2 months, with the final dose administered between 12 and 15 months of age. If the child has not received the vaccine by age 15 months, it is still recommended. C) For children, a pneumococcal vaccine is recommended for administration in a series of four doses beginning at the age of 2 months, with the final dose administered between 12 and 15 months of age. If the child has not received the vaccine by age 15 months, it is still recommended. D) For children, a pneumococcal vaccine is recommended for administration in a series of four doses beginning at the age of 2 months, with the final dose administered between 12 and 15 months of age. If the child has not received the vaccine by age 15 months, it is still recommended. Page Ref: 342 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Evaluation | Learning Outcome: 13.4 Contrast the characteristic features of bacteria, viruses, fungi, prions, protozoa, and helminths, and explain the steps of viral invasion and replication within a human host cell. | QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and wellbeing, and self-care management | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Examine the various bacterial and parasitic agents and their role in the pathogenesis of human diseases.

12) The nurse should expect to observe which findings in a patient during the incubation period of a viral infection? A) A lack of symptoms B) Nonspecific symptoms such as lethargy, fever, and headache C) Specific symptoms associated with the virus D) Local symptoms Answer: A Explanation: A) The asymptomatic period of viral infection is also called the incubation period. Many viral infections are first manifested by a prodrome, which consists of nonspecific symptoms such as lethargy, headache, and fever. The incubation period is not marked by specific symptoms of the virus or local symptoms. B) The asymptomatic period of viral infection is also called the incubation period. Many viral infections are first manifested by a prodrome, which consists of nonspecific symptoms such as lethargy, headache, and fever. The incubation period is not marked by specific symptoms of the virus or local symptoms. C) The asymptomatic period of viral infection is also called the incubation period. Many viral infections are first manifested by a prodrome, which consists of nonspecific symptoms such as lethargy, headache, and fever. The incubation period is not marked by specific symptoms of the virus or local symptoms. D) The asymptomatic period of viral infection is also called the incubation period. Many viral infections are first manifested by a prodrome, which consists of nonspecific symptoms such as lethargy, headache, and fever. The incubation period is not marked by specific symptoms of the virus or local symptoms. Page Ref: 345 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 13.4 Contrast the characteristic features of bacteria, viruses, fungi, prions, protozoa, and helminths, and explain the steps of viral invasion and replication within a human host cell. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Examine viral agents and their role in the pathogenesis of human diseases.

13) Which patients in a community clinic would the nurse recommend receive the human papillomavirus (HPV) vaccine? A) Women younger than 30 years of age B) Healthy men younger than 25 years of age C) Any male who has sex with men D) Children starting at 13 and 14 years of age Answer: C Explanation: A) The HPV vaccine series is recommended for all children at 11 or 12 years of age. The vaccine is recommended for women who are younger than 27 years old and for men who are younger than 21 years old, including any male who has sex with men. The HPV vaccine also is recommended for young males who are immunocompromised (including those who have HIV or AIDS) through age 26 years if previous vaccination has not been completed, and teenage males and females who have not previously received the vaccine. B) The HPV vaccine series is recommended for all children at 11 or 12 years of age. The vaccine is recommended for women who are younger than 27 years old and for men who are younger than 21 years old, including any male who has sex with men. The HPV vaccine also is recommended for young males who are immunocompromised (including those who have HIV or AIDS) through age 26 years if previous vaccination has not been completed, and teenage males and females who have not previously received the vaccine. C) The HPV vaccine series is recommended for all children at 11 or 12 years of age. The vaccine is recommended for women who are younger than 27 years old and for men who are younger than 21 years old, including any male who has sex with men. The HPV vaccine also is recommended for young males who are immunocompromised (including those who have HIV or AIDS) through age 26 years if previous vaccination has not been completed, and teenage males and females who have not previously received the vaccine. D) The HPV vaccine series is recommended for all children at 11 or 12 years of age. The vaccine is recommended for women who are younger than 27 years old and for men who are younger than 21 years old, including any male who has sex with men. The HPV vaccine also is recommended for young males who are immunocompromised (including those who have HIV or AIDS) through age 26 years if previous vaccination has not been completed, and teenage males and females who have not previously received the vaccine. Page Ref: 346 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 13.4 Contrast the characteristic features of bacteria, viruses, fungi, prions, protozoa, and helminths, and explain the steps of viral invasion and replication within a human host cell. | QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and wellbeing, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, costeffectiveness and equity NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Examine viral agents and their role in the pathogenesis of human diseases. 13

14) The nurse is teaching a prenatal class about newborn immunity. Which statement by a participant requires further teaching? A) "Newborns obtain passive immunity from the mother." B) "Newborns obtain active immunity across the placenta." C) "Only antibody to infections to which the mother has been exposed will transfer to the newborn." D) "Maternal antibody provides temporary immunity to the newborn." Answer: B Explanation: A) Passive immunity occurs when maternal preformed antibody is transferred across the placenta to the developing fetus. Only antibody to infectious agents to which the mother has previously been exposed will be transferred. Maternal antibody provides temporary, albeit limited, immune defense during the early newborn period. B) Active immunity develops as a result of activation of the host's own immune system through natural or artificial means. Natural immunity occurs when an individual experiences an infectious disease naturally. Active immunity may also be induced artificially with vaccination with dead or attenuated (weakened) infectious agent or its components. C) Passive immunity occurs when maternal preformed antibody is transferred across the placenta to the developing fetus. Only antibody to infectious agents to which the mother has previously been exposed will be transferred. Maternal antibody provides temporary, albeit limited, immune defense during the early newborn period. D) Passive immunity occurs when maternal preformed antibody is transferred across the placenta to the developing fetus. Only antibody to infectious agents to which the mother has previously been exposed will be transferred. Maternal antibody provides temporary, albeit limited, immune defense during the early newborn period. Page Ref: 355 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Evaluation | Learning Outcome: 13.9 Explain the difference between passive and active immunity and describe how vaccination provides immunity to infectious agents. | QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider how the various mechanisms of the immune system and vaccines protect from disease.

15) A patient is concerned about getting hepatitis A from the hepatitis A vaccine. To allay this concern, the nurse explains that: A) the pathogen is treated with a chemical so it cannot reproduce and cause illness. B) the pathogen is grown under conditions that make is less virulent. C) the vaccine contains purified antigens rather than whole organisms. D) toxins are treated with chemicals to remove toxic components. Answer: A Explanation: A) Hepatitis A vaccine is an inactivated (killed) vaccine in which the pathogen is treated with a chemical so it no longer can reproduce and cause illness. B) In a weakened vaccine, the pathogen is grown under conditions that make it less virulent, such as the measles, mumps, and rubella vaccine. C) A subunit vaccine contains purified antigens rather than whole organisms, such as the hepatitis B vaccine. D) In toxoid vaccines, toxins are treated with chemical to remove toxic components yet retain antigenicity. Page Ref: 356 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 13.9 Explain the difference between passive and active immunity and describe how vaccination provides immunity to infectious agents. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider how the various mechanisms of the immune system and vaccines protect from disease.

16) The nurse has just received his assignment of four patients for the shift. The nurse notes that which of the following patients has a healthcare-acquired infection (HAI)? A) A patient admitted from home with influenza B) A nursing home resident admitted with pneumonia C) A student admitted with measles contracted in college D) A patient admitted from home, via ambulance, with HIV Answer: B Explanation: A) HAIs are infections that develop as a result of being treated in a healthcare facility such as a hospital, outpatient clinic or surgical center, rehabilitation center, or nursing home. This patient was admitted from home and, thus, has a community-acquired infection. B) HAIs are infections that develop as a result of being treated in a healthcare facility such as a hospital, outpatient clinic or surgical center, rehabilitation center, or nursing home. This patient was admitted from a nursing home and, thus, has an HAI. C) HAIs are infections that develop as a result of being treated in a healthcare facility such as a hospital, outpatient clinic or surgical center, rehabilitation center, or nursing home. This patient was admitted from college and, thus, has a community-acquired infection. D) HAIs are infections that develop as a result of being treated in a healthcare facility such as a hospital, outpatient clinic or surgical center, rehabilitation center, or nursing home. This patient was admitted from home and, thus, has a community-acquired infection. Page Ref: 330 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Assessment | Learning Outcome: 13.2 Explain the mutual beneficial relationship between the human host and commensal microorganisms. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Consider the various components involved in the infectious process that lead to disease.

17) The nurse who removes an indwelling catheter is preventing infection by interrupting which link in the chain of infection? A) Portal of entry B) Infectious agent C) Portal of exit D) Reservoir Answer: A Explanation: A) The means by which a pathogen enters the host is called the portal of entry. By removing the indwelling urinary catheter, the portal of entry of pathogens into the bladder has been removed. B) Infectious agents cause disease and include bacteria, viruses, fungi, prions, protozoa, and helminths. C) The portal of exit is how a pathogen exits a reservoir, such as by coughing or sneezing. D) To transmit disease, a pathogen must leave its reservoir or host through a port of exit and must be conveyed by a mode of transmission to a susceptible host through a portal of entry. Page Ref: 331 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Implementation | Learning Outcome: 13.3 Describe the series of events that allow a microbial pathogen to exit an environmental reservoir and to produce infectious disease in humans, and list examples of microbial virulence factors. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Consider the various components involved in the infectious process that lead to disease.

18) The public health nurse is educating the public at a health fair about Ebola virus. Which statement by an audience member indicates that more teaching is needed? A) "The virus is spread through contact with bodily fluids." B) "The virus is only spread through sharing contaminated needles." C) "The virus can be transmitted by direct contact with contaminated objects." D) "The virus can be transmitted through inhalation of droplets." Answer: B Explanation: A) Ebola virus can spread via direct contact with infected body fluids, including saliva, urine, feces, sweat, semen, breast milk, and vomit. Portals of entry include skin and mucous membranes. Transmission of Ebola virus may also occur by way of contact with contaminated materials, objects, and surfaces. B) Ebola virus can spread via direct contact with infected body fluids, including saliva, urine, feces, sweat, semen, breast milk, and vomit. Portals of entry include skin and mucous membranes. Transmission of Ebola virus may also occur by way of contact with contaminated materials, objects, and surfaces. C) Ebola virus can spread via direct contact with infected body fluids, including saliva, urine, feces, sweat, semen, breast milk, and vomit. Portals of entry include skin and mucous membranes. Transmission of Ebola virus may also occur by way of contact with contaminated materials, objects, and surfaces. D) Ebola virus can spread via direct contact with infected body fluids, including saliva, urine, feces, sweat, semen, breast milk, and vomit. Portals of entry include skin and mucous membranes. Transmission of Ebola virus may also occur by way of contact with contaminated materials, objects, and surfaces. Page Ref: 347 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Evaluation | Learning Outcome: 13.4 Contrast the characteristic features of bacteria, viruses, fungi, prions, protozoa, and helminths, and explain the steps of viral invasion and replication within a human host cell. | QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and wellbeing, and self-care management | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Examine viral agents and their role in the pathogenesis of human diseases.

19) What findings should alert the nurse to a potential complication in a patient with Zika virus? A) Fever and muscle aches B) Headaches and conjunctivitis C) Muscle weakness and difficulty breathing D) Rash and arthralgia Answer: C Explanation: A) Individuals infected with Zika virus can either be asymptomatic or have mild symptoms including fever, muscle aches, rash, headache, conjunctivitis, and arthralgia that can last up to a week. B) Individuals infected with Zika virus can either be asymptomatic or have mild symptoms including fever, muscle aches, rash, headache, conjunctivitis, and arthralgia that can last up to a week. C) Guillain-Barré syndrome, a serious neurological complication of Zika virus, is a type of peripheral neuropathy caused by inflammation and demyelination of nerve fibers leading to impaired nerve conduction, which results in weakness and paralysis. It can affect the muscles involved in breathing and may lead to respiratory failure. D) Individuals infected with Zika virus can either be asymptomatic or have mild symptoms including fever, muscle aches, rash, headache, conjunctivitis, and arthralgia that can last up to a week. Page Ref: 347 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 13.4 Contrast the characteristic features of bacteria, viruses, fungi, prions, protozoa, and helminths, and explain the steps of viral invasion and replication within a human host cell. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Examine viral agents and their role in the pathogenesis of human diseases.

20) Which of the following patients should receive the Zostavax® vaccine? A) A healthy patient over 60 years of age B) A patient over age 60 years of age and is taking immunosuppressive drugs C) A patient over 60 years of age with Hodgkin's lymphoma D) A patient over 60 years of age with HIV Answer: A Explanation: A) A vaccine (Zostavax®) is now recommended for individuals 60 years or older and whose immune system is not compromised by other diseases, such as HIV infection or cancer, or by medications such as immunosuppressive drugs. B) A vaccine (Zostavax®) is now recommended for individuals 60 years or older and whose immune system is not compromised by other diseases, such as HIV infection or cancer, or by medications such as immunosuppressive drugs. C) A vaccine (Zostavax®) is now recommended for individuals 60 years or older and whose immune system is not compromised by other diseases, such as HIV infection or cancer, or by medications such as immunosuppressive drugs. D) A vaccine (Zostavax®) is now recommended for individuals 60 years or older and whose immune system is not compromised by other diseases, such as HIV infection or cancer, or by medications such as immunosuppressive drugs. Page Ref: 346 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 13.4 Contrast the characteristic features of bacteria, viruses, fungi, prions, protozoa, and helminths, and explain the steps of viral invasion and replication within a human host cell. | QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and wellbeing, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, costeffectiveness and equity NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Examine viral agents and their role in the pathogenesis of human diseases.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 14 Hypersensitivity and Autoimmune Disorders 1) The nurse is providing education to a client prescribed with intranasal cromolyn. Which statement will the nurse include in the client teaching about this medication? A) "This medication increases your antibodies to the offending allergens." B) "It's best to use this medication when your symptoms are not tolerable." C) "Do not use this medication for more than a week at a time." D) "This medication stabilizes your cells in an effort to fight the offending allergens." Answer: D Explanation: A) Intranasal cromolyn is a mast cell stabilizer, which works to stabilize mast cells and prevents mast cell degranulation. This medication does not increase antibodies to fight offending allergens and should be take prior to exposure of the antigen, if possible. Intranasal corticosteroids, not mast cell stabilizers, should only be taken for a week at a time, due to the risk of rebound congestion. B) Intranasal cromolyn is a mast cell stabilizer, which works to stabilize mast cells and prevents mast cell degranulation. This medication does not increase antibodies to fight offending allergens and should be take prior to exposure of the antigen, if possible. Intranasal corticosteroids, not mast cell stabilizers, should only be taken for a week at a time, due to the risk of rebound congestion. C) Intranasal cromolyn is a mast cell stabilizer, which works to stabilize mast cells and prevents mast cell degranulation. This medication does not increase antibodies to fight offending allergens and should be take prior to exposure of the antigen, if possible. Intranasal corticosteroids, not mast cell stabilizers, should only be taken for a week at a time, due to the risk of rebound congestion. D) Intranasal cromolyn is a mast cell stabilizer, which works to stabilize mast cells and prevents mast cell degranulation. This medication does not increase antibodies to fight offending allergens and should be take prior to exposure of the antigen, if possible. Intranasal corticosteroids, not mast cell stabilizers, should only be taken for a week at a time, due to the risk of rebound congestion. Page Ref: 360 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pathophysiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 14.1 Describe the normal immune response, the results of inappropriate immune response, and concepts related to the immune response. | QSEN Competencies: II.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 14.2: Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypersensitivity disorders and the diagnosis and treatment of these conditions across the lifespan.

2) The nurse is caring for a client who experienced an immune response resulting from exposure to a foreign material. Which blood components or pathophysiological processes represent foreign materials? Select all that apply. A) Autologous stem cells B) One unit of packed red blood cells (PRBCs) C) Thromboembolism D) Normal saline solution E) Renal calculus Answer: B, D Explanation: A) Foreign material is, essentially, anything from outside the body. Autologous stems cells, thromboemboli, and renal calculi all originate within one's own body, and are therefore not considered foreign materials. B) Packed red blood cells from another person originate outside one's own body, and are therefore considered a foreign material. C) Foreign material is, essentially, anything from outside the body. Autologous stems cells, thromboemboli, and renal calculi all originate within one's own body, and are therefore notconsidered foreign materials. D) Normal saline solution does not originate within one's own body, and is therefore considered foreign material. E) Foreign material is, essentially, anything from outside the body. Autologous stems cells, thromboemboli, and renal calculi all originate within one's own body, and are therefore not considered foreign materials. Page Ref: 364 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 14.1 Describe the normal immune response, the results of inappropriate immune response, and concepts related to the immune response. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 14.1: Describe the normal immune response, the results of inappropriate immune response, and concepts related to the immune response.

3) The nurse is educating a client about the functions of the immune system. Which statements will the nurse include in the teaching materials? Select all that apply. A) "The immune system's primary function is autoimmunity." B) "The immune system is responsible for hypersensitivity reactions." C) "The immune system protects against invading microorganisms." D) "The immune system prevents cancer cell proliferation." E) "The immune system mediates the healing of damaged tissue." Answer: C, D, E Explanation: A) Autoimmunity and hypersensitivity reactions are considered dysfunctions of the immune system. B) Autoimmunity and hypersensitivity reactions are considered dysfunctions of the immune system. C) The immune system is responsible from protection against invading microorganisms, prevention of cancer cell proliferation, and the healing of damaged tissue. D) The immune system is responsible from protection against invading microorganisms, prevention of cancer cell proliferation, and the healing of damaged tissue. E) The immune system mediates the healing of damaged tissue through release of various chemical mediators and immune processes. Page Ref: 365 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pathophysiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 14.1 Describe the normal immune response, the results of inappropriate immune response, and concepts related to the immune response. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 14.1: Describe the normal immune response, the results of inappropriate immune response, and concepts related to the immune response.

4) The nurse is caring for a newborn baby. What is the nurse's understanding of this client's immunity? A) The infant is not protected against antigens during the first month of life. B) Maternal IgA is transferred to breastfed infants. C) Breastfeeding does not provide any additional immunity to the baby. D) An infant only receives immunity during gestation. Answer: B Explanation: A) During the first month of life, the newborn infant is protected against antigens as the mother's antibodies passed on from the placenta are still present in the infant. B) Maternal IgA is transferred to the infant during breastfeeding, supporting immunity. C) Maternal IgA is transferred to the infant during breastfeeding, supporting immunity. D) Maternal IgA is transferred to the infant during breastfeeding, supporting immunity. Page Ref: 364 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 14.1 Describe the normal immune response, the results of inappropriate immune response, and concepts related to the immune response. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 14.1: Describe the normal immune response, the results of inappropriate immune response, and concepts related to the immune response.

5) The nurse is caring for a client who is five months pregnant and HIV positive. What is the nurse's understanding of the neonate's HIV status? A) The neonate will be HIV positive. B) The neonate will initially test positive for antibodies. C) The neonate's risk for contracting HIV is unaffected by the mother's HIV positivity. D) The neonate may or may not be infected with HIV. Answer: D Explanation: A) IgG crosses the placenta during the last few weeks of pregnancy and is stored in fetal tissue. As a result of this transfer, a neonate born to an HIV-positive mother tests positive for antibodies. It is important to note, however, that the child is not necessarily infected with the virus. B) IgG crosses the placenta during the last few weeks of pregnancy and is stored in fetal tissue. As a result of this transfer, a neonate born to an HIV-positive mother initially tests positive for antibodies. It is important to note, however, that the child is not necessarily infected with the virus. C) IgG crosses the placenta during the last few weeks of pregnancy and is stored in fetal tissue. As a result of this transfer, a neonate born to an HIV-positive mother tests positive for antibodies. It is important to note, however, that the child is not necessarily infected with the virus. D) IgG crosses the placenta during the last few weeks of pregnancy and is stored in fetal tissue. As a result of this transfer, a neonate born to an HIV-positive mother tests positive for antibodies. It is important to note, however, that the child is not necessarily infected with the virus. Page Ref: 364 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Pathophysiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 14.1 Describe the normal immune response, the results of inappropriate immune response, and concepts related to the immune response. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 14.1: Describe the normal immune response, the results of inappropriate immune response, and concepts related to the immune response.

6) The nurse is educating an older adult client about age-related changes in immunity. Which statements will the nurse include in the education? Select all that apply. A) "There is a higher incidence of cancer with advanced age." B) "Abscesses, scar formation, and persistent inflammation are more common with advanced age." C) "Older adults are more susceptible to infection." D) "Older adults have decreased immunity due to an increase in tissue integrity." E) "Both types of immune responses are affected with advanced age." Answer: A, C, E Explanation: A) There is a higher incidence of cancer in older adults. B) Abscesses, scar formation, and persistent inflammation are all factors that lead to chronic inflammation and are not necessarily related to advanced age. C) Older adults are more susceptible to infection. D) Older adults have decreased immunity due to a decrease in overall tissue integrity. E) Both cell-mediated and humoral immune responses are affected with advanced age. Page Ref: 365 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Pathophysiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 14.1 Describe the normal immune response, the results of inappropriate immune response, and concepts related to the immune response. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 14.1: Describe the normal immune response, the results of inappropriate immune response, and concepts related to the immune response.

7) The nurse is caring for a client with a diagnosis of lymphedema. Which body component does the nurse recognize as making up the peripheral lymphoid organs? Select all that apply. A) Bone marrow B) Tonsils C) Lymph nodes D) Thymus E) Spleen Answer: B, C, E Explanation: A) The bone marrow and thymus are central lymphoid organs. B) Peripheral lymphoid organs include the tonsils, lymph nodes, and spleen. C) Peripheral lymphoid organs include the tonsils, lymph nodes, and spleen. D) The bone marrow and thymus are central lymphoid organs. E) Peripheral lymphoid organs include the tonsils, lymph nodes, and spleen. Page Ref: 364 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Pathophysiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 14.1 Describe the normal immune response, the results of inappropriate immune response, and concepts related to the immune response. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 14.1: Describe the normal immune response, the results of inappropriate immune response, and concepts related to the immune response.

8) The nurse is caring for a client with an allergic reaction. What is the nurse's understanding of this type of hypersensitivity reaction? A) It is a Type I reaction, an IgE mediated disorder. B) It is a Type II reaction, an antibody-mediated disorder. C) It is a type III reaction, a complement-mediated disorder. D) It is a type IV reaction, a T-cell mediated disorder. Answer: A Explanation: A) Type I reactions are IgE-mediated disorders. Type II reactions are antibodymediated disorders and involve IgG or IgM antibodies, not IgE. Type III reactions are complement-mediated immune disorders. Type III reactions lead to localized inflammation, not systemic like types I and II. Type IV reactions are T-cell-mediated disorders, not involving IgE. B) Type I reactions are IgE-mediated disorders. Type II reactions are antibody-mediated disorders and involve IgG or IgM antibodies, not IgE. Type III reactions are complementmediated immune disorders. Type III reactions lead to localized inflammation, not systemic like types I and II. Type IV reactions are T-cell-mediated disorders, not involving IgE. C) Type I reactions are IgE-mediated disorders. Type II reactions are antibody-mediated disorders and involve IgG or IgM antibodies, not IgE. Type III reactions are complementmediated immune disorders. Type III reactions lead to localized inflammation, not systemic like types I and II. Type IV reactions are T-cell-mediated disorders, not involving IgE. D) Type I reactions are IgE-mediated disorders. Type II reactions are antibody-mediated disorders and involve IgG or IgM antibodies, not IgE. Type III reactions are complementmediated immune disorders. Type III reactions lead to localized inflammation, not systemic like types I and II. Type IV reactions are T-cell-mediated disorders, not involving IgE. Page Ref: 367 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Pathophysiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 14.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypersensitivity disorders and the diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 14.2: Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypersensitivity disorders and the diagnosis and treatment of these conditions across the lifespan.

9) The nurse is caring for a client with Graves disease. What concept related to the client's condition does the nurse recognize as true? A) Autoantibodies against TSH stimulates thyroxine production. B) It occurs in hemolytic disease of the newborn due to ABO or Rh incompatibility. C) Antibodies to acetylcholine receptors cause decreased neuromuscular function. D) It is characterized by the vascular rejection of organ transplantation. Answer: A Explanation: A) In Graves disease, an autoantibody is directed against thyroid-stimulating hormone (TSH) receptors on thyroid cells, which stimulates thyroxine production, leading to hyperthyroidism. B) Complement- and antibody receptor-mediated phagocytosis occurs with mismatched blood transfusion reactions, with hemolytic disease of the newborn due to ABO or Rh incompatibility, or with certain drug reactions. C) In myasthenia gravis, autoantibodies to acetylcholine receptors on the neuromuscular endplates either block the action of acetylcholine or mediate internalization or destruction of receptors, causing decreased neuromuscular function. D) Complement- and antibody receptor-mediated inflammation is responsible for the tissue injury seen in glomerulonephritis and vascular rejection in organ transplantation. Page Ref: 371 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Pathophysiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 14.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypersensitivity disorders and the diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 14.2: Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypersensitivity disorders and the diagnosis and treatment of these conditions across the lifespan.

10) The nurse is caring for a client with serum sickness. What does the nurse understand to be a potential cause of this client's condition? Select all that apply. A) Drugs B) Pollen C) Phagocytes D) Foods E) Insect venom Answer: A, D, E Explanation: A) Serum sickness is a disorder that occurs when the immune system reacts to medicines that contain foreign proteins used to treat immune conditions and is caused by antibiotics (e.g., penicillin), other drugs, various foods, and insect venom. B) Serum sickness is a disorder that occurs when the immune system reacts to medicines that contain foreign proteins used to treat immune conditions and is caused by antibiotics (e.g., penicillin), other drugs, various foods, and insect venom. C) Serum sickness is a disorder that occurs when the immune system reacts to medicines that contain foreign proteins used to treat immune conditions and is caused by antibiotics (e.g., penicillin), other drugs, various foods, and insect venom. D) Serum sickness is a disorder that occurs when the immune system reacts to medicines that contain foreign proteins used to treat immune conditions and is caused by antibiotics (e.g., penicillin), other drugs, various foods, and insect venom. E) Serum sickness is a disorder that occurs when the immune system reacts to medicines that contain foreign proteins used to treat immune conditions and is caused by antibiotics (e.g., penicillin), other drugs, various foods, and insect venom. Page Ref: 372 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Pathophysiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 14.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypersensitivity disorders and the diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 14.2: Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypersensitivity disorders and the diagnosis and treatment of these conditions across the lifespan.

11) The nurse is caring for an older adult client with active tuberculosis (TB) who has a negative TB skin test. The nurse understands that this phenomenon is due to: A) prior exposure to TB producing antibody immunity. B) hyperactivity of the immune system occurring with active TB (anergy). C) a diminished immune response due to changes in immunity occurring with age. D) decreased immunity associated with treatment with immune-suppressive agents. Answer: C Explanation: A) The immune response is often diminished in older adults, owing to changes in the immune system that occur with age. This diminished responsiveness is called anergy, and it can result in a negative TB skin test, even when the client has active disease. It is not due to prior exposure to TB producing antibody immunity. B) The immune response is often diminished in older adults, owing to changes in the immune system that occur with age. This diminished responsiveness is called anergy, and it can result in a negative TB skin test, even when the client has active disease. It is not due to hyperactivity of the immune system occurring with active TB, also called anergy. C) The immune response is often diminished in older adults, owing to changes in the immune system that occur with age. This diminished responsiveness is called anergy, and it can result in a negative TB skin test, even when the client has active disease. D) The immune response is often diminished in older adults, owing to changes in the immune system that occur with age. This diminished responsiveness is called anergy, and it can result in a negative TB skin test, even when the client has active disease. It is not due to decreased immunity associated with the treatment of active TB with immunosuppressants. Page Ref: 374 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Pathophysiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 14.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypersensitivity disorders and the diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 14.2: Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypersensitivity disorders and the diagnosis and treatment of these conditions across the lifespan.

12) The nurse is administering a tuberculin skin test for a client. What is the nurse's understanding of the hypersensitivity response associated with this test? Select all that apply. A) The test causes a release of lymphokines, which attract macrophages. B) Macrophages release lysozymes, resulting in local tissue damage. C) The antigen-presenting cell encounters a cytotoxic T-cell. D) Antigens invade the body and bind to antibodies in circulation. E) Antigen-antibody complexes activate complement. Answer: A, B, C Explanation: A) The tuberculin skin test is an example of evaluating whether a type IV, cell mediated hypersensitivity reaction occurred. It is a delayed-type hypersensitivity (DTH) reaction occurring in response to soluble protein antigens. In this type of reaction, antigen-presenting cells encounter cytotoxic T cells, causing the release of lymphokines, which attract macrophages. Macrophages then release lysozymes, resulting in local tissue damage. B) The tuberculin skin test is an example of evaluating whether a type IV, cell mediated hypersensitivity reaction occurred. It is a delayed-type hypersensitivity (DTH) reaction occurring in response to soluble protein antigens. In this type of reaction, antigen-presenting cells encounter cytotoxic T cells, causing the release of lymphokines, which attract macrophages. Macrophages then release lysozymes, resulting in local tissue damage. C) The tuberculin skin test is an example of evaluating whether a type IV, cell mediated hypersensitivity reaction occurred. It is a delayed-type hypersensitivity (DTH) reaction occurring in response to soluble protein antigens. In this type of reaction, antigen-presenting cells encounter cytotoxic T cells, causing the release of lymphokines, which attract macrophages. Macrophages then release lysozymes, resulting in local tissue damage. D) The tuberculin skin test is an example of evaluating whether a type IV, cell mediated hypersensitivity reaction occurred. It is a delayed-type hypersensitivity (DTH) reaction occurring in response to soluble protein antigens. In this type of reaction, antigen-presenting cells encounter cytotoxic T cells, causing the release of lymphokines, which attract macrophages. Macrophages then release lysozymes, resulting in local tissue damage. Antigens that invade the body and bind to antibodies in the circulation occur in Type III reactions, which are immune complex mediated hypersensitivity reactions. E) The tuberculin skin test is an example of evaluating whether a type IV, cell mediated hypersensitivity reaction occurred. It is a delayed-type hypersensitivity (DTH) reaction occurring in response to soluble protein antigens. In this type of reaction, antigen-presenting cells encounter cytotoxic T cells, causing the release of lymphokines, which attract macrophages. Macrophages then release lysozymes, resulting in local tissue damage. Complement is activated in a Type III reaction, an immune complex mediated hypersensitivity reaction. Page Ref: 373 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Pathophysiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 14.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypersensitivity disorders and the diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches 12

NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 14.2: Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypersensitivity disorders and the diagnosis and treatment of these conditions across the lifespan. 13) The nurse is caring for a client with serum sickness. Which interventions will the nurse anticipate will be included in the client's collaborative plan of care? Select all that apply. A) Aspirin for joint pain B) Levothyroxine treatment for hypothyroidism C) Diphenhydramine for pruritus D) Systemic corticosteroid therapy for severe reactions E) Prochlorperazine for nausea Answer: A, C, D Explanation: A) Treatment for serum sickness is directed to remove the sensitizing antigen and provide relief from symptoms. Pharmacologic treatment often includes aspirin for joint pain and antihistamines for pruritus. For severe reactions, epinephrine or systemic corticosteroids may be prescribed. B) Treatment for serum sickness is directed to remove the sensitizing antigen and provide relief from symptoms. Pharmacologic treatment often includes aspirin for joint pain and antihistamines for pruritus. For severe reactions, epinephrine or systemic corticosteroids may be prescribed. C) Treatment for serum sickness is directed to remove the sensitizing antigen and provide relief from symptoms. Pharmacologic treatment often includes aspirin for joint pain and antihistamines for pruritus. For severe reactions, epinephrine or systemic corticosteroids may be prescribed. D) Treatment for serum sickness is directed to remove the sensitizing antigen and provide relief from symptoms. Pharmacologic treatment often includes aspirin for joint pain and antihistamines for pruritus. For severe reactions, epinephrine or systemic corticosteroids may be prescribed. E) Treatment for serum sickness is directed to remove the sensitizing antigen and provide relief from symptoms. Pharmacologic treatment often includes aspirin for joint pain and antihistamines for pruritus. For severe reactions, epinephrine or systemic corticosteroids may be prescribed. Page Ref: 373 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Planning | Learning Outcome: 14.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypersensitivity disorders and the diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 14.2: Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypersensitivity disorders and the diagnosis and treatment of these conditions across the lifespan. 13

14) The nurse acts as a preceptor to a novice nurse, who is caring for a client with a penicillin allergy. Which statement by the novice nurse requires further follow up by the nurse preceptor? A) "The client has a type I hypersensitivity disorder." B) "The client likely has certain food allergies." C) "I will administer the prescribed doxycycline." D) "I will administer the prescribed amoxicillin." Answer: D Explanation: A) It is important to know that individuals with an allergy history may have crossreactivities to other substances. In the case of penicillin allergy, cross-reactivity to other related classes of antibiotics is possible, so extreme precautions must be taken before administering parenteral antibiotics. This is also true of other allergies, such as latex allergy and some foodstuffs (banana, avocado, kiwi, and chestnut together with papaya, fig, potato, and tomato); 30-80% of people with latex allergy experience symptoms when they eat one or more of these foods. Type I hypersensitivity reactions are known as allergic reactions, which may occur with medications such as penicillin. B) It is important to know that individuals with an allergy history may have cross-reactivities to other substances. Individuals with a latex allergy may also be allergic some foodstuffs, such as banana, avocado, kiwi, and chestnut together with papaya, fig, potato, and tomato. It is estimated that 30-80% of people with latex allergy experience symptoms when they eat one or more of these foods. C) It is important to know that individuals with an allergy history may have cross-reactivities to other substances. In the case of penicillin allergy, cross-reactivity to other related classes of antibiotics is possible, so extreme precautions must be taken before administering parenteral antibiotics. Doxycycline, a tetracycline antibiotic, may be prescribed as an alternative to penicillin as this medication is not related penicillin and may be tolerated well in those with a penicillin allergy. D) It is important to know that individuals with an allergy history may have cross-reactivities to other substances. In the case of penicillin allergy, cross-reactivity to other related classes of antibiotics is possible, so extreme precautions must be taken before administering parenteral antibiotics. Amoxicillin is a penicillin-type antibiotic and should not be used in the client with a penicillin allergy. Administering this medication increases the client's risk for a hypersensitivity type I allergic reaction. Page Ref: 370 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Evaluation | Learning Outcome: 14.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypersensitivity disorders and the diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 14.2: Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypersensitivity disorders and the diagnosis and treatment of these conditions across the lifespan. 14

15) The nurse is caring for a client diagnosed with systemic lupus erythematosus (SLE). What does the nurse understand about the etiology and pathogenesis of this condition? Select all that apply. A) Clinical manifestations are mediated by antibody formation and the creation of immune complexes (IC). B) Lupus is more common in men than in women. C) Lupus can be drug-induced by the body's overreaction to medications such as isoniazid, hydralazine, and procainamide. D) It is most common in individuals of Hispanic and Latino descent. E) The rate ICs are cleared in the liver and spleen are believed to be impaired in SLE. Answer: A, C, E Explanation: A) Clinical manifestations of SLE are mediated by antibody formation and the creation of immune complexes (IC). The severity of the immune complexes depends on the characteristics of the antibody and the nature of the antigen. SLE is more common in women than in men, and is most common in individuals of African American and Asian descent. B) SLE is more common in women than in men, and is most common in individuals of African American and Asian descent. C) Lupus can be drug-induced by the body's overreaction to medications such as isoniazid, hydralazine, and procainamide. D) SLE is more common in women than in men, and is most common in individuals of African American and Asian descent. E) The rate at which ICs are cleared in the liver and spleen are believed to be impaired in SLE. Page Ref: 375 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Pathophysiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 14.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of autoimmune disease and the diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 14.3: Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of autoimmune disease and the diagnosis and treatment of these conditions across the lifespan.

16) The nurse is caring for a client with a suspected autoimmune disorder. What concept related to the client's condition does the nurse recognize is true? Select all that apply. A) It is necessary to determine that immunologic findings do not have another cause. B) Diagnosis is currently based on serologic testing and clinical findings. C) Each method of serologic testing involves either concentrating or diluting the client's serum. D) Genetic testing is considered the most reliable way to diagnose autoimmune disorders. E) Serologic testing reveals autoantibodies directed against cellular components. Answer: A, B, E Explanation: A) In order to diagnose an autoimmune disorder, it is necessary to determine that immunologic findings do not have another cause. B) In order to diagnose an autoimmune disorder, it is necessary to determine that immunologic findings do not have another cause. Diagnosis is currently based on serologic testing and clinical findings. C) The serologic testing for autoimmune diseases involves diluting the body's serum until it no longer produces a reaction to antigen-coated material. D) Although genetic testing for autoimmune disorders may be available in the future, there is currently no genetic testing available for the diagnosis of autoimmune disorders. E) Serologic testing reveals autoantibodies directed against cellular components. This means that the testing shows these autoantibodies present in the client, where otherwise they would not be present. Page Ref: 375 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Pathophysiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 14.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of autoimmune disease and the diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 14.3: Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of autoimmune disease and the diagnosis and treatment of these conditions across the lifespan.

17) The nurse is caring for a client who began experiencing symptoms of systemic lupus erythematosus (SLE) about one year ago. What does the nurse understand to be potential causes of this condition? Select all that apply. A) Heredity B) Trigger microorganisms C) Environment D) Substance abuse E) Self-antigen from a tissue in the body Answer: A, B, C, E Explanation: A) Two primary factors are believed to cause autoimmune diseases: heredity and environment. Because autoimmunity does not develop in all individuals who have a genetic predisposition, it is believed that other factors precipitate the altered immune state. This is often referred to as a trigger event. A trigger event may be a virus, a microorganism, a chemical substance, or a self-antigen from a body tissue that has been hidden from the immune system during the development of an autoimmune disease. B) Two primary factors are believed to cause autoimmune diseases: heredity and environment. Because autoimmunity does not develop in all individuals who have a genetic predisposition, it is believed that other factors precipitate the altered immune state. This is often referred to as a trigger event. A trigger event may be a virus, a microorganism, a chemical substance, or a selfantigen from a body tissue that has been hidden from the immune system during the development of an autoimmune disease. C) Two primary factors are believed to cause autoimmune diseases: heredity and environment. Because autoimmunity does not develop in all individuals who have a genetic predisposition, it is believed that other factors precipitate the altered immune state. This is often referred to as a trigger event. A trigger event may be a virus, a microorganism, a chemical substance, or a selfantigen from a body tissue that has been hidden from the immune system during the development of an autoimmune disease. D) Two primary factors are believed to cause autoimmune diseases: heredity and environment. Because autoimmunity does not develop in all individuals who have a genetic predisposition, it is believed that other factors precipitate the altered immune state. This is often referred to as a trigger event. A trigger event may be a virus, a microorganism, a chemical substance, or a selfantigen from a body tissue that has been hidden from the immune system during the development of an autoimmune disease. E) Two primary factors are believed to cause autoimmune diseases: heredity and environment. Because autoimmunity does not develop in all individuals who have a genetic predisposition, it is believed that other factors precipitate the altered immune state. This is often referred to as a trigger event. A trigger event may be a virus, a microorganism, a chemical substance, or a selfantigen from a body tissue that has been hidden from the immune system during the development of an autoimmune disease. Page Ref: 375 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Pathophysiological Adaptation

Standards: Nursing Process: Assessment | Learning Outcome: 14.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of autoimmune disease and the diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 14.3: Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of autoimmune disease and the diagnosis and treatment of these conditions across the lifespan. 18) The nurse is educating a client with an autoimmune disorder about immune tolerance. Which statement should the nurse include in the teaching? A) "Humoral tolerance refers to the ability to differentiate foreign antigens from self-antigens." B) "Self-tolerance refers to the elimination of self-reactive T-cells and B-cells in the thymus." C) "Central tolerance refers to the loss of self-tolerance that occurs as a result of the development of autoantibodies." D) "Peripheral tolerance occurs when certain immune cells are not eliminated in the central lymphoid organs." Answer: D Explanation: A) Humoral tolerance refers to the loss of self-tolerance that occurs as a result of the development of autoantibodies. B) Self-tolerance refers to the ability to differentiate foreign antigens from self-antigens. C) Central tolerance refers to the elimination of self-reactive T-cells and B-cells in the thymus and bone marrow, respectively. D) Peripheral tolerance occurs from the deletion or inactivation of autoreactive T-cells or B-cells that escaped elimination in the central lymphoid organs. Page Ref: 374 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Pathophysiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 14.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of autoimmune disease and the diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 14.3: Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of autoimmune disease and the diagnosis and treatment of these conditions across the lifespan.

19) The nurse is performing a skin assessment on a client diagnosed with systemic lupus erythematosus (SLE). Which assessment findings does the nurse anticipate? Select all that apply. A) Paronychia B) Facial butterfly rash C) Discoid lesions D) Alopecia E) Contact dermatitis Answer: B, C, D Explanation: A) Integumentary assessment findings associated with systemic lupus erythematosus (SLE) include the presence of a facial butterfly rash, discoid lesions, alopecia, photosensitivity, maculopapular rash on exposed body surfaces, erythematous fingertip lesions, splinter hemorrhages, and ulcers. Paronychia is a soft tissue infection of the fingernail as is not associated with SLE. Contact dermatitis refers to a local hypersensitivity reaction that occurs when an allergen comes into contact with the skin. B) Integumentary assessment findings associated with systemic lupus erythematosus (SLE) include the presence of a facial butterfly rash, discoid lesions, alopecia, photosensitivity, maculopapular rash on exposed body surfaces, erythematous fingertip lesions, splinter hemorrhages, and ulcers. Paronychia is a soft tissue infection of the fingernail as is not associated with SLE. Contact dermatitis refers to a local hypersensitivity reaction that occurs when an allergen comes into contact with the skin. C) Integumentary assessment findings associated with systemic lupus erythematosus (SLE) include the presence of a facial butterfly rash, discoid lesions, alopecia, photosensitivity, maculopapular rash on exposed body surfaces, erythematous fingertip lesions, splinter hemorrhages, and ulcers. Paronychia is a soft tissue infection of the fingernail as is not associated with SLE. Contact dermatitis refers to a local hypersensitivity reaction that occurs when an allergen comes into contact with the skin. D) Integumentary assessment findings associated with systemic lupus erythematosus (SLE) include the presence of a facial butterfly rash, discoid lesions, alopecia, photosensitivity, maculopapular rash on exposed body surfaces, erythematous fingertip lesions, splinter hemorrhages, and ulcers. Paronychia is a soft tissue infection of the fingernail as is not associated with SLE. Contact dermatitis refers to a local hypersensitivity reaction that occurs when an allergen comes into contact with the skin. E) Integumentary assessment findings associated with systemic lupus erythematosus (SLE) include the presence of a facial butterfly rash, discoid lesions, alopecia, photosensitivity, maculopapular rash on exposed body surfaces, erythematous fingertip lesions, splinter hemorrhages, and ulcers. Paronychia is a soft tissue infection of the fingernail as is not associated with SLE. Contact dermatitis refers to a local hypersensitivity reaction that occurs when an allergen comes into contact with the skin. Page Ref: 377 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pathophysiological Adaptation

20) The nurse is providing education for a client diagnosed with systemic lupus erythematosus (SLE). Which statement by the client indicates an understanding of the teaching? A) "I can anticipate my care to be managed solely by my rheumatologist." B) "I can expect to no longer need treatment after I finish my prescribed medications." C) "My medications are the mainstay of my treatment." D) "I will use high sun protection factor (SPF) sunscreen when I spend time outdoors." Answer: D Explanation: A) Treatment for SLE focuses on ensuring long-term survival, achieving the lowest possible disease activity, preventing organ damage, minimizing drug toxicity, improving quality of life, and educating patients about their role in disease management. It is not uncommon for an individual with SLE to require a multidisciplinary approach to care, owing to multiorgan system involvement. B) Treatment for SLE focuses on ensuring long-term survival, achieving the lowest possible disease activity, preventing organ damage, minimizing drug toxicity, improving quality of life, and educating patients about their role in disease management. It is not uncommon for an individual with SLE to require a multidisciplinary approach to care, owing to multiorgan system involvement. Several nonpharmacologic measures, along with other medical interventions, are important in the comprehensive management of SLE. Individuals who have been diagnosed with SLE are taught the importance of protection from sunlight, maintaining adequate nutritional intake, getting enough exercise, stopping smoking, and receiving appropriate immunizations. It is important for the nurse to educate the client on the fact that treatment for SLE is ongoing and lifelong. C) Several nonpharmacologic measures, along with other medical interventions, are important in the comprehensive management of SLE. Individuals who have been diagnosed with SLE are taught the importance of protection from sunlight, maintaining adequate nutritional intake, getting enough exercise, stopping smoking, and receiving appropriate immunizations. D) Several nonpharmacologic measures, along with other medical interventions, are important in the comprehensive management of SLE. Individuals who have been diagnosed with SLE are taught the importance of protection from sunlight, maintaining adequate nutritional intake, getting enough exercise, stopping smoking, and receiving appropriate immunizations. Page Ref: 378 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Evaluation | Learning Outcome: 14.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of autoimmune disease and the diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 14.3: Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of autoimmune disease and the diagnosis and treatment of these conditions across the lifespan.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 15 Immunodeficiency Disorders 1) When planning health education programming, the public health nurse is aware that the most common cause of secondary immunodeficiency disorders is: A) nutritional deficiencies. B) infection. C) aging. D) selected malignancies. Answer: A Explanation: A) Secondary immunodeficiency disorders may result from a wide variety of internal and external factors, including aging, stress, nutritional deficiencies, selected malignancies, infection, and immunosuppressive treatment modalities. Worldwide, nutritional deficiencies are the most common cause of secondary immunodeficiency. B) Secondary immunodeficiency disorders may result from a wide variety of internal and external factors, including aging, stress, nutritional deficiencies, selected malignancies, infection, and immunosuppressive treatment modalities. Worldwide, nutritional deficiencies are the most common cause of secondary immunodeficiency. C) Secondary immunodeficiency disorders may result from a wide variety of internal and external factors, including aging, stress, nutritional deficiencies, selected malignancies, infection, and immunosuppressive treatment modalities. Worldwide, nutritional deficiencies are the most common cause of secondary immunodeficiency. D) Secondary immunodeficiency disorders may result from a wide variety of internal and external factors, including aging, stress, nutritional deficiencies, selected malignancies, infection, and immunosuppressive treatment modalities. Worldwide, nutritional deficiencies are the most common cause of secondary immunodeficiency. Page Ref: 382 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 15.1 Describe the types of immunodeficiency disorders and concepts related to immunodeficiency. | QSEN Competencies: I.C.10 Value active partnership with patients or designated surrogates in planning, implementation, and evaluation of care | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of immunodeficiency.

2) When planning care, the nurse recognizes that which primary immunodeficiency disorder (PID) is a pediatric emergency? A) Selective IgA deficiency B) X-linked agammaglobulinemia C) Transient hypogammaglobulinemia of infancy D) Severe combined immunodeficiency Answer: D Explanation: A) The most commonly reported primary immunodeficiency disorders include selective IgA deficiency, X-linked agammaglobulinemia, hypogammaglobulinemia, common variable immunodeficiency, specific antibody deficiency, and transient hypogammaglobulinemia of infancy. A fourth disorder, severe combined immunodeficiency (also known as "bubble boy" disease), is the most serious PID and is considered a pediatric emergency; unless it is treated by stem cell transplantation, death within the first or second year of life often occurs. B) The most commonly reported primary immunodeficiency disorders include selective IgA deficiency, X-linked agammaglobulinemia, hypogammaglobulinemia, common variable immunodeficiency, specific antibody deficiency, and transient hypogammaglobulinemia of infancy. A fourth disorder, severe combined immunodeficiency (also known as "bubble boy" disease), is the most serious PID and is considered a pediatric emergency; unless it is treated by stem cell transplantation, death within the first or second year of life often occurs. C) The most commonly reported primary immunodeficiency disorders include selective IgA deficiency, X-linked agammaglobulinemia, hypogammaglobulinemia, common variable immunodeficiency, specific antibody deficiency, and transient hypogammaglobulinemia of infancy. A fourth disorder, severe combined immunodeficiency (also known as "bubble boy" disease), is the most serious PID and is considered a pediatric emergency; unless it is treated by stem cell transplantation, death within the first or second year of life often occurs. D) The most commonly reported primary immunodeficiency disorders include selective IgA deficiency, X-linked agammaglobulinemia, hypogammaglobulinemia, common variable immunodeficiency, specific antibody deficiency, and transient hypogammaglobulinemia of infancy. A fourth disorder, severe combined immunodeficiency (also known as "bubble boy" disease), is the most serious PID and is considered a pediatric emergency; unless it is treated by stem cell transplantation, death within the first or second year of life often occurs. Page Ref: 382 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 15.1 Describe the types of immunodeficiency disorders and concepts related to immunodeficiency. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of immunodeficiency.

3) How should a nurse respond when a patient with human immunodeficiency virus (HIV) asks about the course of the disease? A) "The disease will progress to AIDS within a few years." B) "You will probably be relatively asymptomatic for 20 years." C) "The disease has a variable progression, so it's hard to know right now." D) "Death typically occurs within 10 to 15 years." Answer: C Explanation: A) HIV progression is highly variable. Some individuals progress to AIDS within a few years of infection; others remain relatively asymptomatic after 20 or more years of infection. B) HIV progression is highly variable. Some individuals progress to AIDS within a few years of infection; others remain relatively asymptomatic after 20 or more years of infection. C) HIV progression is highly variable. Some individuals progress to AIDS within a few years of infection; others remain relatively asymptomatic after 20 or more years of infection. D) HIV progression is highly variable. Some individuals progress to AIDS within a few years of infection; others remain relatively asymptomatic after 20 or more years of infection. Page Ref: 383 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 15.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of acquired immunodeficiency syndrome and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of immunodeficiency to diagnosis and treatment.

4) The school nurse is talking with a high school class about sexual transmission of HIV. Which of the following would the nurse advise the students? A) "Oral-penile intercourse carries the highest risk of transmission." B) "Penile-vaginal and penile-anal intercourse most efficiently transmit the virus." C) "HIV-infected females cannot transmit HIV to their partners." D) "Kissing can transmit HIV." Answer: B Explanation: A) The primary mode of transmission worldwide is through sexual contact. The most efficient sexual transmission modes are penile-anal intercourse and penile-vaginal intercourse. B) The primary mode of transmission worldwide is through sexual contact. The most efficient sexual transmission modes are penile-anal intercourse and penile-vaginal intercourse. C) Viral transmission from infected females to their partners is less efficient than transmission from males, most likely owing to the lower concentration of infectious virus particles in cervicovaginal secretions than in seminal fluid; however, this mode of transmission can occur. D) HIV is transmitted through exchange of body fluids. It has been isolated from most bodily fluids, including blood, semen, cervicovaginal secretions, cerebrospinal fluid, saliva, tears, and breast milk. However, HIV is not known to be transmitted by way of tears or saliva. Page Ref: 384 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 15.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of acquired immunodeficiency syndrome and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of immunodeficiency.

5) When counseling about HIV transmission, which patients does the nurse recognize as being at greatest risk for being newly diagnosed with HIV? A) Black men who have sex with men B) White men who have sex with men C) Black heterosexual men D) Black heterosexual women Answer: A Explanation: A) In the United States, African Americans account for a disproportionate number of new HIV cases. In 2014, there were 11,201 new HIV diagnoses among black men who have sex with men (MSM), 9008 cases in white MSM, 4654 cases in black heterosexual women, and 2018 cases in black heterosexual men. B) In the United States, African Americans account for a disproportionate number of new HIV cases. In 2014, there were 11,201 new HIV diagnoses among black men who have sex with men (MSM), 9008 cases in white MSM, 4654 cases in black heterosexual women, and 2018 cases in black heterosexual men. C) In the United States, African Americans account for a disproportionate number of new HIV cases. In 2014, there were 11,201 new HIV diagnoses among black men who have sex with men (MSM), 9008 cases in white MSM, 4654 cases in black heterosexual women, and 2018 cases in black heterosexual men. D) In the United States, African Americans account for a disproportionate number of new HIV cases. In 2014, there were 11,201 new HIV diagnoses among black men who have sex with men (MSM), 9008 cases in white MSM, 4654 cases in black heterosexual women, and 2018 cases in black heterosexual men. Page Ref: 384 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 15.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of acquired immunodeficiency syndrome and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of immunodeficiency.

6) Which of the following is the nurse most likely to expect in a newborn with DiGeorge syndrome? A) Reduced B-cells B) Hyperplasia of the parathyroid glands C) Hypoplasia of the thymus gland D) Hypercalcemia Answer: C Explanation: A) In DiGeorge syndrome, B-cell numbers are normal or increased. B) Variable T-cell deficiency caused by defective embryologic development of the third and fourth pharyngeal pouches; leads to hypoplasia or aplasia of the thymus and parathyroid glands. C) Variable T-cell deficiency caused by defective embryologic development of the third and fourth pharyngeal pouches; leads to hypoplasia or aplasia of the thymus and parathyroid glands. D) Hypocalcemic tetany may occur in 50-60% of infants with DiGeorge syndrome. Page Ref: 394 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 15.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of primary immunodeficiencies and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of immunodeficiency to diagnosis and treatment.

7) When taking a health history from a patient during the period of chronic HIV, the nurse would expect to find: A) no clinical manifestations of HIV infection. B) nonspecific symptoms including fever, fatigue, headache, lymphadenopathy, arthralgias, and rash. C) fever, night sweats, diarrhea, and mucocutaneous abnormalities. D) opportunistic infections and malignancies. Answer: A Explanation: A) During the period of chronic HIV infection and after the acute infection subsides, most individuals show no clinical manifestations of HIV infection for several years, even in the absence of treatment. B) Primary HIV infection is a nonspecific, acute syndrome that occurs 2-4 weeks after viral infection and lasts for 1-2 weeks. The most common signs and symptoms are fever, fatigue, headache, lymphadenopathy, arthralgias, and a maculopapular rash that affects the face and trunk. C) HIV-related conditions develop as CD4+ T-lymphocyte counts decline. Early conditions are generally non-life-threatening and include headache and fatigue. Over time, the conditions become more severe and include fever, night sweats, diarrhea, and mucocutaneous abnormalities. D) Acquired immunodeficiency syndrome (AIDS) is characterized by severe immunodeficiency (i.e., CD4+ T-lymphocyte count <200 cells/mm3), opportunistic infections, and/or malignancies. Page Ref: 389 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 15.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of acquired immunodeficiency syndrome and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of immunodeficiency.

8) Which patient statement indicates to the nurse that more teaching regarding early highly active antiretroviral therapy (HAART) is needed? A) "Early HAART can have negative effects." B) "Early HAART can preserve my immune function." C) "Early HAART can reduce the risk of viral transmission." D) "Early HAART reduces the potential for developing drug-resistant strains." Answer: D Explanation: A) Although HAART is indicated for all individuals with HIV, early treatment has both positive and negative effects. The potential benefits for early therapy include preservation of immune function, prolongation of clinical latency, and a reduced risk of transmission. Risks of early therapy include drug toxicities, possible development of drug-resistant mutants that limit treatment options in symptomatic disease, and the risk of transmitting drug-resistant mutants to uninfected individuals, limiting their treatment options. B) Although HAART is indicated for all individuals with HIV, early treatment has both positive and negative effects. The potential benefits for early therapy include preservation of immune function, prolongation of clinical latency, and a reduced risk of transmission. Risks of early therapy include drug toxicities, possible development of drug-resistant mutants that limit treatment options in symptomatic disease, and the risk of transmitting drug-resistant mutants to uninfected individuals, limiting their treatment options. C) Although HAART is indicated for all individuals with HIV, early treatment has both positive and negative effects. The potential benefits for early therapy include preservation of immune function, prolongation of clinical latency, and a reduced risk of transmission. Risks of early therapy include drug toxicities, possible development of drug-resistant mutants that limit treatment options in symptomatic disease, and the risk of transmitting drug-resistant mutants to uninfected individuals, limiting their treatment options. D) Although HAART is indicated for all individuals with HIV, early treatment has both positive and negative effects. The potential benefits for early therapy include preservation of immune function, prolongation of clinical latency, and a reduced risk of transmission. Risks of early therapy include drug toxicities, possible development of drug-resistant mutants that limit treatment options in symptomatic disease, and the risk of transmitting drug-resistant mutants to uninfected individuals, limiting their treatment options. Page Ref: 390 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Evaluation | Learning Outcome: 15.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of acquired immunodeficiency syndrome and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of immunodeficiency to diagnosis and treatment.

9) In response to an HIV-infected patient asking about tuberculosis (TB), the nurse should explain that: A) TB is often transmitted at the time of HIV transmission. B) HIV infection increases the risk of acquiring TB. C) HIV suppresses the activation of latent TB. D) TB is the leading cause of death in HIV-infected people. Answer: D Explanation: A) TB is not transmitted at the time of HIV transmission. B) HIV infection does not confer increased the risk for acquiring TB infection. C) HIV infection increases the risk of activation of latent TB and subsequent dissemination. D) Among individuals who are infected with HIV, TB is the leading cause of death. Page Ref: 391 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 15.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of common conditions associated with HIV and AIDS and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of immunodeficiency.

10) In the initial stages of distal symmetric polyneuropathy (DSP) in an HIV-infected patient, the nurse would expect to find on physical assessment: A) a diminished brachioradialis reflex. B) a diminished ankle reflex. C) a hyperreflexive patellar reflex D) a positive Babinski sign Answer: B Explanation: A) Distal symmetric polyneuropathy (DSP) is one of the most common forms of HIV-associated peripheral neuropathy. It is a sensory axonal neuropathy that involves the toes and soles of the feet; the fingers and hands may become involved over time. Because the client is in the initial stages of neuropathy, the upper extremities are not affected. B) The most common manifestations of DSP involve absent or diminished ankle jerks and diminished vibration and pinprick sensations in the distal lower extremities. C) Reflexes in the lower extremities would be diminished, not hyperreflexive. D) The Babinski sign is not affected in polyneuropathy. Page Ref: 392 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 15.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of common conditions associated with HIV and AIDS and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of immunodeficiency.

11) A 1-year-old baby is being seen at the clinic because his parents are worried that he is always sick. The healthcare team is concerned that the baby may have a primary immunodeficiency (PI). Which assessment data would support a diagnosis of PI? A) Four or more new ear infections within 1 year and failure to gain weight normally B) One bout of pneumonia in a year and failure to gain weight normally C) One month on antibiotics with little effect and failure to gain weight normally D) One serious sinus infection in a year and failure to gain weight normally Answer: A Explanation: A) The Jeffrey Modell Foundation and the American Red Cross have identified 10 warning signs of PI in an attempt to assist with early detection. If an individual has two or more of the following, a diagnosis of PI should be considered: four or more new ear infections within 1 year; two or more serious sinus infections within 1 year; two or more months on antibiotics with little effect; two or more pneumonias within 1 year; failure of an infant to gain weight or grow normally; recurrent, deep skin or organ abscesses; persistent thrush or fungal infection on skin; need for intravenous antibiotics to clear infection; two or more deep-seated infections including septicemia; a family history of PI. B) The Jeffrey Modell Foundation and the American Red Cross have identified 10 warning signs of PI in an attempt to assist with early detection. If an individual has two or more of the following, a diagnosis of PI should be considered: four or more new ear infections within 1 year; two or more serious sinus infections within 1 year; two or more months on antibiotics with little effect; two or more pneumonias within 1 year; failure of an infant to gain weight or grow normally; recurrent, deep skin or organ abscesses; persistent thrush or fungal infection on skin; need for intravenous antibiotics to clear infection; two or more deep-seated infections including septicemia; a family history of PI. C) The Jeffrey Modell Foundation and the American Red Cross have identified 10 warning signs of PI in an attempt to assist with early detection. If an individual has two or more of the following, a diagnosis of PI should be considered: four or more new ear infections within 1 year; two or more serious sinus infections within 1 year; two or more months on antibiotics with little effect; two or more pneumonias within 1 year; failure of an infant to gain weight or grow normally; recurrent, deep skin or organ abscesses; persistent thrush or fungal infection on skin; need for intravenous antibiotics to clear infection; two or more deep-seated infections including septicemia; a family history of PI. D) The Jeffrey Modell Foundation and the American Red Cross have identified 10 warning signs of PI in an attempt to assist with early detection. If an individual has two or more of the following, a diagnosis of PI should be considered: four or more new ear infections within 1 year; two or more serious sinus infections within 1 year; two or more months on antibiotics with little effect; two or more pneumonias within 1 year; failure of an infant to gain weight or grow normally; recurrent, deep skin or organ abscesses; persistent thrush or fungal infection on skin; need for intravenous antibiotics to clear infection; two or more deep-seated infections including septicemia; a family history of PI. Page Ref: 393 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation

Standards: Nursing Process: Assessment | Learning Outcome: 15.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of primary immunodeficiencies and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of immunodeficiency to diagnosis and treatment.

12) The nurse is teaching an HIV-infected patient about highly active antiretroviral therapy (HAART). The nurse should consider the teaching effective if the patient says: A) "HAART reduces antiretroviral drug toxicity." B) "HAART includes drugs from two different antiretroviral drug classes." C) "HAART with a minimum of three antiretroviral medications reduces the chance of developing viral resistance." D) "Therapy starts with one medication with others added as needed." Answer: C Explanation: A) Typically, treatment of HIV combines a minimum of three medications that diminish viral replication. Use of a combination of antiretroviral drugs, which is sometimes referred to as highly active antiretroviral therapy (HAART), helps to decrease viral resistance to the medications. A risk of HAART is the development of drug toxicity. B) Typically, treatment of HIV combines a minimum of three medications that diminish viral replication. Use of a combination of antiretroviral drugs, which is sometimes referred to as highly active antiretroviral therapy (HAART), helps to decrease viral resistance to the medications. A risk of HAART is the development of drug toxicity. C) Typically, treatment of HIV combines a minimum of three medications that diminish viral replication. Use of a combination of antiretroviral drugs, which is sometimes referred to as highly active antiretroviral therapy (HAART), helps to decrease viral resistance to the medications. A risk of HAART is the development of drug toxicity. D) Typically, treatment of HIV combines a minimum of three medications that diminish viral replication. Use of a combination of antiretroviral drugs, which is sometimes referred to as highly active antiretroviral therapy (HAART), helps to decrease viral resistance to the medications. A risk of HAART is the development of drug toxicity. Page Ref: 390-391 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Evaluation | Learning Outcome: 15.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of acquired immunodeficiency syndrome and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of immunodeficiency to diagnosis and treatment.

13) An HIV-infected patient has cytomegalovirus (CMV) retinitis and a CD4+ lymphocyte count of 150 cells/mm3. How should the nurse interpret this data? A) The patient has primary HIV infection. B) The patient is in the chronic stage of HIV infection. C) The patient has symptomatic HIV. D) The patient has AIDS. Answer: D Explanation: A) Primary HIV infection is a nonspecific, acute syndrome that occurs 2-4 weeks after viral infection and lasts for 1-2 weeks. The most common signs and symptoms are fever, fatigue, headache, arthralgias, lymphadenopathy, and a maculopapular rash that affects the face and trunk. CD4+ may have a transient decrease followed by a rise, although not to preinfection levels. B) After the acute infection subsides, most individuals show no clinical manifestations of HIV infection for several years. However, during this prolonged asymptomatic period, HIV actively replicates, and there is an intense reduction in the half-life of circulating CD4+ T lymphocytes. C) HIV-related conditions develop as CD4+ T-lymphocyte counts decline. Early conditions are generally non-life-threatening and include headache and fatigue. Over time, the conditions become more severe and include fever, night sweats, diarrhea, and mucocutaneous abnormalities. D) HIV-related conditions develop as CD4+ T-lymphocyte counts decline. Early conditions include headache and fatigue. Over time, the conditions become more severe and include fever, night sweats, diarrhea, and mucocutaneous abnormalities. The most advanced stage of HIV infection is AIDS, characterized by severe immunodeficiency (i.e., CD4+ T-lymphocyte count < 200 cells/mm3), opportunistic infections (such as CMV), and/or malignancies. Page Ref: 389 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 15.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of acquired immunodeficiency syndrome and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of immunodeficiency.

14) The nurse is instructing an HIV-infected patient who is starting HAART. Which statement indicates that the teaching has been effective? A) "I will not stop taking my medication without contacting my doctor." B) "If side effects develop, I will stop the medication until symptoms subside." C) "I can stop my medication once my viral load is undetectable." D) "I cannot transmit the virus while I am taking my medication." Answer: A Explanation: A) Interruption of antiretroviral therapy typically is not recommended, as cessation of treatment may result in viral rebound, leading to even more pronounced immunosuppression and worsening of the individual's overall health status. B) Interruption of antiretroviral therapy typically is not recommended, as cessation of treatment may result in viral rebound, leading to even more pronounced immunosuppression and worsening of the individual's overall health status. If side effects develop, the client should contact the healthcare provider for direction and should not stop taking medication on his own. C) Interruption of antiretroviral therapy typically is not recommended, as cessation of treatment may result in viral rebound, leading to even more pronounced immunosuppression and worsening of the individual's overall health status. An undetectable viral load is not an indication to stop the medication. D) Interruption of antiretroviral therapy typically is not recommended, as cessation of treatment may result in viral rebound, leading to even more pronounced immunosuppression and worsening of the individual's overall health status. HIV can still be transmitted while taking HAART. Page Ref: 390 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Evaluation | Learning Outcome: 15.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of acquired immunodeficiency syndrome and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of immunodeficiency to diagnosis and treatment.

15) The nurse is teaching a patient about the use of early HAART to treat HIV. Which statement by the patient indicates that he does not understand the teaching? A) "Early HAART increases the risk of drug toxicities that will limit treatment options in the future." B) "Early HAART can increase the risk of developing drug-resistant mutants that will limit treatment options for symptomatic disease." C) "Early HAART does not affect the ability to transmit drug-resistant mutants to uninfected people." D) "Early HAART reduces the risk of transmitting HIV to uninfected people." Answer: C Explanation: A) The potential benefits for early therapy include preservation of immune function, prolongation of clinical latency, and a possible reduced risk of transmission. Potential risks of early therapy include drug toxicities, possible development of drug-resistant mutants that will limit treatment options in symptomatic disease, and the risk of transmitting drug-resistant mutants to uninfected individuals, thus limiting their treatment options. B) The potential benefits for early therapy include preservation of immune function, prolongation of clinical latency, and a possible reduced risk of transmission. Potential risks of early therapy include drug toxicities, possible development of drug-resistant mutants that will limit treatment options in symptomatic disease, and the risk of transmitting drug-resistant mutants to uninfected individuals, thus limiting their treatment options. C) The potential benefits for early therapy include preservation of immune function, prolongation of clinical latency, and a possible reduced risk of transmission. Potential risks of early therapy include drug toxicities, possible development of drug-resistant mutants that will limit treatment options in symptomatic disease, and the risk of transmitting drug-resistant mutants to uninfected individuals, thus limiting their treatment options. D) The potential benefits for early therapy include preservation of immune function, prolongation of clinical latency, and a possible reduced risk of transmission. Potential risks of early therapy include drug toxicities, possible development of drug-resistant mutants that will limit treatment options in symptomatic disease, and the risk of transmitting drug-resistant mutants to uninfected individuals, thus limiting their treatment options. Page Ref: 391 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Evaluation | Learning Outcome: 15.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of acquired immunodeficiency syndrome and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of immunodeficiency to diagnosis and treatment.

16) What finding should alert the nurse to a potential cytomegalovirus (CMV) infection in an HIV-infected patient? A) Blurry vision B) Burning on urination (dysuria) C) Sore throat D) Muscle aches Answer: A Explanation: A) Cytomegalovirus (CMV) is a virus carried by 60% of the U.S. population. It can be found in blood, saliva, semen, cervical secretions, and urine. Normally, the immune system inhibits CMV replication. In individuals with severe immunosuppression (typically when the CD4+ T-lymphocyte count drops below 50 cells/mm3), active viral replication can occur with dissemination to target tissues such as the retina, gut, lungs, and CNS. CMV retinitis is the most common CMV infection, accounting for 80-90% of all CMV infections among AIDS patients. Dysuria, sore throat, and muscle aches are not typical symptoms of CMV. B) Cytomegalovirus (CMV) is a virus carried by 60% of the U.S. population. It can be found in blood, saliva, semen, cervical secretions, and urine. Normally, the immune system inhibits CMV replication. In individuals with severe immunosuppression (typically when the CD4+ Tlymphocyte count drops below 50 cells/mm3), active viral replication can occur with dissemination to target tissues such as the retina, gut, lungs, and CNS. CMV retinitis is the most common CMV infection, accounting for 80-90% of all CMV infections among AIDS patients. Dysuria, sore throat, and muscle aches are not typical symptoms of CMV. C) Cytomegalovirus (CMV) is a virus carried by 60% of the U.S. population. It can be found in blood, saliva, semen, cervical secretions, and urine. Normally, the immune system inhibits CMV replication. In individuals with severe immunosuppression (typically when the CD4+ Tlymphocyte count drops below 50 cells/mm3), active viral replication can occur with dissemination to target tissues such as the retina, gut, lungs, and CNS. CMV retinitis is the most common CMV infection, accounting for 80-90% of all CMV infections among AIDS patients. Dysuria, sore throat, and muscle aches are not typical symptoms of CMV. D) Cytomegalovirus (CMV) is a virus carried by 60% of the U.S. population. It can be found in blood, saliva, semen, cervical secretions, and urine. Normally, the immune system inhibits CMV replication. In individuals with severe immunosuppression (typically when the CD4+ Tlymphocyte count drops below 50 cells/mm3), active viral replication can occur with dissemination to target tissues such as the retina, gut, lungs, and CNS. CMV retinitis is the most common CMV infection, accounting for 80-90% of all CMV infections among AIDS patients. Dysuria, sore throat, and muscle aches are not typical symptoms of CMV. Page Ref: 391 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 15.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of common conditions associated with HIV and AIDS and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches 17

NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of immunodeficiency. 17) Which laboratory test results would the nurse check to determine the effectiveness of an antiretroviral medication in an HIV-infected patient? A) Western blot B) HIV RNA C) HIV ELISA D) Phenotypic resistance analyses Answer: B Explanation: A) Western Blot is used to confirm seropositive HIV ELISA results. B) HIV RNA test quantitates viral load in plasma and is used to monitor the response to antiretroviral therapy. C) HIV ELISA detects the presence of anti-HIV antibodies. If reactive, the results are confirmed with Western blot. D) Phenotypic resistance analysis determines viral susceptibility to antiretroviral drugs. Page Ref: 389 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Evaluation | Learning Outcome: 15.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of acquired immunodeficiency syndrome and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of immunodeficiency to diagnosis and treatment.

18) Laboratory results indicate that the viral load of a newly diagnosed, untreated HIV-infected client has stabilized. The nurse explains to the patient that: A) he has primary HIV infection. B) he is experiencing seroconversion. C) he has reached the viral set point. D) he has chronic HIV. Answer: C Explanation: A) Primary HIV infection is a nonspecific, acute syndrome that occurs 2-4 weeks after viral infection and lasts for 1-2 weeks. Because an effective immune response has not yet been mounted, viral titers are typically very high. B) Seroconversion occurs when neutralizing antibodies appear, generally within a few weeks to a few months after infection. The period between infection and the appearance of neutralizing antibodies is called the window period. C) In untreated individuals, the viral load tends to stabilize approximately 6 months after infection. This stable viral load is known as the viral set point, and higher levels have been shown to correlate with rapid CD4+ T-lymphocyte depletion and subsequent disease progression. D) After the acute infection subsides, most individuals show no clinical manifestations of HIV infection for several years, even in the absence of treatment. However, during this prolonged asymptomatic period of chronic disease, HIV actively replicates, and there is an intense reduction in the half-life of circulating CD4+ T lymphocytes. Page Ref: 387 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 15.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of acquired immunodeficiency syndrome and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of immunodeficiency to diagnosis and treatment.

19) Which combination of antiretroviral drugs would the nurse be most likely to administer in a patient when antiviral drug resistance testing is not available? A) Ritonavir-boosted protease inhibitors (RTV-boosted PIs) and nucleoside reverse transcriptase inhibitors (NRTIs) B) Nonnucleoside reverse transcriptase inhibitors (NNRTIs) and NRTIs C) Protease inhibitors and fusion inhibitors D) Early inhibitors and integrase strand transfer inhibitors (INSTIs) Answer: A Explanation: A) To guide the choice of medications, treatment of individuals who have earlystage HIV infection should be preceded by genotypic antiviral resistance testing. When genotypic antiviral drug resistance testing is unavailable, HAART still may be initiated. Resistance to ritonavir (RTV)-boosted protease inhibitors typically develops slowly, and NRTIs are not prone to clinically significant TDR. As such, a combination of RTV-boosted PIs and NRTIs is recommended for individuals who do not undergo genotypic antiviral drug resistance testing. B) To guide the choice of medications, treatment of individuals who have early-stage HIV infection should be preceded by genotypic antiviral resistance testing. When genotypic antiviral drug resistance testing is unavailable, HAART still may be initiated. Resistance to ritonavir (RTV)-boosted protease inhibitors typically develops slowly, and NRTIs are not prone to clinically significant TDR. As such, a combination of RTV-boosted PIs and NRTIs is recommended for individuals who do not undergo genotypic antiviral drug resistance testing. C) To guide the choice of medications, treatment of individuals who have early-stage HIV infection should be preceded by genotypic antiviral resistance testing. When genotypic antiviral drug resistance testing is unavailable, HAART still may be initiated. Resistance to ritonavir (RTV)-boosted protease inhibitors typically develops slowly, and NRTIs are not prone to clinically significant TDR. As such, a combination of RTV-boosted PIs and NRTIs is recommended for individuals who do not undergo genotypic antiviral drug resistance testing. D) To guide the choice of medications, treatment of individuals who have early-stage HIV infection should be preceded by genotypic antiviral resistance testing. When genotypic antiviral drug resistance testing is unavailable, HAART still may be initiated. Resistance to ritonavir (RTV)-boosted protease inhibitors typically develops slowly, and NRTIs are not prone to clinically significant TDR. As such, a combination of RTV-boosted PIs and NRTIs is recommended for individuals who do not undergo genotypic antiviral drug resistance testing. Page Ref: 390 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Implementation | Learning Outcome: 15.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of acquired immunodeficiency syndrome and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: | AACN Essential Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of immunodeficiency to diagnosis and treatment.

20) When assessing a patient with HIV-related lipodystrophy, the nurse would expect to find: A) truncal obesity and hypoglycemia. B) dyslipidemia and insulin resistance. C) hypoglycemia and dyslipidemia. D) increased subcutaneous fat deposits and truncal obesity. Answer: B Explanation: A) HIV-associated lipodystrophy syndrome refers to a collection of morphologic and metabolic abnormalities that include insulin resistance, glucose intolerance, dyslipidemia, and fat redistribution (i.e., truncal obesity and peripheral wasting). Glucose intolerance and insulin resistance results in hyperglycemia (elevated blood glucose), and peripheral wasting results in decreased subcutaneous fat deposits in regions of the face, arms, legs, and buttocks. B) HIV-associated lipodystrophy syndrome refers to a collection of morphologic and metabolic abnormalities that include insulin resistance, glucose intolerance, dyslipidemia, and fat redistribution (i.e., truncal obesity and peripheral wasting). Glucose intolerance and insulin resistance results in hyperglycemia (elevated blood glucose), and peripheral wasting results in decreased subcutaneous fat deposits in regions of the face, arms, legs, and buttocks. C) HIV-associated lipodystrophy syndrome refers to a collection of morphologic and metabolic abnormalities that include insulin resistance, glucose intolerance, dyslipidemia, and fat redistribution (i.e., truncal obesity and peripheral wasting). Glucose intolerance and insulin resistance results in hyperglycemia (elevated blood glucose), and peripheral wasting results in decreased subcutaneous fat deposits in regions of the face, arms, legs, and buttocks. D) HIV-associated lipodystrophy syndrome refers to a collection of morphologic and metabolic abnormalities that include insulin resistance, glucose intolerance, dyslipidemia, and fat redistribution (i.e., truncal obesity and peripheral wasting). Glucose intolerance and insulin resistance results in hyperglycemia (elevated blood glucose), and peripheral wasting results in decreased subcutaneous fat deposits in regions of the face, arms, legs, and buttocks. Page Ref: 392 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 15.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of common conditions associated with HIV and AIDS and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of immunodeficiency.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 16 Disorders of White Blood Cells 1) When reviewing the medical record of a patient with Hodgkin lymphoma, the oncology nurse would expect to note the presence of: A) Reed-Sternberg cells. B) hypercalcemia. C) a history of substance abuse. D) malignant plasma cells. Answer: A Explanation: A) Hodgkin lymphoma, named after the British physician who first described the disease, is a specific type of lymphoma characterized by the presence of Reed-Sternberg cells. B) In multiple myeloma, heightened levels of calcium can occur in the bloodstream, leading to hypercalcemia, a disruption of fluid and electrolyte balance. C) The causes of multiple myeloma are not well understood, but obesity, toxin exposure, and substance abuse appear to play roles along with genetic influences. D) Multiple myeloma is a cancer involving a group of B cells known as plasma cells. These are B cells that produce large amounts of antibodies. Page Ref: 402 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 16.1 Describe the basis of disorders of white blood cells and concepts related to those disorders. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of disorders of white blood cells.

2) Which statement by a patient recently diagnosed with acute myelogenous leukemia indicates that the patient does not understand the staging process? A) "Staging helps my doctors plan my treatment." B) "Staging will help determine my prognosis." C) "Staging can help the doctors determine how long I have to live." D) "Staging is useful for research on my type of cancer." Answer: C Explanation: A) For all cancers, the stage of the disease determines the treatment. Staging or classifying cancers, such as leukemias, serves a number or very important functions such as (1) helping the clinician to plan an appropriate treatment strategy, (2) providing some indication of prognosis, (3) facilitating communication between clinicians and across institutions, and (4) facilitating clinical research. A classification system also helps the patient understand the prognosis so that the patient and family can make the needed adjustments in their lives. B) For all cancers, the stage of the disease determines the treatment. Staging or classifying cancers, such as leukemias, serves a number or very important functions such as (1) helping the clinician to plan an appropriate treatment strategy, (2) providing some indication of prognosis, (3) facilitating communication between clinicians and across institutions, and (4) facilitating clinical research. A classification system also helps the patient understand the prognosis so that the patient and family can make the needed adjustments in their lives. C) For all cancers, the stage of the disease determines the treatment. Staging or classifying cancers, such as leukemias, serves a number or very important functions such as (1) helping the clinician to plan an appropriate treatment strategy, (2) providing some indication of prognosis, (3) facilitating communication between clinicians and across institutions, and (4) facilitating clinical research. A classification system also helps the patient understand the prognosis so that the patient and family can make the needed adjustments in their lives. Staging does not predict how long a patient has to live. D) For all cancers, the stage of the disease determines the treatment. Staging or classifying cancers, such as leukemias, serves a number or very important functions such as (1) helping the clinician to plan an appropriate treatment strategy, (2) providing some indication of prognosis, (3) facilitating communication between clinicians and across institutions, and (4) facilitating clinical research. A classification system also helps the patient understand the prognosis so that the patient and family can make the needed adjustments in their lives. Page Ref: 403 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 16.2 Identify the morphologic classification, etiology and pathogenesis, and clinical manifestations of acute myelogenous leukemia and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.9 Monitor client outcomes to evaluate the effectiveness of psychobiological interventions. NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of immunodeficiency to diagnosis and treatment.

3) Which laboratory result would the nurse expect in a patient with acute myelogenous leukemia (AML)? A) Polycythemia B) Thrombocytosis C) Pancytopenia D) Hemoglobinemia Answer: C Explanation: A) In AML, crowding of the bone marrow with abnormal cells results in loss of function and eventually leads to pancytopenia (anemia, neutropenia, and thrombocytopenia), as the bone marrow is unable to produce sufficient numbers of normal hematopoietic cells. Pancytopenia may lead to anemia, infections, and bleeding. B) In AML, crowding of the bone marrow with abnormal cells results in loss of function and eventually leads to pancytopenia (anemia, neutropenia, and thrombocytopenia), as the bone marrow is unable to produce sufficient numbers of normal hematopoietic cells. Pancytopenia may lead to anemia, infections, and bleeding. C) In AML, crowding of the bone marrow with abnormal cells results in loss of function and eventually leads to pancytopenia (anemia, neutropenia, and thrombocytopenia), as the bone marrow is unable to produce sufficient numbers of normal hematopoietic cells. Pancytopenia may lead to anemia, infections, and bleeding. D) In AML, crowding of the bone marrow with abnormal cells results in loss of function and eventually leads to pancytopenia (anemia, neutropenia, and thrombocytopenia), as the bone marrow is unable to produce sufficient numbers of normal hematopoietic cells. Pancytopenia may lead to anemia, infections, and bleeding. Page Ref: 404 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 16.2 Identify the morphologic classification, etiology and pathogenesis, and clinical manifestations of acute myelogenous leukemia and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of disorders of white blood cells.

4) Which findings are typical of data collected on patients with AML who experience leukocytosis? A) Headache and diplopia B) Weakness and fatigue C) Fever and infection D) Ecchymosis and epistaxis Answer: A Explanation: A) Patients with AML who experience leukocytosis (an abnormally elevated white blood cell count) occasionally present with headache, diplopia, cranial nerve palsies, and mental status changes. B) Weakness and fatigue related to anemia are common complaints in people with AML, not just those with leukocytosis. C) Unresolved fever and infection related to neutropenia may be present and are potentially life threatening, depending on the severity of the infection. These issues are found in all patients with AML, not just those with leukocytosis. D) Individuals with AML may present with bleeding problems related to thrombocytopenia. This may present as ecchymoses, petechiae, epistaxis, bleeding from the gums, and menorrhagia in women. The severity of the symptoms ranges from mild bleeding to frank hemorrhaging, depending on the degree of thrombocytopenia. These issues are found in all patients with AML, not just those with leukocytosis. Page Ref: 404 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 16.2 Identify the morphologic classification, etiology and pathogenesis, and clinical manifestations of acute myelogenous leukemia and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of disorders of white blood cells.

5) When developing a plan of care for a patient with acute myelogenous leukemia (AML), the oncology nurse should keep in mind that: A) consolidation therapy uses low-dose chemotherapy to maintain remission. B) induction therapy reduces the leukemic cell burden. C) consolidation therapy is given to induce remission. D) induction therapy eliminates all cancer cells Answer: B Explanation: A) Consolidation therapy, consisting of one or more courses of high-dose chemotherapy and/or hematopoietic stem cell transplantation, is given to eradicate undetected leukemic cells so that a cure is possible. B) Induction chemotherapy is given to induce a complete remission. Although induction therapy substantially reduces the leukemic cell burden, it is generally assumed that residual disease still exists and that some leukemic cells (fewer than 1 0 9 cells) will have survived induction therapy. This minimal residual disease is the target of consolidation therapy. C) Induction chemotherapy is given to induce a complete remission. D) Although induction therapy substantially reduces the leukemic cell burden, it is generally assumed that residual disease still exists and that some leukemic cells (fewer than 109 cells) will have survived induction therapy. Page Ref: 405 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Planning | Learning Outcome: 16.2 Identify the morphologic classification, etiology and pathogenesis, and clinical manifestations of acute myelogenous leukemia and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of white blood cells to diagnosis and treatment.

6) The pediatric oncology nurse is caring for a 5-year-old child newly diagnosed with acute lymphocytic leukemia (ALL). How should the nurse respond when the parent asks about the prognosis of this disease? A) "Five-year-old children fare better than infants or teens." B) "Male children tend to have a better prognosis than females." C) "African American children have a slightly higher survival rate than Caucasian children." D) "Children with a white blood cell count below 50,000/µL have a poorer prognosis." Answer: A Explanation: A) The prognostic variables for childhood ALL include (1) age at diagnosis, children between the ages of 1 and 9 years faring better than infants or older children; (2) white blood cell count at diagnosis, as counts above 50,000/mL are indicative of a poorer prognosis; (3) central nervous system (CNS) status at diagnosis, CNS involvement signifying greater risk for relapse; (4) gender, girls faring better than boys (although this is not evident in all studies); and (5) race, survival rates for Caucasian children being slightly higher than those for African American and Hispanic children. B) The prognostic variables for childhood ALL include (1) age at diagnosis, children between the ages of 1 and 9 years faring better than infants or older children; (2) white blood cell count at diagnosis, as counts above 50,000/mL are indicative of a poorer prognosis; (3) central nervous system (CNS) status at diagnosis, CNS involvement signifying greater risk for relapse; (4) gender, girls faring better than boys (although this is not evident in all studies); and (5) race, survival rates for Caucasian children being slightly higher than those for African American and Hispanic children. C) The prognostic variables for childhood ALL include (1) age at diagnosis, children between the ages of 1 and 9 years faring better than infants or older children; (2) white blood cell count at diagnosis, as counts above 50,000/mL are indicative of a poorer prognosis; (3) central nervous system (CNS) status at diagnosis, CNS involvement signifying greater risk for relapse; (4) gender, girls faring better than boys (although this is not evident in all studies); and (5) race, survival rates for Caucasian children being slightly higher than those for African American and Hispanic children. D) The prognostic variables for childhood ALL include (1) age at diagnosis, children between the ages of 1 and 9 years faring better than infants or older children; (2) white blood cell count at diagnosis, as counts above 50,000/mL are indicative of a poorer prognosis; (3) central nervous system (CNS) status at diagnosis, CNS involvement signifying greater risk for relapse; (4) gender, girls faring better than boys (although this is not evident in all studies); and (5) race, survival rates for Caucasian children being slightly higher than those for African American and Hispanic children. Page Ref: 406 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 16.3 Identify the morphologic classification, etiology and pathogenesis, and clinical manifestations of acute lymphocytic leukemia and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care 6

NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of disorders of white blood cells. 7) In a child with acute lymphocytic leukemia (ALL), which manifestations are due to thrombocytopenia? A) Weakness and fatigue B) Bleeding and bruising C) Fever and enlarged lymph nodes D) Bone pain and limping Answer: B Explanation: A) Infection related to neutropenia, weakness and fatigue related to anemia, and bleeding related to thrombocytopenia may be clinically evident on diagnosis in children. Children with ALL may present with additional signs and symptoms that are consistent with sitespecific organ infiltration of leukemic cells, such as bone pain and enlarged lymph nodes. B) Infection related to neutropenia, weakness and fatigue related to anemia, and bleeding related to thrombocytopenia may be clinically evident on diagnosis in children. Children with ALL may present with additional signs and symptoms that are consistent with site-specific organ infiltration of leukemic cells, such as bone pain and enlarged lymph nodes. C) Infection related to neutropenia, weakness and fatigue related to anemia, and bleeding related to thrombocytopenia may be clinically evident on diagnosis in children. Children with ALL may present with additional signs and symptoms that are consistent with site-specific organ infiltration of leukemic cells, such as bone pain and enlarged lymph nodes. D) Infection related to neutropenia, weakness and fatigue related to anemia, and bleeding related to thrombocytopenia may be clinically evident on diagnosis in children. Children with ALL may present with additional signs and symptoms that are consistent with site-specific organ infiltration of leukemic cells, such as bone pain and enlarged lymph nodes. Page Ref: 407 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 16.3 Identify the morphologic classification, etiology and pathogenesis, and clinical manifestations of acute lymphocytic leukemia and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of white blood cells.

8) In evaluating the effectiveness of induction therapy in a child with acute lymphocytic leukemia, the nurse should expect: A) eradication of 99% of leukemic cells. B) no rejection of stem cell transplantation. C) elimination of residual disease. D) complete eradication of the disease. Answer: A Explanation: A) The goal of induction therapy is to eradicate 99% of leukemic cells. B) Consolidation therapy, not induction therapy, consists of one or more courses of high-dose chemotherapy and/or hematopoietic stem cell transplantation and is given to eradicate undetected leukemic cells and potentially obtain a cure. C) Induction therapy is given to induce a remission, followed by consolidation therapy to eliminate residual disease. D) Consolidation therapy, consisting of one or more courses of high-dose chemotherapy and/or hematopoietic stem cell transplantation, is given to eradicate undetected leukemic cells and potentially obtain a cure. Page Ref: 408 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 16.3 Identify the morphologic classification, etiology and pathogenesis, and clinical manifestations of acute lymphocytic leukemia and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of white blood cells to diagnosis and treatment.

9) A patient in the chronic phase of chronic myelogenous leukemia (CML) will meet which criteria? A) Blast cells account for less than 10% of all cells in blood or bone marrow. B) Blast cells account for 10-19% of all cells in blood or bone marrow. C) Blast cells account for 20-49% of all cells in blood or bone marrow. D) Blast cells account for more than 50% of all cells in blood or bone marrow. Answer: A Explanation: A) Staging systems for CML do not exist; instead, CML is classified according to phase (chronic, accelerated, or blast), which is based on the number of blast cells present in the blood and bone marrow. In chronic phase CML, blast cells account for fewer than 10% of all cells in the blood or bone marrow. In accelerated phase CML, blast cells increase and account for 10-19% of all cells in the blood or marrow. During the blastic phase, blast cells account for over 20% of all cells in the blood or marrow. B) Staging systems for CML do not exist; instead, CML is classified according to phase (chronic, accelerated, or blast), which is based on the number of blast cells present in the blood and bone marrow. In chronic phase CML, blast cells account for fewer than 10% of all cells in the blood or bone marrow. In accelerated phase CML, blast cells increase and account for 1019% of all cells in the blood or marrow. During the blastic phase, blast cells account for over 20% of all cells in the blood or marrow. C) Staging systems for CML do not exist; instead, CML is classified according to phase (chronic, accelerated, or blast), which is based on the number of blast cells present in the blood and bone marrow. In chronic phase CML, blast cells account for fewer than 10% of all cells in the blood or bone marrow. In accelerated phase CML, blast cells increase and account for 1019% of all cells in the blood or marrow. During the blastic phase, blast cells account for over 20% of all cells in the blood or marrow. D) Staging systems for CML do not exist; instead, CML is classified according to phase (chronic, accelerated, or blast), which is based on the number of blast cells present in the blood and bone marrow. In chronic phase CML, blast cells account for fewer than 10% of all cells in the blood or bone marrow. In accelerated phase CML, blast cells increase and account for 1019% of all cells in the blood or marrow. During the blastic phase, blast cells account for over 20% of all cells in the blood or marrow. Page Ref: 408 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 16.4 Identify the morphologic classification, etiology and pathogenesis, and clinical manifestations of chronic myelogenous leukemia and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of white blood cells to diagnosis and treatment.

10) In a patient with chronic myelogenous leukemia (CML), which manifestation(s) would the nurse expect to find caused by splenomegaly? A) Excessive sweating and night sweats B) Joint pain with joint splinting C) Weakness and fatigue D) Abdominal pain referred to the left shoulder Answer: D Explanation: A) The degree of pancytopenia that is seen in CML depends on the degree of marrow overcrowding. Infection related to neutropenia, weakness and fatigue related to anemia, and bleeding related to thrombocytopenia may be present on diagnosis. Symptoms can also include excessive sweating or night sweats. However, these manifestations of illness are not due to splenomegaly. B) Acute gouty arthritis manifested as joint pain may also present in CML, caused by an overproduction of uric acid. However, these manifestations of illness are not due to splenomegaly. C) The degree of pancytopenia that is seen in CML depends on the degree of marrow overcrowding. Infection related to neutropenia, weakness and fatigue related to anemia, and bleeding related to thrombocytopenia may be present on diagnosis. Symptoms can also include excessive sweating or night sweats. However, these manifestations of illness are not due to splenomegaly. D) Infiltration of the abnormal cells in the spleen can cause splenomegaly with abdominal pain, discomfort, early satiety, and upper left quadrant pain that is sometimes referred to the left shoulder. Page Ref: 409 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 16.4 Identify the morphologic classification, etiology and pathogenesis, and clinical manifestations of chronic myelogenous leukemia and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of white blood cells.

11) Which individual is at most risk for developing chronic lymphocytic leukemia (CLL)? A) A 65-year-old Caucasian man B) A 65-year-old Asian man C) A 25-year-old Caucasian man D) A 25-year-old Asian man Answer: A Explanation: A) CLL is primarily a disease of older adults, the incidence increasing dramatically in people over the age of 50 years. People as young as 30-39 years are being diagnosed with CLL, although this is less common. The incidence of CLL is highest among whites, while people of Asian descent have the lowest incidence rates. B) CLL is primarily a disease of older adults, the incidence increasing dramatically in people over the age of 50 years. People as young as 30-39 years are being diagnosed with CLL, although this is less common. The incidence of CLL is highest among whites, while people of Asian descent have the lowest incidence rates. C) CLL is primarily a disease of older adults, the incidence increasing dramatically in people over the age of 50 years. People as young as 30-39 years are being diagnosed with CLL, although this is less common. The incidence of CLL is highest among whites, while people of Asian descent have the lowest incidence rates. D) CLL is primarily a disease of older adults, the incidence increasing dramatically in people over the age of 50 years. People as young as 30-39 years are being diagnosed with CLL, although this is less common. The incidence of CLL is highest among whites, while people of Asian descent have the lowest incidence rates. Page Ref: 410 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 16.5 Identify the morphologic classification, etiology and pathogenesis, and clinical manifestations of chronic lymphocytic leukemia and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of disorders of white blood cells.

12) The oncology nurse assessing a patient with Rai stage II chronic lymphocytic leukemia (CLL) will most likely find: A) lymphocytosis and no enlargement of the lymph nodes, spleen, or liver. B) lymphocytosis, an enlarged spleen, and possibly an enlarged liver. C) lymphocytosis, anemia, and possibly an enlarged spleen or liver. D) lymphocytosis, thrombocytopenia, and possibly anemia, enlarged lymph nodes, spleen, or liver. Answer: B Explanation: A) Rai stage I is characterized by lymphocytosis plus enlarged lymph nodes. The spleen and liver are not enlarged, and the red blood cell and platelet counts are near normal. This is not Rai Stage II. B) Rai stage II is characterized by lymphocytosis plus an enlarged spleen (and possibly an enlarged liver), with or without enlarged lymph nodes. The red blood cell and platelet counts are near normal. C) Rai stage III is characterized by lymphocytosis plus anemia, with or without enlarged lymph nodes, spleen, or liver. Platelet counts are near normal. This is not Rai Stage II. D) Rai stage IV is characterized by lymphocytosis plus thrombocytopenia, with or without anemia, enlarged lymph nodes, spleen, or liver. This is not Rai Stage II. Page Ref: 410 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 16.5 Identify the morphologic classification, etiology and pathogenesis, and clinical manifestations of chronic lymphocytic leukemia and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of white blood cells.

13) The oncology nurse is preparing a teaching plan for a patient with Binet Stage B chronic lymphocytic leukemia (CLL). Which patient statement indicates that the patient understands her current stage? A) "I have two areas of lymph node involvement, and my red cell and platelet counts are good." B) "I have three areas of lymph node involvement, and my red cell and platelet counts are good." C) "I have three areas of lymph node involvement, and my red cell and platelet counts are low." D) "I have two areas of lymph node involvement, and my red cell and platelet counts are low." Answer: B Explanation: A) The Binet system classifies CLL according to the number of affected lymphoid tissues in an effort to better address prognostic indicators. The areas of lymphoid tissue to be assessed include the axillary, cervical, and inguinal lymph nodes (unilateral or bilateral); the spleen; and the liver. In Stage A, the assessment indicates fewer than three areas of involvement with no anemia or thrombocytopenia. In Stage B, the assessment indicates three or more areas of enlarged lymphoid tissue with no anemia or thrombocytopenia. In Stage C, the assessment indicates anemia (hemoglobin less than 10 g/dL) and/or thrombocytopenia (platelets less than 100,000/mm3). B) The Binet system classifies CLL according to the number of affected lymphoid tissues in an effort to better address prognostic indicators. The areas of lymphoid tissue to be assessed include the axillary, cervical, and inguinal lymph nodes (unilateral or bilateral); the spleen; and the liver. In Stage A, the assessment indicates fewer than three areas of involvement with no anemia or thrombocytopenia. In Stage B, the assessment indicates three or more areas of enlarged lymphoid tissue with no anemia or thrombocytopenia. In Stage C, the assessment indicates anemia (hemoglobin less than 10 g/dL) and/or thrombocytopenia (platelets less than 100,000/mm3). C) The Binet system classifies CLL according to the number of affected lymphoid tissues in an effort to better address prognostic indicators. The areas of lymphoid tissue to be assessed include the axillary, cervical, and inguinal lymph nodes (unilateral or bilateral); the spleen; and the liver. In Stage A, the assessment indicates fewer than three areas of involvement with no anemia or thrombocytopenia. In Stage B, the assessment indicates three or more areas of enlarged lymphoid tissue with no anemia or thrombocytopenia. In Stage C, the assessment indicates anemia (hemoglobin less than 10 g/dL) and/or thrombocytopenia (platelets less than 100,000/mm3). D) The Binet system classifies CLL according to the number of affected lymphoid tissues in an effort to better address prognostic indicators. The areas of lymphoid tissue to be assessed include the axillary, cervical, and inguinal lymph nodes (unilateral or bilateral); the spleen; and the liver. In Stage A, the assessment indicates fewer than three areas of involvement with no anemia or thrombocytopenia. In Stage B, the assessment indicates three or more areas of enlarged lymphoid tissue with no anemia or thrombocytopenia. In Stage C, the assessment indicates anemia (hemoglobin less than 10 g/dL) and/or thrombocytopenia (platelets less than 100,000/mm3). Page Ref: 410 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation

Standards: Nursing Process: Evaluation | Learning Outcome: 16.5 Identify the morphologic classification, etiology and pathogenesis, and clinical manifestations of chronic lymphocytic leukemia and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of white blood cells to diagnosis and treatment. 14) Which symptoms would the nurse expect in a patient with chronic lymphocytic leukemia (CLL) who is being admitted to the oncology unit with B symptoms? A) Agranulocytosis and hypogammaglobinemia B) Anemia, thrombocytopenia, and autoimmune hemolytic anemia C) Night sweats and fever but no infection D) Lymphadenopathy, splenomegaly, and hepatomegaly Answer: C Explanation: A) Clinical findings in the patient with CLL may include anemia, thrombocytopenia, autoimmune hemolytic anemia, agranulocytosis, and hypogammaglobinemia, but these are not B symptoms. B) Clinical findings in the patient with CLL may include anemia, thrombocytopenia, autoimmune hemolytic anemia, agranulocytosis, and hypogammaglobinemia, but these are not B symptoms. C) Constitutional symptoms (B symptoms) may be present and include fever greater than 100.5°F for 2 weeks without evidence of infection, night sweats without evidence of infection, unintentional weight loss that can be 10% of body weight in the preceding 6 months, and fatigue that interferes with the patient's ability to perform activities of daily living. D) On physical examination, patients with CLL present with lymphadenopathy, splenomegaly, and/or hepatomegaly, but these are not B symptoms. Page Ref: 410 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 16.5 Identify the morphologic classification, etiology and pathogenesis, and clinical manifestations of chronic lymphocytic leukemia and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of white blood cells. 14

15) Which statement by the oncology nurse is most appropriate when teaching an asymptomatic patient in the early stage of chronic lymphocytic leukemia (CLL) about treatment? A) "CLL requires aggressive treatment in the early stages." B) "There is no treatment because CLL is not curable." C) "CLL is treated conservatively in the early stages." D) "In those who are asymptomatic, chemotherapy is used to induce remission." Answer: C Explanation: A) CLL generally progresses slowly, often with long periods of stability and occasional spontaneous remissions. Because the disease occurs primarily in older adults, follows an indolent course, and is not curable, a conservative approach to treatment is generally indicated. In patients with early-stage disease and without symptoms, watchful waiting is generally indicated. For patients with symptoms and/or more progressive disease, chemoimmunotherapy may be used. B) CLL generally progresses slowly, often with long periods of stability and occasional spontaneous remissions. Because the disease occurs primarily in older adults, follows an indolent course, and is not curable, a conservative approach to treatment is generally indicated. In patients with early-stage disease and without symptoms, watchful waiting is generally indicated. For patients with symptoms and/or more progressive disease, chemoimmunotherapy may be used. C) CLL generally progresses slowly, often with long periods of stability and occasional spontaneous remissions. Because the disease occurs primarily in older adults, follows an indolent course, and is not curable, a conservative approach to treatment is generally indicated. In patients with early-stage disease and without symptoms, watchful waiting is generally indicated. For patients with symptoms and/or more progressive disease, chemoimmunotherapy may be used. D) CLL generally progresses slowly, often with long periods of stability and occasional spontaneous remissions. Because the disease occurs primarily in older adults, follows an indolent course, and is not curable, a conservative approach to treatment is generally indicated. In patients with early-stage disease and without symptoms, watchful waiting is generally indicated. For patients with symptoms and/or more progressive disease, chemoimmunotherapy may be used. Page Ref: 411 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 16.5 Identify the morphologic classification, etiology and pathogenesis, and clinical manifestations of chronic lymphocytic leukemia and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of white blood cells to diagnosis and treatment.

16) Which characteristics should the oncology nurse expect when assessing a patient recently diagnosed with indolent non-Hodgkin lymphoma (NHL)? A) No discernible symptoms B) Painful lymphadenopathy C) Night sweats and unexplained fever D) Anemia and fatigue Answer: A Explanation: A) Indolent tumors, also called low-grade tumors, grow slowly and often do not result in discernible symptoms for patients at the time of diagnosis. Indolent lymphomas are frequently found accidentally in the course of a workup for another disorder. B) Lymphadenopathy or painless swelling of one or more lymph nodes (less than 1 centimeter) is the most common presenting sign of NHL. Lymphadenopathy, particularly nodes that are painful and localized, is a common manifestation of inflammation, particularly during an infectious process. However, these findings are not seen in indolent NHL. C) B symptoms include night sweats, unexplained fever, severe fatigue, weight loss, and appetite loss. However, these symptoms are not seen in indolent NHL. D) If the lymphoma involves the bone marrow, anemia may also be present, further contributing to fatigue. However, these manifestations of disease are not seen in indolent NHL. Page Ref: 412 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 16.6 Identify the morphologic classification, etiology and pathogenesis, and clinical manifestations of non-Hodgkin lymphoma and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of white blood cells.

17) Which statement by a patient with non-Hodgkin lymphoma (NHL) indicates that more teaching about chemotherapy is needed? A) "High grade NHL is treated with combination chemotherapy." B) "A watch and wait approach may be used in indolent NHL." C) "Slow growing NHL may be treated with one chemotherapeutic agent." D) "Chemotherapy is more effective in treating indolent disease." Answer: D Explanation: A) Low-grade or slow-growing NHL may be treated with only one drug. Intermediate or high-grade NHLs that are considered fast growing or aggressive are typically treated with combination chemotherapy. Because chemotherapy works best on cells that are actively dividing, chemotherapy for NHL is more effective for treating aggressive disease than indolent disease. In some cases of indolent disease without symptoms, watchful waiting or waiting until symptoms appear may be the treatment of choice. B) Low-grade or slow-growing NHL may be treated with only one drug. Intermediate or highgrade NHLs that are considered fast growing or aggressive are typically treated with combination chemotherapy. Because chemotherapy works best on cells that are actively dividing, chemotherapy for NHL is more effective for treating aggressive disease than indolent disease. In some cases of indolent disease without symptoms, watchful waiting or waiting until symptoms appear may be the treatment of choice. C) Low-grade or slow-growing NHL may be treated with only one drug. Intermediate or highgrade NHLs that are considered fast growing or aggressive are typically treated with combination chemotherapy. Because chemotherapy works best on cells that are actively dividing, chemotherapy for NHL is more effective for treating aggressive disease than indolent disease. In some cases of indolent disease without symptoms, watchful waiting or waiting until symptoms appear may be the treatment of choice. D) Low-grade or slow-growing NHL may be treated with only one drug. Intermediate or highgrade NHLs that are considered fast growing or aggressive are typically treated with combination chemotherapy. Because chemotherapy works best on cells that are actively dividing, chemotherapy for NHL is more effective for treating aggressive disease than indolent disease. In some cases of indolent disease without symptoms, watchful waiting or waiting until symptoms appear may be the treatment of choice. Page Ref: 414 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 16.6 Identify the morphologic classification, etiology and pathogenesis, and clinical manifestations of non-Hodgkin lymphoma and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: I.C.10 Value active partnership with patients or designated surrogates in planning, implementation, and evaluation of care | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of white blood cells to diagnosis and treatment.

18) When assessing a patient with newly diagnosed Hodgkin lymphoma (HL), the oncology nurse is most likely to palpate enlarged lymph nodes in the: A) neck. B) axilla. C) inguinal area. D) postauricular area. Answer: A Explanation: A) The most commonly involved site of lymph node enlargement is the neck; 6080% of patients have enlarged supraclavicular and/or cervical nodes. Enlarged lymph nodes in the axillae and the inguinal area are less common. B) The most commonly involved site of lymph node enlargement is the neck; 60-80% of patients have enlarged supraclavicular and/or cervical nodes. Enlarged lymph nodes in the axillae and theinguinal area are less common. C) The most commonly involved site of lymph node enlargement is the neck; 60-80% of patients have enlarged supraclavicular and/or cervical nodes. Enlarged lymph nodes in the axillae and theinguinal area are less common. D) The most commonly involved site of lymph node enlargement is the neck; 60-80% of patients have enlarged supraclavicular and/or cervical nodes. Enlarged lymph nodes in the axillae and the inguinal area are less common. Page Ref: 415 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 16.7 Identify the morphologic classification, etiology and pathogenesis, and clinical manifestations of Hodgkin lymphoma and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of white blood cells.

19) Multiple myeloma occurs predominantly in which patients? A) Young Black patients B) Young White patients C) Elderly Black patients D) Elderly White patients Answer: C Explanation: A) Multiple myeloma occurs primarily in individuals over age 60, and it occurs twice as often in Blacks as in Whites. B) Multiple myeloma occurs primarily in individuals over age 60, and it occurs twice as often in Blacks as in Whites. C) Multiple myeloma occurs primarily in individuals over age 60, and it occurs twice as often in Blacks as in Whites. D) Multiple myeloma occurs primarily in individuals over age 60, and it occurs twice as often in Blacks as in Whites. Page Ref: 415 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 16.8 Identify the morphologic classification, etiology and pathogenesis, and clinical manifestations of multiple myeloma and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: VII.1 Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities and populations NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of disorders of white blood cells.

20) A patient with multiple myeloma will most likely exhibit signs and symptoms of which type of anemia? A) Normochromic B) Macrocytic C) Hypochromic D) Microcytic Answer: A Explanation: A) Anemia (normocytic or normochromic) is a common symptom of multiple myeloma, resulting from the infiltration of bone marrow by plasma cells. B) Anemia (normocytic or normochromic) is a common symptom of multiple myeloma, resulting from the infiltration of bone marrow by plasma cells. C) Anemia (normocytic or normochromic) is a common symptom of multiple myeloma, resulting from the infiltration of bone marrow by plasma cells. D) Anemia (normocytic or normochromic) is a common symptom of multiple myeloma, resulting from the infiltration of bone marrow by plasma cells. Page Ref: 415 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 16.8 Identify the morphologic classification, etiology and pathogenesis, and clinical manifestations of multiple myeloma and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of white blood cells.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 17 Restrictive Lung Disorders 1) An assessment of a patient with restrictive lung disease will most likely reveal: A) shallow, rapid breathing. B) deep, slow breathing. C) shallow, slow breathing. D) deep, rapid breathing. Answer: A Explanation: A) When chest expansion is difficult because of a stiff, noncompliant chest wall or stiff lungs, more muscle work is required for a normal breath, so the body conserves energy with shallow, rapid respirations. B) When chest expansion is difficult because of a stiff, noncompliant chest wall or stiff lungs, more muscle work is required for a normal breath, so the body conserves energy with shallow, rapid respirations. C) When chest expansion is difficult because of a stiff, noncompliant chest wall or stiff lungs, more muscle work is required for a normal breath, so the body conserves energy with shallow, rapid respirations. D) When chest expansion is difficult because of a stiff, noncompliant chest wall or stiff lungs, more muscle work is required for a normal breath, so the body conserves energy with shallow, rapid respirations. Page Ref: 425 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 17.1 Explain the factors that alter ventilation and oxygenation in restrictive lung disorders and concepts related to restrictive lung disorders. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of neoplastic, infectious, and pulmonary vascular lung disorders.

2) Calculate the alveolar ventilation of a patient in the postanesthesia care unit, following general anesthesia, if the patient inhales 400 mL of air in each breath 10 times per minute. A) 1.5 L/min B) 2.0 L/min C) 2.5 L/min D) 3.0 L/min Answer: C Explanation: A) First subtract the dead space: 400 mL - 150 mL = 250 mL. Then, multiply the volume by the breaths per minute: 250 mL * 10 breaths/minute = 2500 mL/min. Convert to L/min: 2.5 L/min. B) First subtract the dead space: 400 mL - 150 mL = 250 mL. Then, multiply the volume by the breaths per minute: 250 mL * 10 breaths/minute = 2500 mL/min. Convert to L/min: 2.5 L/min C) First subtract the dead space: 400 mL - 150 mL = 250 mL. Then, multiply the volume by the breaths per minute: 250 mL * 10 breaths/minute = 2500 mL/min. Convert to L/min: 2.5 L/min D) First subtract the dead space: 400 mL - 150 mL = 250 mL. Then, multiply the volume by the breaths per minute: 250 mL * 10 breaths/minute = 2500 mL/min. Convert to L/min: 2.5 L/min Page Ref: 426 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 17.1 Explain the factors that alter ventilation and oxygenation in restrictive lung disorders and concepts related to restrictive lung disorders. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of neoplastic, infectious, and pulmonary vascular lung disorders.

3) How many breaths per minute does a patient who breathes 250 mL/breath need to achieve a normal alveolar ventilation of 4.2 L/minute? A) 12 breaths per minute B) 16 breaths per minute C) 20 breaths per minute D) 42 breaths per minute Answer: D Explanation: A) To achieve a normal alveolar ventilation of 4.2 L/min with breaths of 250 mL/breath first calculate the alveolar volume by subtracting the dead space: 250 mL - 150 mL = 100 mL. Then, convert the alveolar ventilation value from L to mL: 4200 mL/min. Now divide: 4200/100 = 42 breaths/minute. B) To achieve a normal alveolar ventilation of 4.2 L/min with breaths of 250 mL/breath first calculate the alveolar volume by subtracting the dead space: 250 mL - 150 mL = 100 mL. Then, convert the alveolar ventilation value from L to mL: 4200 mL/min. Now divide: 4200/100 = 42 breaths/minute. C) To achieve a normal alveolar ventilation of 4.2 L/min with breaths of 250 mL/breath, first calculate the alveolar volume by subtracting the dead space: 250 mL - 150 mL = 100 mL. Then, convert the alveolar ventilation value from L to mL: 4200 mL/min. Now divide: 4200/100 = 42 breaths/minute. D) To achieve a normal alveolar ventilation of 4.2 L/min with breaths of 250 mL/breath, first calculate the alveolar volume by subtracting the dead space: 250 mL - 150 mL = 100 mL. Then, convert the alveolar ventilation value from L to mL: 4200 mL/min. Now divide: 4200/100 = 42 breaths/minute. Page Ref: 426 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 17.1 Explain the factors that alter ventilation and oxygenation in restrictive lung disorders and concepts related to restrictive lung disorders. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of neoplastic, infectious, and pulmonary vascular lung disorders.

4) Which of the following healthy individuals is most at risk for aspiration? A) A 3-year-old B) A 22-year-old C) A 55-year-old D) A 78-year-old Answer: A Explanation: A) Among healthy individuals, children under 4 years of age are at highest risk of aspiration because they have no molar teeth and have a strong tendency to put things in their mouth. B) Among healthy individuals, children under 4 years of age are at highest risk of aspiration because they have no molar teeth and have a strong tendency to put things in their mouth. C) Among healthy individuals, children under 4 years of age are at highest risk of aspiration because they have no molar teeth and have a strong tendency to put things in their mouth. D) Among healthy individuals, children under 4 years of age are at highest risk of aspiration because they have no molar teeth and have a strong tendency to put things in their mouth. Page Ref: 428 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 17.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of restrictive lung disorders that primarily limit pulmonary expansion and approaches to diagnosis and treatment of those conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of neoplastic, infectious, and pulmonary vascular lung disorders.

5) Which of the following teaching points should the nurse include as part of a community program on aspiration in adults? A) The use of dentures reduces the risk of aspiration. B) Alcohol increases the risk of aspiration. C) The risk of aspiration increases in warm weather. D) A foreign body is more likely to obstruct both bronchi. Answer: B Explanation: A) Adults over 50 years of age are at increased risk of aspiration, particularly those who wear dentures and drink alcohol. B) Adults over 50 years of age are at increased risk of aspiration, particularly those who wear dentures and drink alcohol. C) The incidence of foreign body aspiration in older adults increases during the winter holidays, not warm weather. D) In adults, a small foreign body is more likely to enter the more vertical right mainstem bronchus. Page Ref: 428 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 17.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of restrictive lung disorders that primarily limit pulmonary expansion and approaches to diagnosis and treatment of those conditions across the lifespan. | QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essential Competencies: VII.1 Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities and populations NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of neoplastic, infectious, and pulmonary vascular lung disorders.

6) When planning care for a patient with resorption atelectasis, the nurse should keep which of the following principles in mind? A) Alveolar collapse occurs that is undetected by chest x-ray. B) Fibrotic changes reduce lung expansion. C) An accumulation of excess air compresses lung tissue. D) Excess mucous production is the most common cause of the associated obstruction. Answer: D Explanation: A) A less severe form of atelectasis, microatelectasis involves closure or collapse of the alveoli or respiratory microstructures to a degree that usually is undetectable on a CXR. B) Contraction atelectasis occurs when fibrotic changes in the lung or the pleura confine the lung and diminish lung expansion. C) Compression atelectasis occurs when an accumulation of exudates, fluid, air, or blood or a tumor in the pleural space mechanically collapses lung tissue. D) When airway obstruction occurs, gases trapped in the alveoli located distal to the obstruction may be absorbed by circulating blood without subsequent replacement by inhaled air. Resorption atelectasis can develop as a result. Most often, the associated obstruction is caused by excess mucus secretions. Page Ref: 429 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 17.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of restrictive lung disorders that primarily limit pulmonary expansion and approaches to diagnosis and treatment of those conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of neoplastic, infectious, and pulmonary vascular lung disorders.

7) When assessing a patient with right-sided closed tension pneumothorax, the nurse would expect to find: A) the trachea displaced to the right. B) the trachea displaced to the left. C) an open chest wound. D) air exits the chest wall during exhalation. Answer: B Explanation: A) In a tension pneumothorax, the lung or bronchial injury acts as a one-way valve, allowing air into the pleural space but preventing air from escaping during exhalation. As the air volume in the pleural space increases, the pressure collapses lung tissue and pushes the mediastinum toward the contralateral side. B) In a tension pneumothorax, the lung or bronchial injury acts as a one-way valve, allowing air into the pleural space but preventing air from escaping during exhalation. As the air volume in the pleural space increases, the pressure collapses lung tissue and pushes the mediastinum toward the contralateral side. C) With a closed pneumothorax, the chest wall is intact with no defects or open wounds. D) With a closed pneumothorax, the chest wall is intact with no defects or open wounds. Page Ref: 430 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 17.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of restrictive lung disorders that primarily limit pulmonary expansion and approaches to diagnosis and treatment of those conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of neoplastic, infectious, and pulmonary vascular lung disorders.

8) When assessing a patient with left-sided tension pneumothorax, the nurse would expect to auscultate: A) wheezing on expiration. B) adventitious breath sounds over the left lung. C) lack of breath sounds over the right lung. D) a sucking sound across both lung fields. Answer: B Explanation: A) In tension pneumothorax, the patient will have respiratory distress and either ipsilateral adventitious breath sounds or no breath sounds over a large pneumothorax. B) In tension pneumothorax, the patient will have respiratory distress and either ipsilateral adventitious breath sounds or no breath sounds over a large pneumothorax. C) In tension pneumothorax, the patient will have respiratory distress and either ipsilateral adventitious breath sounds or no breath sounds over a large pneumothorax. D) In tension pneumothorax, the patient will have respiratory distress and either ipsilateral adventitious breath sounds or no breath sounds over a large pneumothorax. Page Ref: 431 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 17.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of restrictive lung disorders that primarily limit pulmonary expansion and approaches to diagnosis and treatment of those conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of neoplastic, infectious, and pulmonary vascular lung disorders.

9) Which finding would the nurse expect in a patient with a large tension pneumothorax? A) Diaphragm is lower on the affected side. B) Diaphragm is lower on the ipsilateral side. C) Diaphragm is higher on the affected side. D) Diaphragm is higher on the ipsilateral side. Answer: A Explanation: A) With a large tension pneumothorax, the diaphragm is lower on the affected side, and a mediastinal shift with tracheal deviation away from the pneumothorax may be evident with an increased expansion of the contralateral chest wall. B) With a large tension pneumothorax, the diaphragm is lower on the affected side, and a mediastinal shift with tracheal deviation away from the pneumothorax may be evident with an increased expansion of the contralateral chest wall. C) With a large tension pneumothorax, the diaphragm is lower on the affected side, and a mediastinal shift with tracheal deviation away from the pneumothorax may be evident with an increased expansion of the contralateral chest wall. D) With a large tension pneumothorax, the diaphragm is lower on the affected side, and a mediastinal shift with tracheal deviation away from the pneumothorax may be evident with an increased expansion of the contralateral chest wall. Page Ref: 431 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessing | Learning Outcome: 17.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of restrictive lung disorders that primarily limit pulmonary expansion and approaches to diagnosis and treatment of those conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of neoplastic, infectious, and pulmonary vascular lung disorders.

10) Which laboratory finding would the nurse expect in a patient with empyema secondary to lung abscess? A) Straw-colored clear pleural fluid B) Cloudy pleural fluid with frank pus C) Purulent exudate with yellow-green pus D) Blood tinged pleural fluid Answer: C Explanation: A) Transudate pleural fluid is straw-colored and clear. It is caused by a noninflammatory process, such as heart failure, ascites, or atelectasis. B) Exudate pleural fluid is cloudy and may have frank pus. It is caused by an infectious process in the pleural space, cancer, pulmonary infarction, and viral pleuritis. C) Empyema produces a yellow-green pus purulent exudate and is caused by pneumonia, lung abscess, or an infected wound or sepsis. D) Hemothorax produces blood tinged to frankly bloody pleural fluid. Page Ref: 432 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 17.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of restrictive lung disorders that primarily limit pulmonary expansion and approaches to diagnosis and treatment of those conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of neoplastic, infectious, and pulmonary vascular lung disorders.

11) Which assessment is the nurse most likely to make in a patient with flail chest? A) The flail portion of the chest moves inward with inspiration. B) The flail portion of the chest moves inward with expiration. C) The flail portion of the chest moves outward with inspiration. D) The flail portion of the chest does not move with respiration. Answer: A Explanation: A) The unstable section of the chest wall allows paradoxic movement during respirations: with inspiration, the unstable section of the chest wall moves inward, but during exhalation, the unstable section of the chest wall moves outward. B) The unstable section of the chest wall allows paradoxic movement during respirations: with inspiration, the unstable section of the chest wall moves inward, but during exhalation, the unstable section of the chest wall moves outward. C) The unstable section of the chest wall allows paradoxic movement during respirations: with inspiration, the unstable section of the chest wall moves inward, but during exhalation, the unstable section of the chest wall moves outward. D) The unstable section of the chest wall allows paradoxic movement during respirations: with inspiration, the unstable section of the chest wall moves inward, but during exhalation, the unstable section of the chest wall moves outward. Page Ref: 433 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 17.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of restrictive lung disorders that primarily limit pulmonary expansion and approaches to diagnosis and treatment of those conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of neoplastic, infectious, and pulmonary vascular lung disorders.

12) The school nurse notes a concave appearance to the anterior chest wall in a middle-school child. The nurse documents this finding as: A) pectus carinatum. B) pectus excavatum. C) kyphoscoliosis. D) lordosis. Answer: B Explanation: A) The congenital deformity pectus carinatum, also called pigeon chest, gives a convex appearance to the anterior chest wall. B) Pectus excavatum, also known as a sunken or funnel chest, gives a concave appearance to the anterior chest wall. With the rapid growth during adolescence, the abnormal growth of the sternum and four or five ribs on each side of the sternum becomes more obvious. C) Kyphoscoliosis is an abnormal progressive curvature of the spine. It combines an abnormal front-to-back curvature, which causes a dowager's hump, with a lateral curvature that leaves the shoulders or the hips uneven. D) In lordosis, the spine curves considerably inward at the lower back. Page Ref: 433 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 17.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of restrictive lung disorders that primarily limit pulmonary expansion and approaches to diagnosis and treatment of those conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of neoplastic, infectious, and pulmonary vascular lung disorders.

13) Which of the following descriptions of the course of idiopathic pulmonary fibrosis (IPF) would the nurse include in a teaching plan to a patient newly diagnosed with this disorder? A) It is an acute disorder. B) It is progressive and may be lethal. C) It can be cured. D) It can be successfully controlled with medication. Answer: B Explanation: A) Idiopathic pulmonary fibrosis (IPF) is a progressive, lethal disease that profoundly affects the individual's quality of life. B) Idiopathic pulmonary fibrosis (IPF) is a progressive, lethal disease that profoundly affects the individual's quality of life. C) Idiopathic pulmonary fibrosis (IPF) is a progressive, lethal disease that profoundly affects the individual's quality of life. D) Idiopathic pulmonary fibrosis (IPF) is a progressive, lethal disease that profoundly affects the individual's quality of life. Page Ref: 434 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 17.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of restrictive lung disorders that primarily decrease pulmonary compliance and approaches to diagnosis and treatment of those conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of neoplastic, infectious, and pulmonary vascular lung disorders to diagnosis and treatment.

14) Which of the following individuals is at greatest risk for developing idiopathic pulmonary fibrosis (IPF)? A) A 55-year-old African American nonsmoking man B) A 65-year-old Caucasian man who currently smokes C) A 58-year-old Asian nonsmoking woman D) A 30-year-old Caucasian women who smoked briefly in her early 20s Answer: B Explanation: A) Individuals who are at increased risk for IPF include older adults, especially white males, who currently smoke or have a history of smoking. Exposures to occupational or environmental toxins or radiation therapy and chemotherapy increase the risk for IPF. B) Individuals who are at increased risk for IPF include older adults, especially white males, who currently smoke or have a history of smoking. Exposures to occupational or environmental toxins or radiation therapy and chemotherapy increase the risk for IPF. C) Individuals who are at increased risk for IPF include older adults, especially white males, who currently smoke or have a history of smoking. Exposures to occupational or environmental toxins or radiation therapy and chemotherapy increase the risk for IPF. D) Individuals who are at increased risk for IPF include older adults, especially white males, who currently smoke or have a history of smoking. Exposures to occupational or environmental toxins or radiation therapy and chemotherapy increase the risk for IPF. Page Ref: 434 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 17.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of restrictive lung disorders that primarily decrease pulmonary compliance and approaches to diagnosis and treatment of those conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of neoplastic, infectious, and pulmonary vascular lung disorders.

15) Which findings typically cause an individual with idiopathic pulmonary fibrosis (IPF) to first seek medical care? A) Peripheral edema and dyspnea on exertion B) Shallow and fast respirations C) Cyanosis and clubbing of fingernails D) Dyspnea on exertion and cough with minimal sputum production Answer: D Explanation: A) IPF has an insidious onset that begins with dyspnea on exertion (DOE) and/or a cough that produces very little sputum. Disease progression may occur in a steplike process, with periods of relative stability, then marked worsening of the disease with an acute exacerbation. Deterioration of lung function can occur secondary to an infection, pulmonary embolism, pneumothorax, or heart failure. Even at rest, individuals with IPF have rapid, shallow respirations to limit the work of ventilating stiff lungs. Bibasilar inspiratory crackles and clubbing of the distal fingers are commonly present. Disease progression or acute exacerbation may cause increasing DOE, hypoxemia, and cyanosis. Heart failure and peripheral edema also may occur. B) IPF has an insidious onset that begins with dyspnea on exertion (DOE) and/or a cough that produces very little sputum. Disease progression may occur in a steplike process, with periods of relative stability, then marked worsening of the disease with an acute exacerbation. Deterioration of lung function can occur secondary to an infection, pulmonary embolism, pneumothorax, or heart failure. Even at rest, individuals with IPF have rapid, shallow respirations to limit the work of ventilating stiff lungs. Bibasilar inspiratory crackles and clubbing of the distal fingers are commonly present. Disease progression or acute exacerbation may cause increasing DOE, hypoxemia, and cyanosis. Heart failure and peripheral edema also may occur. C) IPF has an insidious onset that begins with dyspnea on exertion (DOE) and/or a cough that produces very little sputum. Disease progression may occur in a steplike process, with periods of relative stability, then marked worsening of the disease with an acute exacerbation. Deterioration of lung function can occur secondary to an infection, pulmonary embolism, pneumothorax, or heart failure. Even at rest, individuals with IPF have rapid, shallow respirations to limit the work of ventilating stiff lungs. Bibasilar inspiratory crackles and clubbing of the distal fingers are commonly present. Disease progression or acute exacerbation may cause increasing DOE, hypoxemia, and cyanosis. Heart failure and peripheral edema also may occur. D) IPF has an insidious onset that begins with dyspnea on exertion (DOE) and/or a cough that produces very little sputum. Disease progression may occur in a steplike process, with periods of relative stability, then marked worsening of the disease with an acute exacerbation. Deterioration of lung function can occur secondary to an infection, pulmonary embolism, pneumothorax, or heart failure. Even at rest, individuals with IPF have rapid, shallow respirations to limit the work of ventilating stiff lungs. Bibasilar inspiratory crackles and clubbing of the distal fingers are commonly present. Disease progression or acute exacerbation may cause increasing DOE, hypoxemia, and cyanosis. Heart failure and peripheral edema also may occur. Page Ref: 435 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation

Standards: Nursing Process: Assessment | Learning Outcome: 17.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of restrictive lung disorders that primarily decrease pulmonary compliance and approaches to diagnosis and treatment of those conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of neoplastic, infectious, and pulmonary vascular lung disorders.

16) Which clinical manifestation would the nurse expect when assessing an adult obese patient with bibasilar atelectasis? A) Diminished chest expansion B) Intercostal retractions on inspiration C) Diminished breath sounds in all lung fields D) Barrel-shaped chest Answer: A Explanation: A) The clinical presentation of atelectasis includes dyspnea, shortness of breath, tachypnea, tachycardia, and diminished chest expansion; a respiratory infection may follow. Cyanosis may be present. In very young children and thin adults who experience severe atelectasis, intercostal retractions (retraction of muscles between the ribs) may be visible during inspiration. On physical exam, breath sounds will be diminished or absent in the area of atelectasis. B) The clinical presentation of atelectasis includes dyspnea, shortness of breath, tachypnea, tachycardia, and diminished chest expansion; a respiratory infection may follow. Cyanosis may be present. In very young children and thin adults who experience severe atelectasis, intercostal retractions (retraction of muscles between the ribs) may be visible during inspiration. On physical exam, breath sounds will be diminished or absent in the area of atelectasis. C) The clinical presentation of atelectasis includes dyspnea, shortness of breath, tachypnea, tachycardia, and diminished chest expansion; a respiratory infection may follow. Cyanosis may be present. In very young children and thin adults who experience severe atelectasis, intercostal retractions (retraction of muscles between the ribs) may be visible during inspiration. On physical exam, breath sounds will be diminished or absent in the area of atelectasis. D) The clinical presentation of atelectasis includes dyspnea, shortness of breath, tachypnea, tachycardia, and diminished chest expansion; a respiratory infection may follow. Cyanosis may be present. In very young children and thin adults who experience severe atelectasis, intercostal retractions (retraction of muscles between the ribs) may be visible during inspiration. On physical exam, breath sounds will be diminished or absent in the area of atelectasis. Page Ref: 429 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 17.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of restrictive lung disorders that primarily limit pulmonary expansion and approaches to diagnosis and treatment of those conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.8. Implement evidencebased nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of neoplastic, infectious, and pulmonary vascular lung disorders.

17) Which statement made by a patient with suspected sarcoidosis requires more teaching by the nurse? A) "As an African American women, I have a higher risk of dying from this disease than a Caucasian woman." B) "My red, watery eyes are most likely from my sarcoidosis." C) "A blood test can diagnosis sarcoidosis." D) "Corticosteroids can help reduce acute symptoms of sarcoidosis." Answer: C Explanation: A) The mortality rate for African Americans with sarcoidosis is 17 times higher than that for Caucasians. B) Sarcoidosis may cause reddened, sore, watery eyes. C) There are no laboratory tests for sarcoidosis; it is a diagnosis of exclusion. D) Acute symptomatic sarcoidosis is effectively treated with corticosteroids. Page Ref: 435-436 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 17.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of restrictive lung disorders that primarily decrease pulmonary compliance and approaches to diagnosis and treatment of those conditions across the lifespan. | QSEN Competencies: I.C.10 Value active partnership with patients or designated surrogates in planning, implementation, and evaluation of care | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of neoplastic, infectious, and pulmonary vascular lung disorders to diagnosis and treatment.

18) When preparing a nursing care plan for a patient with a restrictive lung disorder, the nurse should keep in mind that restrictive lung disorders: A) decrease the volume of airflow to the lungs. B) result in overinflated alveoli. C) increase elasticity of the lungs. D) do not affect lung perfusion. Answer: A Explanation: A) Restrictive lung disorders decrease the volume of airflow to the lungs by preventing expansion of the pulmonary structures and/or by decreasing the compliance (elasticity) of the lungs or chest wall. Many restrictive disorders damage the alveolar epithelium and capillaries, causing ventilation and perfusion abnormalities and/or diffusion defects, which can cause hypoxemia. B) Restrictive lung disorders decrease the volume of airflow to the lungs by preventing expansion of the pulmonary structures and/or by decreasing the compliance (elasticity) of the lungs or chest wall. Many restrictive disorders damage the alveolar epithelium and capillaries, causing ventilation and perfusion abnormalities and/or diffusion defects, which can cause hypoxemia. C) Restrictive lung disorders decrease the volume of airflow to the lungs by preventing expansion of the pulmonary structures and/or by decreasing the compliance (elasticity) of the lungs or chest wall. Many restrictive disorders damage the alveolar epithelium and capillaries, causing ventilation and perfusion abnormalities and/or diffusion defects, which can cause hypoxemia. D) Restrictive lung disorders decrease the volume of airflow to the lungs by preventing expansion of the pulmonary structures and/or by decreasing the compliance (elasticity) of the lungs or chest wall. Many restrictive disorders damage the alveolar epithelium and capillaries, causing ventilation and perfusion abnormalities and/or diffusion defects, which can cause hypoxemia. Page Ref: 425 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 17.1 Explain the factors that alter ventilation and oxygenation in restrictive lung disorders and concepts related to restrictive lung disorders. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of neoplastic, infectious, and pulmonary vascular lung disorders.

19) Which of the following is not an indication for administering 100% oxygen to a patient with a restrictive lung disorder? A) Hypoxemia caused by a thickened alveolar-capillary membrane B) Hypoxemia caused by hypoventilation C) Hypoxemia caused by a venous-to-arterial shunt D) Hypoxemia caused by deep breathing Answer: C Explanation: A) Inhaling 100% oxygen can correct the hypoxemia caused by a thickened alveolar-capillary membrane or hypoventilation but cannot correct hypoxemia caused by a venous-to-arterial shunt of blood. B) Inhaling 100% oxygen can correct the hypoxemia caused by a thickened alveolar-capillary membrane or hypoventilation but cannot correct hypoxemia caused by a venous-to-arterial shunt of blood. C) Inhaling 100% oxygen can correct the hypoxemia caused by a thickened alveolar-capillary membrane or hypoventilation but cannot correct hypoxemia caused by a venous-to-arterial shunt of blood. D) Shallow breathing, rather than hyperventilation, occurs with restrictive lung disorders. Page Ref: 426 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 17.1 Explain the factors that alter ventilation and oxygenation in restrictive lung disorders and concepts related to restrictive lung disorders. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of neoplastic, infectious, and pulmonary vascular lung disorders.

20) Which principle should the emergency department nurse bear in mind when treating patients for foreign body obstruction of the airway? A) An adult is more likely to aspirate a small foreign body into the right mainstem bronchus. B) An adult is more likely to aspirate a small foreign body into the left mainstem bronchus. C) A school-age child is more likely to aspirate a small foreign body into the right mainstem bronchus. D) A school-age child is more likely to aspirate a small foreign body into the left mainstem bronchus. Answer: A Explanation: A) In adults, a small foreign body is more likely to enter the more vertical right mainstem bronchus. However, in children younger than 15 years of age, the angles of the mainstem bronchi are similar, so objects may tend to enter either bronchus. B) In adults, a small foreign body is more likely to enter the more vertical right mainstem bronchus. However, in children younger than 15 years of age, the angles of the mainstem bronchi are similar, so objects may tend to enter either bronchus. C) In adults, a small foreign body is more likely to enter the more vertical right mainstem bronchus. However, in children younger than 15 years of age, the angles of the mainstem bronchi are similar, so objects may tend to enter either bronchus. D) In adults, a small foreign body is more likely to enter the more vertical right mainstem bronchus. However, in children younger than 15 years of age, the angles of the mainstem bronchi are similar, so objects may tend to enter either bronchus. Page Ref: 428 Cognitive Level: Applying Client Need & Sub: Pathophysiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 17.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of restrictive lung disorders that primarily limit pulmonary expansion and approaches to diagnosis and treatment of those conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of neoplastic, infectious, and pulmonary vascular lung disorders.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 18 Obstructive Lung Disorders 1) When assessing a healthy adult, the nurse would expect an inspiratory:expiratory (I:E) ratio of: A) 1:2. B) 1:3. C) 1:4. D) 1:5. Answer: A Explanation: A) For healthy individuals, the normal inspiratory to expiratory ratio (I:E ratio) is approximately 1:2, meaning that expiration takes approximately twice as long as inspiration. Individuals with an obstructive lung disease demonstrate a prolonged expiratory phase, with an I:E ratio of up to 1:5 or longer. B) For healthy individuals, the normal inspiratory to expiratory ratio (I:E ratio) is approximately 1:2, meaning that expiration takes approximately twice as long as inspiration. Individuals with an obstructive lung disease demonstrate a prolonged expiratory phase, with an I:E ratio of up to 1:5 or longer. C) For healthy individuals, the normal inspiratory to expiratory ratio (I:E ratio) is approximately 1:2, meaning that expiration takes approximately twice as long as inspiration. Individuals with an obstructive lung disease demonstrate a prolonged expiratory phase, with an I:E ratio of up to 1:5 or longer. D) For healthy individuals, the normal inspiratory to expiratory ratio (I:E ratio) is approximately 1:2, meaning that expiration takes approximately twice as long as inspiration. Individuals with an obstructive lung disease demonstrate a prolonged expiratory phase, with an I:E ratio of up to 1:5 or longer. Page Ref: 443 Cognitive Level: Remembering Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 18.2 Describe the alterations of the anatomic airway structure and pulmonary function present in individuals with obstructive lung disorders. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of obstructive lung disorders.

2) A patient is having a test to measure airflow speed during maximal exhalation through the mouth. Which test does the nurse explain to the patient? A) Spirometry B) Body plethysmography C) Nitrogen washout D) Incentive spirometry Answer: A Explanation: A) Spirometry, which measures airflow through the mouth when nasal airflow is obstructed, is used to measure the volume and speed of airflow during a maximal inhalation or maximal exhalation. B) Body plethysmography measures the total volume of air in the lungs or total lung capacity (TLC). C) Nitrogen washout is an alternative method that is used to estimate TLC when body plethysmography is not available. D) Incentive spirometry is the use of a device to encourage maximal inhalation to prevent lung atelectasis. It is not a pulmonary function test. Page Ref: 443 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 18.2 Describe the alterations of the anatomic airway structure and pulmonary function present in individuals with obstructive lung disorders. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of obstructive lung disorders to diagnosis and treatment.

3) The nurse is reviewing the pulmonary function test of a patient. Which result would the nurse expect to find in a patient with normal lung function? A) Tidal volume 500 mL B) Inspiratory reserve volume 1,500 mL C) Inspiratory capacity 2,000 mL D) Expiratory reserve volume 500 mL Answer: A Explanation: A) Tidal volume (TV), the volume of air inhaled and exhaled during one cycle of normal quiet breathing, is typically 500 mL. The typical inspiratory reserve volume (IRV), the maximal volume of air that can be inhaled after TV inhalation, is 3,000 mL. A normal value for inspiratory capacity (IC), the maximal volume of air that can be inhaled after a normal exhalation (TV + IRV = IC), is 3,500 mL. Expiratory reserve volume is the maximal volume of air that can be exhaled following TV exhalation and is typically 1,200 mL. B) Tidal volume (TV), the volume of air inhaled and exhaled during one cycle of normal quiet breathing, is typically 500 mL. The typical inspiratory reserve volume (IRV), the maximal volume of air that can be inhaled after TV inhalation, is 3,000 mL. A normal value for inspiratory capacity (IC), the maximal volume of air that can be inhaled after a normal exhalation (TV + IRV = IC), is 3,500 mL. Expiratory reserve volume is the maximal volume of air that can be exhaled following TV exhalation and is typically 1,200 mL. C) Tidal volume (TV), the volume of air inhaled and exhaled during one cycle of normal quiet breathing, is typically 500 mL. The typical inspiratory reserve volume (IRV), the maximal volume of air that can be inhaled after TV inhalation, is 3,000 mL. A normal value for inspiratory capacity (IC), the maximal volume of air that can be inhaled after a normal exhalation (TV + IRV = IC), is 3,500 mL. Expiratory reserve volume is the maximal volume of air that can be exhaled following TV exhalation and is typically 1,200 mL. D) Tidal volume (TV), the volume of air inhaled and exhaled during one cycle of normal quiet breathing, is typically 500 mL. The typical inspiratory reserve volume (IRV), the maximal volume of air that can be inhaled after TV inhalation, is 3,000 mL. A normal value for inspiratory capacity (IC), the maximal volume of air that can be inhaled after a normal exhalation (TV + IRV = IC), is 3,500 mL. Expiratory reserve volume is the maximal volume of air that can be exhaled following TV exhalation and is typically 1,200 mL. Page Ref: 444 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 18.2 Describe the alterations of the anatomic airway structure and pulmonary function present in individuals with obstructive lung disorders. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of obstructive lung disorders to diagnosis and treatment.

4) When conducting community assessments, the nurse knows that which population has the highest risk of asthma? A) Puerto Ricans B) African Americans C) Hispanics D) Asians Answer: A Explanation: A) Among racial and ethnic groups, asthma prevalence is lower among Caucasians (7.7%) than among individuals of African American (11.2%) and American Indian or Alaska Native (9.4%) descent. The overall prevalence among Hispanics is 6.5%, with a higher prevalence among individuals of Puerto Rican (16.1%) descent than among those of Mexican (5.4%) descent. The lowest rates are found among Asians (5.2%). B) Among racial and ethnic groups, asthma prevalence is lower among Caucasians (7.7%) than among individuals of African American (11.2%) and American Indian or Alaska Native (9.4%) descent. The overall prevalence among Hispanics is 6.5%, with a higher prevalence among individuals of Puerto Rican (16.1%) descent than among those of Mexican (5.4%) descent. The lowest rates are found among Asians (5.2%). C) Among racial and ethnic groups, asthma prevalence is lower among Caucasians (7.7%) than among individuals of African American (11.2%) and American Indian or Alaska Native (9.4%) descent. The overall prevalence among Hispanics is 6.5%, with a higher prevalence among individuals of Puerto Rican (16.1%) descent than among those of Mexican (5.4%) descent. The lowest rates are found among Asians (5.2%). D) Among racial and ethnic groups, asthma prevalence is lower among Caucasians (7.7%) than among individuals of African American (11.2%) and American Indian or Alaska Native (9.4%) descent. The overall prevalence among Hispanics is 6.5%, with a higher prevalence among individuals of Puerto Rican (16.1%) descent than among those of Mexican (5.4%) descent. The lowest rates are found among Asians (5.2%). Page Ref: 445 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 18.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of asthma and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of obstructive lung disorders.

5) A patient in the emergency department reports tightness in his chest and shortness of breath after mowing his lawn several hours ago on a warm, humid day. On assessment, the patient has a heart rate of 110 beats/minute, respiratory rate of 32 breaths/minute, blood pressure of 130/80 mm Hg, and an oral temperature of 97.2 degrees F. Expiratory wheezing is heard on auscultation of his lungs. The nurse suspects that the patient is most likely experiencing asthma due to: A) air pollution. B) infection. C) exercise. D) allergens. Answer: D Explanation: A) Because the patient was outdoors, it is possible that air pollution was the cause of the symptoms; however, the known precipitating factor that most likely caused the symptoms was allergens from mowing the lawn. B) The patient does not have signs of an infection and is normothermic. C) Although the patient was engaged in the exercise of mowing the lawn, typically exerciseinduced asthma is triggered within 10 to 15 minutes of beginning physical exertion. It is also more likely when the air is cold and dry, and on this day it was warm and humid. D) Because the patient was mowing the lawn several hours ago, this presentation is most likely due to exposure to allergens. Page Ref: 446 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 18.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of asthma and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of obstructive lung disorders to diagnosis and treatment.

6) The assessment of a patient with persistent moderate severity asthma will most likely reveal: A) normal FEV1 between exacerbations. B) daily use of short-acting beta-2 agonist for symptom control. C) awakening from sleep no more that 3 to 4 times/month. D) normal activity is extremely limited. Answer: B Explanation: A) A normal FEV1 between exacerbations is indicative of intermittent asthma severity. B) Daily use of short-acting beta-2 agonist for symptom control is characteristic of persistent moderate asthma. C) Awakening from sleep no more that 3 to 4 times/month suggests persistent mild asthma. D) Extremely limited normal activity is a sign of persistent severe asthma. Page Ref: 449 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 18.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of asthma and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of obstructive lung disorders to diagnosis and treatment.

7) A patient with suspected asthma is scheduled for a challenge test. What result would confirm the diagnosis? A) Exhalation of low amounts of nitrogen oxide B) Exhalation of high amounts of nitrogen oxide C) Exhalation of low amounts of carbon dioxide D) Exhalation of high amounts of carbon dioxide Answer: B Explanation: A) The classic confirmatory test for asthma is a challenge test. During this test, the individual breathes dilute amounts of an irritating substance, such as methacholine or very cold air, to provoke airway obstruction and asthma symptoms. Asthmatics exhale higher levels of nitrogen oxide than do control subjects matched by age, gender, and lung function, and levels are higher when asthma is not in good control. B) The classic confirmatory test for asthma is a challenge test. During this test, the individual breathes dilute amounts of an irritating substance, such as methacholine or very cold air, to provoke airway obstruction and asthma symptoms. Asthmatics exhale higher levels of nitrogen oxide than do control subjects matched by age, gender, and lung function, and levels are higher when asthma is not in good control. C) The classic confirmatory test for asthma is a challenge test. During this test, the individual breathes dilute amounts of an irritating substance, such as methacholine or very cold air, to provoke airway obstruction and asthma symptoms. Asthmatics exhale higher levels of nitrogen oxide than do control subjects matched by age, gender, and lung function, and levels are higher when asthma is not in good control. D) The classic confirmatory test for asthma is a challenge test. During this test, the individual breathes dilute amounts of an irritating substance, such as methacholine or very cold air, to provoke airway obstruction and asthma symptoms. Asthmatics exhale higher levels of nitrogen oxide than do control subjects matched by age, gender, and lung function, and levels are higher when asthma is not in good control. Page Ref: 449 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 18.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of asthma and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of obstructive lung disorders to diagnosis and treatment.

8) The plan of care to reduce asthma risks in a patient with poorly controlled asthma would be to: A) preventing symptoms. B) requiring a short-acting bronchodilator not more than twice a week. C) being satisfied with care received. D) preventing emergency room visits. Answer: D Explanation: A) Goals of asthma management include reduction of impairments and asthma risks. Impairments are reduced when symptoms are prevented, a short-acting bronchodilator is needed not more than twice a week, PFTs are normal or nearly normal, and the individual can perform normal activities and is satisfied with the care received. The reduction of risk includes preventing exacerbations, emergency room visits, hospitalizations, and loss of lung function as well as minimizing the adverse effects of drug therapy. B) Goals of asthma management include reduction of impairments and asthma risks. Impairments are reduced when symptoms are prevented, a short-acting bronchodilator is needed not more than twice a week, PFTs are normal or nearly normal, and the individual can perform normal activities and is satisfied with the care received. The reduction of risk includes preventing exacerbations, emergency room visits, hospitalizations, and loss of lung function as well as minimizing the adverse effects of drug therapy. C) Goals of asthma management include reduction of impairments and asthma risks. Impairments are reduced when symptoms are prevented, a short-acting bronchodilator is needed not more than twice a week, PFTs are normal or nearly normal, and the individual can perform normal activities and is satisfied with the care received. The reduction of risk includes preventing exacerbations, emergency room visits, hospitalizations, and loss of lung function as well as minimizing the adverse effects of drug therapy. D) Goals of asthma management include reduction of impairments and asthma risks. Impairments are reduced when symptoms are prevented, a short-acting bronchodilator is needed not more than twice a week, PFTs are normal or nearly normal, and the individual can perform normal activities and is satisfied with the care received. The reduction of risk includes preventing exacerbations, emergency room visits, hospitalizations, and loss of lung function as well as minimizing the adverse effects of drug therapy. Page Ref: 450 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 18.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of asthma and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of obstructive lung disorders to diagnosis and treatment.

9) When planning home care for a child with asthma, the nurse should tell the family to: A) remove all animals from the house. B) remove stuffed animals from the bed. C) remove items that seem to trigger an attack. D) remove items that commonly trigger attacks. Answer: C Explanation: A) Components of asthma management include environmental control, asthma education for patients and families, and bronchodilator and anti-inflammatory medications. Environmental control to remove the stimuli that trigger asthma is tailored to an individual because each person responds to different triggers. All possible triggers should not be removed, only those that may be triggers. B) Components of asthma management include environmental control, asthma education for patients and families, and bronchodilator and anti-inflammatory medications. Environmental control to remove the stimuli that trigger asthma is tailored to an individual because each person responds to different triggers. All possible triggers should not be removed, only those that may be triggers. C) Components of asthma management include environmental control, asthma education for patients and families, and bronchodilator and anti-inflammatory medications. Environmental control to remove the stimuli that trigger asthma is tailored to an individual because each person responds to different triggers. All possible triggers should not be removed, only those that may be triggers. D) Components of asthma management include environmental control, asthma education for patients and families, and bronchodilator and anti-inflammatory medications. Environmental control to remove the stimuli that trigger asthma is tailored to an individual because each person responds to different triggers. All possible triggers should not be removed, only those that may be triggers. Page Ref: 450 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 18.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of asthma and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of obstructive lung disorders to diagnosis and treatment.

10) The hospital outreach nurse is teaching a community program about chronic obstructive pulmonary disease (COPD). Which concept should the nurse keep in mind while preparing for this program? A) Smoking is associated with all cases of COPD. B) COPD is always caused by a genetic mutation. C) An interaction between genetic and inhaled irritants may cause COPD. D) Nonsmokers do not develop COPD. Answer: C Explanation: A) Cigarette smoking accounts for 90% of the cases of COPD in industrialized countries; COPD remains relatively rare in nonsmokers, but cases do occur. Only an estimated 20% of smokers develop COPD, so additional factors such as genetics and/or inhalation of other irritants are involved. B) Cigarette smoking accounts for 90% of the cases of COPD in industrialized countries; COPD remains relatively rare in nonsmokers, but cases do occur. Only an estimated 20% of smokers develop COPD, so additional factors such as genetics and/or inhalation of other irritants are involved. C) Cigarette smoking accounts for 90% of the cases of COPD in industrialized countries; COPD remains relatively rare in nonsmokers, but cases do occur. Only an estimated 20% of smokers develop COPD, so additional factors such as genetics and/or inhalation of other irritants are involved. D) Cigarette smoking accounts for 90% of the cases of COPD in industrialized countries; COPD remains relatively rare in nonsmokers, but cases do occur. Only an estimated 20% of smokers develop COPD, so additional factors such as genetics and/or inhalation of other irritants are involved. Page Ref: 451 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Prevention Standards: Nursing Process: Planning | Learning Outcome: 18.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of chronic obstructive pulmonary disease and approaches to diagnosis and treatment of the condition. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of obstructive lung disorders.

11) Which patient statement indicates that the nurse's teaching about prevention of COPD has been effective? A) "Only cigarette smoking can cause COPD." B) "Secondhand smoke does not lead to COPD." C) "Use of a water pipe does not lead to COPD." D) "Pipe smoking can cause COPD." Answer: D Explanation: A) Direct inhalation of tobacco smoke from smoking cigarettes, as well as smoking cigars or a pipe (including a water pipe), increases the risk of developing COPD. Environmental tobacco smoke, also known as secondhand smoke or passive smoking exposure, increases the risk for COPD. B) Direct inhalation of tobacco smoke from smoking cigarettes, as well as smoking cigars or a pipe (including a water pipe), increases the risk of developing COPD. Environmental tobacco smoke, also known as secondhand smoke or passive smoking exposure, increases the risk for COPD. C) Direct inhalation of tobacco smoke from smoking cigarettes, as well as smoking cigars or a pipe (including a water pipe), increases the risk of developing COPD. Environmental tobacco smoke, also known as secondhand smoke or passive smoking exposure, increases the risk for COPD. D) Direct inhalation of tobacco smoke from smoking cigarettes, as well as smoking cigars or a pipe (including a water pipe), increases the risk of developing COPD. Environmental tobacco smoke, also known as secondhand smoke or passive smoking exposure, increases the risk for COPD. Page Ref: 451 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Evaluation | Learning Outcome: 18.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of chronic obstructive pulmonary disease and approaches to diagnosis and treatment of the condition. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of obstructive lung disorders.

12) Which findings would the nurse expect to assess in a history from a patient with moderate (Gold 2) COPD? A) Not aware of respiratory symptoms, cough and sputum may be present B) Dyspnea on exertion, chronic cough, and sputum production C) Shortness of breath (SOB), reduced exercise capacity, fatigue, and exacerbations D) Chronic respiratory failure Answer: B Explanation: A) In the mild stage (GOLD 1), symptoms of chronic cough and sputum production may be present but are not always present. At this stage, the individual may not be aware that lung function is abnormal. In moderate (GOLD 2) COPD, the individual typically has SOB developing on exertion, and cough and sputum production are sometimes also present. This is the stage at which patients typically seek medical care because of chronic respiratory symptoms or an exacerbation of their disease. In severe (GOLD 3) COPD, the individual experiences greater SOB, reduced exercise capacity, fatigue, and repeated exacerbations that almost always have an impact on the individual's quality of life. In very severe (GOLD 4) COPD, the individual has chronic respiratory failure. B) In the mild stage (GOLD 1), symptoms of chronic cough and sputum production may be present but are not always present. At this stage, the individual may not be aware that lung function is abnormal. In moderate (GOLD 2) COPD, the individual typically has SOB developing on exertion, and cough and sputum production are sometimes also present. This is the stage at which patients typically seek medical care because of chronic respiratory symptoms or an exacerbation of their disease. In severe (GOLD 3) COPD, the individual experiences greater SOB, reduced exercise capacity, fatigue, and repeated exacerbations that almost always have an impact on the individual's quality of life. In very severe (GOLD 4) COPD, the individual has chronic respiratory failure. C) In the mild stage (GOLD 1), symptoms of chronic cough and sputum production may be present but are not always present. At this stage, the individual may not be aware that lung function is abnormal. In moderate (GOLD 2) COPD, the individual typically has SOB developing on exertion, and cough and sputum production are sometimes also present. This is the stage at which patients typically seek medical care because of chronic respiratory symptoms or an exacerbation of their disease. In severe (GOLD 3) COPD, the individual experiences greater SOB, reduced exercise capacity, fatigue, and repeated exacerbations that almost always have an impact on the individual's quality of life. In very severe (GOLD 4) COPD, the individual has chronic respiratory failure. D) In the mild stage (GOLD 1), symptoms of chronic cough and sputum production may be present but are not always present. At this stage, the individual may not be aware that lung function is abnormal. In moderate (GOLD 2) COPD, the individual typically has SOB developing on exertion, and cough and sputum production are sometimes also present. This is the stage at which patients typically seek medical care because of chronic respiratory symptoms or an exacerbation of their disease. In severe (GOLD 3) COPD, the individual experiences greater SOB, reduced exercise capacity, fatigue, and repeated exacerbations that almost always have an impact on the individual's quality of life. In very severe (GOLD 4) COPD, the individual has chronic respiratory failure. Page Ref: 452 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation 12

Standards: Nursing Process: Assessment | Learning Outcome: 18.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of chronic obstructive pulmonary disease and approaches to diagnosis and treatment of the condition. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of obstructive lung disorders. 13) Which pulmonary function test result would the nurse expect to find in a patient with mild COPD? A) FEV1/FVC < 70%, FEV1 > 80% predicted B) FEV1/FVC < 70%, 50% <FEV1 < 80% predicted C) FEV1/FVC < 70%, 30% <FEV1 < 50% predicted D) FEV1/FVC < 70%, FEV1 < 30% predicted Answer: A Explanation: A) Pulmonary function testing for mild COPD reveals FEV1/FVC < 70%, FEV1 > 80% predicted. B) Pulmonary function testing for moderate COPD reveals FEV1/FVC < 70%, 50% <FEV1 < 80% predicted. C) Pulmonary function testing for severe COPD reveals FEV1/FVC < 70%, 30% <FEV1 < 50% predicted. D) Pulmonary function testing for very severe COPD reveals FEV1/FVC < 70%, FEV1 < 30% predicted. Page Ref: 452 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 18.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of chronic obstructive pulmonary disease and approaches to diagnosis and treatment of the condition. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of obstructive lung disorders to diagnosis and treatment.

14) The nurse is teaching pursed lip breathing to a patient with severe COPD. Which behavior indicates to the nurse that teaching has been effective? A) Lips are puckered on inhalation. B) Lips are wide apart on inhalation. C) Lips are pursed on inhalation and exhalation. D) Lips are puckered on exhalation. Answer: D Explanation: A) Pursed lip exhalation exerts a back pressure on small airways, helping to hold them open during exhalation. Prolonging the pursed lip exhalation time to approximately twice the inhalation time allows exhalation of inhaled air through narrowed airways, thus limiting air trapping. B) Pursed lip exhalation exerts a back pressure on small airways, helping to hold them open during exhalation. Prolonging the pursed lip exhalation time to approximately twice the inhalation time allows exhalation of inhaled air through narrowed airways, thus limiting air trapping. C) Pursed lip exhalation exerts a back pressure on small airways, helping to hold them open during exhalation. Prolonging the pursed lip exhalation time to approximately twice the inhalation time allows exhalation of inhaled air through narrowed airways, thus limiting air trapping. D) Pursed lip exhalation exerts a back pressure on small airways, helping to hold them open during exhalation. Prolonging the pursed lip exhalation time to approximately twice the inhalation time allows exhalation of inhaled air through narrowed airways, thus limiting air trapping. Page Ref: 453 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Evaluation | Learning Outcome: 18.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of chronic obstructive pulmonary disease and approaches to diagnosis and treatment of the condition. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of obstructive lung disorders to diagnosis and treatment.

15) Which finding is most likely when assessing the chest of a patient with emphysema? A) 1:2 anteroposterior (AP) diameter/transverse diameter B) 1:3 anteroposterior (AP) diameter/transverse diameter C) 1:4 anteroposterior (AP) diameter/transverse diameter D) 2:1 anteroposterior (AP) diameter/transverse diameter Answer: D Explanation: A) The patient with emphysema has a barrel chest, with an increased 2:1 anteriorposterior diameter to transverse diameter because of hyperinflation. A normal AP diameter/transverse diameter is 1:2. B) The patient with emphysema has a barrel chest, with an increased 2:1 anterior-posterior diameter to transverse diameter because of hyperinflation. A normal AP diameter/transverse diameter is 1:2. C) The patient with emphysema has a barrel chest, with an increased 2:1 anterior-posterior diameter to transverse diameter because of hyperinflation. A normal AP diameter/transverse diameter is 1:2. D) The patient with emphysema has a barrel chest, with an increased 2:1 anterior-posterior diameter to transverse diameter because of hyperinflation. A normal AP diameter/transverse diameter is 1:2. Page Ref: 455 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 18.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of chronic obstructive pulmonary disease and approaches to diagnosis and treatment of the condition. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of obstructive lung disorders.

16) Which is the most appropriate medication for the nurse to administer when a patient with COPD experiences acute shortness of breath? A) Inhaled corticosteroids B) Inhaled fast-acting bronchodilator C) Oral antibiotics D) Oral mucolytic agents Answer: B Explanation: A) Inhaled corticosteroids can reduce the frequency of exacerbations and improve health status but are not used for acute SOB. B) Fast-acting bronchodilators are used on an as-needed basis for the immediate relief of acute SOB. Long-acting bronchodilators are used preventively. C) Antibiotics are recommended only for bacterial infections. D) Mucolytic agents may help to thin viscous sputum. Page Ref: 456 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 18.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of chronic obstructive pulmonary disease and approaches to diagnosis and treatment of the condition. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of obstructive lung disorders to diagnosis and treatment.

17) The nurse is conducting family planning with a healthy couple. The man's father had cystic fibrosis and his mother was healthy with no family history of the condition. The woman's family has no history of cystic fibrosis. Which is the most appropriate response for the nurse to make when asked about the risk of their child having cystic fibrosis? A) All children will have cystic fibrosis. B) Each child has a 50% chance of cystic fibrosis. C) Each child has a 50% chance of being a carrier for cystic fibrosis. D) All children will be carriers for cystic fibrosis. Answer: C Explanation: A) Because it is a recessive disorder, an affected individual must inherit one defective cystic fibrosis gene from each parent for the disease to be expressed. In this couple, the man's father must have had two recessive genes in order to develop the condition, and his son (the man in this couple) would be a carrier. The woman in this couple has no genes for cystic fibrosis. In this scenario, each child has a 50% chance of carrying the gene (being a carrier). No children will develop cystic fibrosis. B) Because it is a recessive disorder, an affected individual must inherit one defective cystic fibrosis gene from each parent for the disease to be expressed. In this couple, the man's father must have had two recessive genes in order to develop the condition, and his son (the man in this couple) would be a carrier. The woman in this couple has no genes for cystic fibrosis. In this scenario, each child has a 50% chance of carrying the gene (being a carrier). No children will develop cystic fibrosis. C) Because it is a recessive disorder, an affected individual must inherit one defective cystic fibrosis gene from each parent for the disease to be expressed. In this couple, the man's father must have had two recessive genes in order to develop the condition, and his son (the man in this couple) would be a carrier. The woman in this couple has no genes for cystic fibrosis. In this scenario, each child has a 50% chance of carrying the gene (being a carrier). No children will develop cystic fibrosis. D) Because it is a recessive disorder, an affected individual must inherit one defective cystic fibrosis gene from each parent for the disease to be expressed. In this couple, the man's father must have had two recessive genes in order to develop the condition, and his son (the man in this couple) would be a carrier. The woman in this couple has no genes for cystic fibrosis. In this scenario, each child has a 50% chance of carrying the gene (being a carrier). No children will develop cystic fibrosis. Page Ref: 457 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 18.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of cystic fibrosis and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII.1 Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities and populations NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of obstructive lung disorders. 17

18) When developing a nursing care plan for a child with cystic fibrosis, which problem should be addressed? A) Malabsorption of fat-soluble vitamins B) Malabsorption of proteins C) Malabsorption of water-soluble vitamins D) Malabsorption of carbohydrates Answer: A Explanation: A) When pancreatic ducts are completely blocked, pancreatic cells that produced digestive enzymes atrophy; over time, bile ducts become blocked. The result is severe malabsorption, especially of fats and fat-soluble vitamins. B) When pancreatic ducts are completely blocked, pancreatic cells that produced digestive enzymes atrophy; over time, bile ducts become blocked. The result is severe malabsorption, especially of fats and fat-soluble vitamins. C) When pancreatic ducts are completely blocked, pancreatic cells that produced digestive enzymes atrophy; over time, bile ducts become blocked. The result is severe malabsorption, especially of fats and fat-soluble vitamins. D) When pancreatic ducts are completely blocked, pancreatic cells that produced digestive enzymes atrophy; over time, bile ducts become blocked. The result is severe malabsorption, especially of fats and fat-soluble vitamins. Page Ref: 459 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 18.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of cystic fibrosis and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of obstructive lung disorders to diagnosis and treatment.

19) Which of the following would the nurse expect to assess in a child with bronchiectasis? A) A mild nonproductive cough B) An intermittent dry hacking cough C) A severe persistent cough with mucopurulent sputum D) A cough that produces clear frothy sputum Answer: C Explanation: A) The classic signs and symptoms of bronchiectasis are a severe persistent cough with a daily production of tenacious, mucopurulent sputum that can persist over months or years. B) The classic signs and symptoms of bronchiectasis are a severe persistent cough with a daily production of tenacious, mucopurulent sputum that can persist over months or years. C) The classic signs and symptoms of bronchiectasis are a severe persistent cough with a daily production of tenacious, mucopurulent sputum that can persist over months or years. D) The classic signs and symptoms of bronchiectasis are a severe persistent cough with a daily production of tenacious, mucopurulent sputum that can persist over months or years. Page Ref: 459 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 18.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of bronchiectasis and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of obstructive lung disorders.

20) Which characteristics would the nurse expect in the stool of a child with cystic fibrosis? A) Clay-colored stools B) Large foul-smelling stools C) Black tarry stools D) Thin pencil-like stools Answer: B Explanation: A) Clay colored stools may indicate liver disease. B) The lack of pancreatic enzymes in children with cystic fibrosis results in large, foul-smelling stools that float because of their high fat content. C) Black tarry stools may occur with upper gastrointestinal bleeding. D) An obstruction in the colon, such as from a tumor, may cause thin, pencil-like stools. Page Ref: 459 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 18.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of cystic fibrosis and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of obstructive lung disorders.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 19 Neoplastic, Infectious, and Pulmonary Vascular Respiratory Disorders 1) When taking a health history from a client with lung cancer, the nurse would most likely expect to find which modifiable primary risk factor? A) Cigarette smoking B) Pipe smoking C) Cigar smoking D) Secondhand smoke Answer: A Explanation: A) Smoking cigarettes is the most important risk factor for cancer. Eighty-seven percent of lung cancers occur in active smokers or in people who stopped smoking less than 5 years ago; only 2% of lifelong nonsmokers develop lung cancer. Other modifiable risk factors are cigar or pipe smoking and exposure to secondhand smoke. Smoking cigars or a pipe increases the risk for lung cancer by two to five times compared to nonsmokers, but the risk is less than that for cigarette smokers. B) Smoking cigarettes is the most important risk factor for cancer. Eighty-seven percent of lung cancers occur in active smokers or in people who stopped smoking less than 5 years ago; only 2% of lifelong nonsmokers develop lung cancer. Smoking cigars or a pipe increases the risk for lung cancer by two to five times compared to nonsmokers, but the risk is less than that for cigarette smokers. C) Smoking cigarettes is the most important risk factor for cancer. Eighty-seven percent of lung cancers occur in active smokers or in people who stopped smoking less than 5 years ago; only 2% of lifelong nonsmokers develop lung cancer. Smoking cigars or a pipe increases the risk for lung cancer by two to five times compared to nonsmokers, but the risk is less than that for cigarette smokers. D) Smoking cigarettes is the most important risk factor for cancer. Eighty-seven percent of lung cancers occur in active smokers or in people who stopped smoking less than 5 years ago; only 2% of lifelong nonsmokers develop lung cancer. Passive smoke exposure doubles lung cancer risk for exposures during childhood and adolescence and increases for spouses with the number of pack-years exposure, but the risk is less than that for cigarette smoking. Page Ref: 468 Cognitive Level: Remembering Client Need & Sub: Health Promotion and Integrity Standards: Nursing Process: Assessment | Learning Outcome: 19.1 Describe the primary considerations and concepts related to pulmonary vascular, neoplastic, and infectious respiratory disorders. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 19.2: Examine the etiology, incidence and pathogenesis of neoplastic, infectious, and pulmonary vascular lung disorders.

2) Which finding should the nurse expect in a client, who is newly diagnosed with small cell lung cancer (SCLC)? A) A well-circumscribed tumor without metastasis B) A bronchial tumor with metastasis C) A single-nodule in the lung periphery D) Tumors in the bronchial wall Answer: B Explanation: A) SCLC originates in the bronchi or periphery of the lung. Because SCLC tends toward rapid growth and metastasis, this virulent form of cancer frequently has already spread to distant sites before it is identified. B) SCLC originates in the bronchi or periphery of the lung. Because SCLC tends toward rapid growth and metastasis, this virulent form of cancer frequently has already spread to distant sites before it is identified. C) SCLC originates in the bronchi or periphery of the lung. Because SCLC tends toward rapid growth and metastasis, this virulent form of cancer frequently has already spread to distant sites before it is identified. D) SCLC originates in the bronchi or periphery of the lung. Because SCLC tends toward rapid growth and metastasis, this virulent form of cancer frequently has already spread to distant sites before it is identified. Page Ref: 469 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 19.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of malignant lung cancers and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of neoplastic, infectious, and pulmonary vascular lung disorders.

3) To monitor for superior venal cava syndrome in the client with enlarging tumors of the mediastinal lymph nodes, the nurse should be alert for: A) lower extremity edema. B) improvement in signs and symptoms when lying down (supine). C) flat or nonvisible neck veins. D) facial edema. Answer: D Explanation: A) Enlarging cancer in mediastinal lymph nodes impedes blood return to the superior vena cava, causing the insidious development of a superior vena cava syndrome. There is a progressive blockage of blood return from the upper part of the body; blockage results in slowly developing signs such as distention of veins in the neck and chest wall, facial and upper extremity edema, and mental changes. When lying down (supine), the increased blood return to the heart may cause worsening of the signs and symptoms associated with vena cava syndrome. B) Enlarging cancer in mediastinal lymph nodes impedes blood return to the superior vena cava, causing the insidious development of a superior vena cava syndrome. There is a progressive blockage of blood return from the upper part of the body; blockage results in slowly developing signs such as distention of veins in the neck and chest wall, facial and upper extremity edema, and mental changes. When lying down (supine), the increased blood return to the heart may cause worsening of the signs and symptoms associated with vena cava syndrome. C) Enlarging cancer in mediastinal lymph nodes impedes blood return to the superior vena cava, causing the insidious development of a superior vena cava syndrome. There is a progressive blockage of blood return from the upper part of the body; blockage results in slowly developing signs such as distention of veins in the neck and chest wall, facial and upper extremity edema, and mental changes. When lying down (supine), the increased blood return to the heart may cause worsening of the signs and symptoms associated with vena cava syndrome. D) Enlarging cancer in mediastinal lymph nodes impedes blood return to the superior vena cava, causing the insidious development of a superior vena cava syndrome. There is a progressive blockage of blood return from the upper part of the body; blockage results in slowly developing signs such as distention of veins in the neck and chest wall, facial and upper extremity edema, and mental changes. When lying down (supine), the increased blood return to the heart may cause worsening of the signs and symptoms associated with vena cava syndrome. Page Ref: 469 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Diagnosis/Analysis | Learning Outcome: 19.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of malignant lung cancers and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of neoplastic, infectious, and pulmonary vascular lung disorders.

4) Which finding would the nurse expect in a client with a tumor compressing the laryngeal nerve? A) Hoarseness B) Chest pain C) Dyspnea D) Weight loss Answer: A Explanation: A) Hoarseness occurs if the laryngeal nerve is compressed or invaded by the tumor. B) Chest pain varies with the lung cancer site. Mediastinal pain is generally dull and poorly localized. Retrosternal pain is poorly localized because pain receptors are limited to the peribronchial vagal afferent nerves, larger blood vessels, and mediastinum. C) Dyspnea may be due to a pleural effusion (an accumulation of fluid within the pleural space), which compresses normal lung, resulting in shortness of breath. D) Although systemic signs and symptoms of tumors do include fatigue and weight loss, these are not specific to laryngeal nerve compression. Page Ref: 470 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 19.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of malignant lung cancers and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of neoplastic, infectious, and pulmonary vascular lung disorders.

5) In caring for a client undergoing thoracentesis, the nurse should instruct the client that: A) a thin gauge needle will be inserted into the tumor. B) a thin tube will be inserted through the nose and down the trachea to the lung. C) a small incision will be made in the neck above the sternum. D) a large gauge needle will be inserted into the pleural space. Answer: D Explanation: A) This procedure describes tumor biopsy, requiring insertion of a thin needle into a peripheral tumor to obtain a sample for histology. B) This procedure describes bronchoscopy, which is the insertion of a thin lighted tube through the nose or mouth, down the trachea to the lung. Any suspicious-appearing tissue can be lavaged (washed), brushed, or biopsied for cells for cytologic or histologic analysis. C) A small incision as described would be needed for a mediastinoscopy procedure, which is used to sample lymph node tissue in the upper mediastinum. A small incision is made in the neck above the sternum, a thin lighted scope is inserted into the mediastinum, and suspicious nodes can be biopsied. D) Thoracentesis requires insertion of a large-gauge needle into the pleural space to remove fluid and cells for cytologic analysis. The needle is large gauge to allow removal of sufficient fluid. In addition to thoracentesis being used as a diagnostic procedure, it is often necessary to remove large volumes of fluid when pleural fluid buildup interferes with breathing. Page Ref: 7470 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 19.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of malignant lung cancers and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: LO 3: Relate alterations in function to clinical manifestations of neoplastic, infectious, and pulmonary vascular lung disorders. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of neoplastic, infectious, and pulmonary vascular lung disorders to diagnosis and treatment.

6) Which statement by a client with stage 1 non-small cell lung cancer (NSCLC) indicates an understanding of staging and treatment? A) "I only need surgery." B) "I need surgery and chemotherapy." C) "I need surgery, followed by radiation and chemotherapy." D) "Treatment will not help me." Answer: A Explanation: A) Surgery alone may be the treatment of choice when NSCLC is localized with no regional lymph node involvement and no metastases (stages 0 and I).With stage IB non-small cell cancer, chemotherapy and radiation may be included to reduce the risk of cancer recurrence. For stage II through stage IV cancer, surgery depends on a variety of factors, including the presence and extent of metastasis. If surgery is performed and it is determined that the stage is higher than stage 1, radiation and/or chemotherapy may be added to the treatment plan to help reduce the risk of cancer recurrence. B) Surgery alone may be the treatment of choice when NSCLC is localized with no regional lymph node involvement and no metastases (stages 0 and I).With stage IB non-small cell cancer, chemotherapy and radiation may be included to reduce the risk of cancer recurrence. For stage II through stage IV cancer, surgery depends on a variety of factors, including the presence and extent of metastasis. If surgery is performed and it is determined that the stage is higher than stage 1, radiation and/or chemotherapy may be added to the treatment plan to help reduce the risk of cancer recurrence. C) Surgery alone may be the treatment of choice when NSCLC is localized with no regional lymph node involvement and no metastases (stages 0 and I).With stage IB non-small cell cancer, chemotherapy and radiation may be included to reduce the risk of cancer recurrence. For stage II through stage IV cancer, surgery depends on a variety of factors, including the presence and extent of metastasis. If surgery is performed and it is determined that the stage is higher than stage 1, radiation and/or chemotherapy may be added to the treatment plan to help reduce the risk of cancer recurrence. D) Surgery alone may be the treatment of choice when NSCLC is localized with no regional lymph node involvement and no metastases (stages 0 and I).With stage IB non-small cell cancer, chemotherapy and radiation may be included to reduce the risk of cancer recurrence. For stage II through stage IV cancer, surgery depends on a variety of factors, including the presence and extent of metastasis. If surgery is performed and it is determined that the stage is higher than stage 1, radiation and/or chemotherapy may be added to the treatment plan to help reduce the risk of cancer recurrence. Page Ref: 470 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 19.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of malignant lung cancers and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage clients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings 6

NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of neoplastic, infectious, and pulmonary vascular lung disorders to diagnosis and treatment. 7) Which instruction should the nurse give the client with the disease tuberculosis (TB)? A) "Don't worry, your disease is not contagious." B) "You will need to be isolated until your sputum smear is negative." C) "Once you start taking isoniazid, you will not be contagious." D) "You will need to be isolated while you have an active cough." Answer: B Explanation: A) When individuals have the disease TB, a brief isolation period is necessary until sputum smears are negative, whether or not they have a cough. Medications for TB take time to work, and the individual with the disease should still be isolated until a sputum smear is negative. B) When individuals have the disease TB, a brief isolation period is necessary until sputum smears are negative, whether or not they have a cough. Medications for TB take time to work, and the individual with the disease should still be isolated until a sputum smear is negative. C) When individuals have the disease TB, a brief isolation period is necessary until sputum smears are negative, whether or not they have a cough. Medications for TB take time to work, and the individual with the disease should still be isolated until a sputum smear is negative. D) When individuals have the disease TB, a brief isolation period is necessary until sputum smears are negative, whether or not they have a cough. Medications for TB take time to work, and the individual with the disease should still be isolated until a sputum smear is negative. Page Ref: 475 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 19.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of benign lung lesions and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage clients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of neoplastic, infectious, and pulmonary vascular lung disorders to diagnosis and treatment.

8) In planning care for a client with tuberculosis and a Ghon complex, which intervention should the nurse include? A) Nursing staff should wear a respirator when entering the client's room. B) Have the client wear a mask when leaving his room. C) Nursing staff should wear a face shield when entering the client's room D) Nursing staff should wear a face shield if there is a risk of body fluid splashing on the nurse's face. Answer: D Explanation: A) The development of a granuloma with an associated lymph node, called a Ghon complex, signals an immune response to the bacilli. This is a type IV hypersensitivity reaction mediated by TH1 helper T cells. At this stage, the individual is infected but is not contagious. Because the client is not infectious, the nurse does not need to wear a respirator or face shield nor does the client need to wear a mask. The nurse should always wear a face shield if splashing of the face with bodily fluids is a risk with any diagnosis. B) The development of a granuloma with an associated lymph node, called a Ghon complex, signals an immune response to the bacilli. This is a type IV hypersensitivity reaction mediated by TH1 helper T cells. At this stage, the individual is infected but is not contagious. Because the client is not infectious, the nurse does not need to wear a respirator or face shield nor does the client need to wear a mask. The nurse should always wear a face shield if splashing of the face with bodily fluids is a risk with any diagnosis. C) The development of a granuloma with an associated lymph node, called a Ghon complex, signals an immune response to the bacilli. This is a type IV hypersensitivity reaction mediated by TH1 helper T cells. At this stage, the individual is infected but is not contagious. Because the client is not infectious, the nurse does not need to wear a respirator or face shield nor does the client need to wear a mask. The nurse should always wear a face shield if splashing of the face with bodily fluids is a risk with any diagnosis. D) The development of a granuloma with an associated lymph node, called a Ghon complex, signals an immune response to the bacilli. This is a type IV hypersensitivity reaction mediated by TH1 helper T cells. At this stage, the individual is infected but is not contagious. Because the client is not infectious, the nurse does not need to wear a respirator or face shield nor does the client need to wear a mask. The nurse should always wear a face shield if splashing of the face with bodily fluids is a risk with any diagnosis. Page Ref: 474 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 19.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of benign lung lesions and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of neoplastic, infectious, and pulmonary vascular lung disorders to diagnosis and treatment. 8

9) Which assessment finding would the nurse expect in a client with latent tuberculosis? A) A low-grade morning fever that subsides in the afternoon B) Insidious onset of symptoms C) An abrupt onset of symptoms D) A high fever with night sweats Answer: B Explanation: A) The classic symptoms of active tuberculosis can include cough, weight loss and anorexia, fever, night sweats, dull aching chest pain, and hemoptysis, but about 20% of individuals may be asymptomatic. In latent TB, the individual is asymptomatic at first, but TB is activated when host immune defenses are weakened. Symptom onset is generally insidious, with systemic symptoms of malaise, anorexia, fever, and weight loss. A low-grade fever appears in the late afternoon and then subsides, and night sweats occur. Increasing pulmonary involvement is indicated by increasing cough and sputum, and cavitation can result in hemoptysis. B) The classic symptoms of active tuberculosis can include cough, weight loss and anorexia, fever, night sweats, dull aching chest pain, and hemoptysis, but about 20% of individuals may be asymptomatic. In latent TB, the individual is asymptomatic at first, but TB is activated when host immune defenses are weakened. Symptom onset is generally insidious, with systemic symptoms of malaise, anorexia, fever, and weight loss. A low-grade fever appears in the late afternoon and then subsides, and night sweats occur. Increasing pulmonary involvement is indicated by increasing cough and sputum, and cavitation can result in hemoptysis. C) The classic symptoms of active tuberculosis can include cough, weight loss and anorexia, fever, night sweats, dull aching chest pain, and hemoptysis, but about 20% of individuals may be asymptomatic. In latent TB, the individual is asymptomatic at first, but TB is activated when host immune defenses are weakened. Symptom onset is generally insidious, with systemic symptoms of malaise, anorexia, fever, and weight loss. A low-grade fever appears in the late afternoon and then subsides, and night sweats occur. Increasing pulmonary involvement is indicated by increasing cough and sputum, and cavitation can result in hemoptysis. D) The classic symptoms of active tuberculosis can include cough, weight loss and anorexia, fever, night sweats, dull aching chest pain, and hemoptysis, but about 20% of individuals may be asymptomatic. In latent TB, the individual is asymptomatic at first, but TB is activated when host immune defenses are weakened. Symptom onset is generally insidious, with systemic symptoms of malaise, anorexia, fever, and weight loss. A low-grade fever appears in the late afternoon and then subsides, and night sweats occur. Increasing pulmonary involvement is indicated by increasing cough and sputum, and cavitation can result in hemoptysis. Page Ref: 474 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 19.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of benign lung lesions and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings 9

NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of neoplastic, infectious, and pulmonary vascular lung disorders. 10) To prevent transmission of tuberculosis, the nurse should instruct the client that the disease is spread by: A) tears. B) blood. C) direct contact. D) respiratory droplets. Answer: D Explanation: A) Tuberculosis is spread via respiratory droplet nuclei from an infected person to a susceptible host. Droplet nuclei are tiny droplets of respiratory secretions spread via coughing, sneezing, or speaking. It is not spread through saliva, blood, tears, or direct contact. B) Tuberculosis is spread via respiratory droplet nuclei from an infected person to a susceptible host. Droplet nuclei are tiny droplets of respiratory secretions spread via coughing, sneezing, or speaking. It is not spread through saliva, blood, tears, or direct contact. C) Tuberculosis is spread via respiratory droplet nuclei from an infected person to a susceptible host. Droplet nuclei are tiny droplets of respiratory secretions spread via coughing, sneezing, or speaking. It is not spread through saliva, blood, tears or direct contact. D) Tuberculosis is spread via respiratory droplet nuclei from an infected person to a susceptible host. Droplet nuclei are tiny droplets of respiratory secretions spread via coughing, sneezing, orspeaking. It is not spread through saliva, blood, tears, or direct contact. Page Ref: 472 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 19.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of benign lung lesions and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of neoplastic, infectious, and pulmonary vascular lung disorders.

11) Which nursing action is a priority in the client at risk for respiratory aspiration? A) Orient the client to person, place, and time. B) Position the client with the head of the bed at 45 degrees. C) Administer intravenous antibiotics, as ordered. D) Encourage cough and deep breathing exercises. Answer: B Explanation: A) While all the listed nursing actions are appropriate for a client at risk for aspiration, the priority is given to keeping the head of the bed elevated. The risk for aspiration is greatly increased with a decreased level of consciousness and in a recumbent individual, whose more vertical airways in the right lung provide more direct paths to the posterior segment of the upper lobe or the apical segments of the lower lobe. B) While all the listed nursing actions are appropriate for a client at risk for aspiration, the priority is given to keeping the head of the bed elevated. The risk for aspiration is greatly increased with a decreased level of consciousness and in a recumbent individual whose more vertical airways in the right lung provide more direct paths to the posterior segment of the upper lobe or the apical segments of the lower lobe. C) While all the listed nursing actions are appropriate for a client at risk for aspiration, the priority is given to keeping the head of the bed elevated. The risk for aspiration is greatly increased with a decreased level of consciousness and in a recumbent individual whose more vertical airways in the right lung provide more direct paths to the posterior segment of the upper lobe or the apical segments of the lower lobe. D) While all the listed nursing actions are appropriate for a client at risk for aspiration, the priority is given to keeping the head of the bed elevated. The risk for aspiration is greatly increased with a decreased level of consciousness and in a recumbent individual whose more vertical airways in the right lung provide more direct paths to the posterior segment of the upper lobe or the apical segments of the lower lobe. Page Ref: 475 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 19.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of upper respiratory tract infections and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: VII. 11. Participate in clinical prevention and populationfocused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of neoplastic, infectious, and pulmonary vascular lung disorders.

12) What is the initial action the nurse should take when admitting a 2-year-old child with epiglottitis? A) Suction excess secretions. B) Administer antibiotics. C) Maintain an open airway. D) Administer a Haemophilus influenzae type b (Hib) vaccination. Answer: C Explanation: A) Epiglottitis is a rapidly progressive inflammation of the epiglottis. Because the abrupt onset of severe inflammation results in edema that can obstruct the upper airway, the priority is maintaining an open airway. Suctioning of secretions may aggravate the airway obstruction. Antibiotics may be administered, but are a lesser priority than maintaining a patent airway. The Hib vaccine should be administered during infancy, and acute administration now will not relieve the acute manifestations of epiglottitis. B) Epiglottitis is a rapidly progressive inflammation of the epiglottis. Because the abrupt onset of severe inflammation results in edema that can obstruct the upper airway, the priority is maintaining an open airway. Suctioning of secretions may aggravate the airway obstruction. Antibiotics may be administered, but are a lesser priority than maintaining a patent airway. The Hib vaccine should be administered during infancy, and acute administration now will not relieve the acute manifestations of epiglottitis. C) Epiglottitis is a rapidly progressive inflammation of the epiglottis. Because the abrupt onset of severe inflammation results in edema that can obstruct the upper airway, the priority is maintaining an open airway. Suctioning of secretions may aggravate the airway obstruction. Antibiotics may be administered, but are a lesser priority than maintaining a patent airway. The Hib vaccine should be administered during infancy, and acute administration now will not relieve the acute manifestations of epiglottitis. D) Epiglottitis is a rapidly progressive inflammation of the epiglottis. Because the abrupt onset of severe inflammation results in edema that can obstruct the upper airway, the priority is maintaining an open airway. Suctioning of secretions may aggravate the airway obstruction. Antibiotics may be administered, but are a lesser priority than maintaining a patent airway. The Hib vaccine should be administered during infancy, and acute administration now will not relieve the acute manifestations of epiglottitis. Page Ref: 478 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 19.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of upper respiratory tract infections and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of neoplastic, infectious, and pulmonary vascular lung disorders to diagnosis and treatment. 12

13) When caring for a client with acute bronchitis, which findings indicate a viral infection? A) A severe and prolonged cough B) A cough that produces copious amounts of sputum C) Finding of increased lung density (consolidation) on the chest x-ray D) The cough only lasts several hours Answer: A Explanation: A) Acute bronchitis caused by a viral infection produces a cough that may be severe and prolonged but not produce much sputum. Pneumonia can be differentiated from acute bronchitis by the consolidation (increased lung density) that is evident on chest x-ray in pneumonia. B) Acute bronchitis caused by a viral infection produces a cough that may be severe and prolonged but not produce much sputum. Pneumonia can be differentiated from acute bronchitis by the consolidation (increased lung density) that is evident on chest x-ray in pneumonia. C) Acute bronchitis caused by a viral infection produces a cough that may be severe and prolonged but not produce much sputum. Pneumonia can be differentiated from acute bronchitis by the consolidation (increased lung density) that is evident on chest x-ray in pneumonia. D) Acute bronchitis caused by a viral infection produces a cough that may be severe and prolonged but not produce much sputum. Pneumonia can be differentiated from acute bronchitis by the consolidation (increased lung density) that is evident on chest x-ray in pneumonia. Page Ref: 479 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 19.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of lower respiratory tract infections and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of neoplastic, infectious, and pulmonary vascular lung disorders.

14) The nurse is assigned to care for a child with bronchiolitis. Which one of the following pediatric individuals is at greatest risk for developing bronchiolitis? A) A child over one year of age B) A newborn infant C) A toddler in preschool D) A 5-month-old infant Answer: D Explanation: A) The incidence of bronchiolitis peaks in infants 2-6 months old; in 80% of cases, the child is younger than 1 year of age. B) The incidence of bronchiolitis peaks in infants 2-6 months old; in 80% of cases, the child is younger than 1 year of age. C) The incidence of bronchiolitis peaks in infants 2-6 months old; in 80% of cases, the child is younger than 1 year of age. D) The incidence of bronchiolitis peaks in infants 2-6 months old; in 80% of cases, the child is younger than 1 year of age. Page Ref: 480 Cognitive Level: Remembering Client Need & Sub: Health Promotion and Maintenance: Reduction of Risk Potential Standards: Nursing Process: Analysis | Learning Outcome: 19.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of lower respiratory tract infections and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of neoplastic, infectious, and pulmonary vascular lung disorders.

15) Which is the most appropriate action for the nurse to take when sternal and intercostal retractions are noted in an infant? A) Nothing, as this finding is normal in infants. B) Notify the physician or provider immediately. C) Assess the infant again in 15 minutes. D) Increase fluid intake. Answer: B Explanation: A) Infants have compliant chest walls, so sternal and intercostal retractions indicate that the infant is working hard to breathe and, coupled with hypoxemia, signal serious respiratory distress. Therefore, the nurse should notify the physician or provider immediately so that actions can be taken to treat the respiratory distress. This is not a normal finding in infants. The nurse should not wait another 15 minutes and reassess the infant as the infant is already struggling to breathe. While increased fluid intake would help humidify the airways and sputum, this is not a priority action. B) Infants have compliant chest walls, so sternal and intercostal retractions indicate that the infant is working hard to breathe and, coupled with hypoxemia, signal serious respiratory distress. Therefore, the nurse should notify the physician or provider immediately so that actions can be taken to treat the respiratory distress. This is not a normal finding in infants. The nurse should not wait another 15 minutes and reassess the infant as the infant is already struggling to breathe. While increased fluid intake would help humidify the airways and sputum, this is not a priority action. C) Infants have compliant chest walls, so sternal and intercostal retractions indicate that the infant is working hard to breathe and, coupled with hypoxemia, signal serious respiratory distress. Therefore, the nurse should notify the physician or provider immediately so that actions can be taken to treat the respiratory distress. This is not a normal finding in infants. The nurse should not wait another 15 minutes and reassess the infant as the infant is already struggling to breathe. While increased fluid intake would help humidify the airways and sputum, this is not a priority action. D) Infants have compliant chest walls, so sternal and intercostal retractions indicate that the infant is working hard to breathe and, coupled with hypoxemia, signal serious respiratory distress. Therefore, the nurse should notify the physician or provider immediately so that actions can be taken to treat the respiratory distress. This is not a normal finding in infants. The nurse should not wait another 15 minutes and reassess the infant as the infant is already struggling to breathe. While increased fluid intake would help humidify the airways and sputum, this is not a priority action. Page Ref: 480 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 19.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of lower respiratory tract infections and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings 15

NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of neoplastic, infectious, and pulmonary vascular lung disorders to diagnosis and treatment. 16) The nurse working in a community health clinic has a limited supply of influenza vaccine. Which of the following clients is a priority for receiving this vaccine? A) Children under the age of 2 B) Individuals between the ages of 30 and 50 C) Individuals who live alone D) Postpartum women Answer: A Explanation: A) Individuals who are at high risk for influenza-related complications and severe disease include the following: children under 5 years of age, especially those under the age of 2 years; pregnant women; individuals over 50 years of age; individuals of any age with chronic medical conditions such as cardiac or pulmonary disease or diabetes mellitus; individuals who live with or care for individuals at high risk (e.g., household contacts, healthcare workers). B) Individuals who are at high risk for influenza-related complications and severe disease include the following: children under 5 years of age, especially those under the age of 2 years; pregnant women; individuals over 50 years of age; individuals of any age with chronic medical conditions such as cardiac or pulmonary disease or diabetes mellitus; individuals who live with or care for individuals at high risk (e.g., household contacts, healthcare workers). C) Individuals who are at high risk for influenza-related complications and severe disease include the following: children under 5 years of age, especially those under the age of 2 years; pregnant women; individuals over 50 years of age; individuals of any age with chronic medical conditions such as cardiac or pulmonary disease or diabetes mellitus; individuals who live with or care for individuals at high risk (e.g., household contacts, healthcare workers). D) Individuals who are at high risk for influenza-related complications and severe disease include the following: children under 5 years of age, especially those under the age of 2 years; pregnant women; individuals over 50 years of age; individuals of any age with chronic medical conditions such as cardiac or pulmonary disease or diabetes mellitus; individuals who live with or care for individuals at high risk (e.g., household contacts, healthcare workers). Page Ref: 480 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 19.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of lower respiratory tract infections and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: VII. 11. Participate in clinical prevention and populationfocused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of neoplastic, infectious, and pulmonary vascular lung disorders.

17) In order for a nurse working at a community health clinic to appropriately plan care, he knows that which of the following populations is most at risk for pneumonia? A) A preschool-age child B) A 72-year-old African American man with diabetes C) A 70-year-old Caucasian man D) A 30-year-old woman Answer: B Explanation: A) The patterns of pneumonia occurrence vary with different organisms and the person's age, health status, and environment. In general, pneumonia is more common in winter than summer, in men than women, and in African Americans than Caucasians and is common among older adults with chronic diseases. B) The patterns of pneumonia occurrence vary with different organisms and the person's age, health status, and environment. In general, pneumonia is more common in winter than summer, in men than women, and in African Americans than Caucasians and is common among older adults with chronic diseases. C) The patterns of pneumonia occurrence vary with different organisms and the person's age, health status, and environment. In general, pneumonia is more common in winter than summer, in men than women, and in African Americans than Caucasians and is common among older adults with chronic diseases D) The patterns of pneumonia occurrence vary with different organisms and the person's age, health status, and environment. In general, pneumonia is more common in winter than summer, in men than women, and in African Americans than Caucasians and is common among older adults with chronic diseases. Page Ref: 482 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 19.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of lower respiratory tract infections and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: VII. 11. Participate in clinical prevention and populationfocused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of neoplastic, infectious, and pulmonary vascular lung disorders.

18) The nurse is planning care for a client on a ventilator. Which intervention should be given priority in preventing ventilator-associated pneumonia (VAP)? A) Providing regular oral care B) Ensuring adequate nutrition C) Administering supplemental oxygen D) Infusing intravenous fluids Answer: A Explanation: A) In VAP, the risks for infection are decreased by adequate oral and airway care, use of saline instillation with suctioning, a semi-recumbent 45-degree position, and early tracheostomy in older adults. While all the listed interventions may be appropriate, providing regular oral care decreases the risk of infection leading to VAP. B) In VAP, the risks for infection are decreased by adequate oral and airway care, use of saline instillation with suctioning, a semi-recumbent 45-degree position, and early tracheostomy in older adults. While all the listed interventions may be appropriate, providing regular oral care decreases the risk of infection leading to VAP. C) In VAP, the risks for infection are decreased by adequate oral and airway care, use of saline instillation with suctioning, a semi-recumbent 45-degree position, and early tracheostomy in older adults. While all the listed interventions may be appropriate, providing regular oral care decreases the risk of infection leading to VAP. D) In VAP, the risks for infection are decreased by adequate oral and airway care, use of saline instillation with suctioning, a semi-recumbent 45-degree position, and early tracheostomy in older adults. While all the listed interventions may be appropriate, providing regular oral care decreases the risk of infection leading to VAP. Page Ref: 482 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 19.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of lower respiratory tract infections and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of neoplastic, infectious, and pulmonary vascular lung disorders to diagnosis and treatment.

19) Which triad of symptoms should alert the nurse to a potential problem in a client with a fractured femur? A) Chest pain, shoulder pain, hemoptysis B) Tachycardia, dyspnea, pleuritic pain C) Hemoptysis, chest pain, dyspnea D) Dyspnea, shoulder pain, tachycardia Answer: C Explanation: A) The client with a fractured long bone, such as a femur, is at risk for fat emboli formed from lipid droplets from the marrow of the fractured bone. The classic clinical presentation of PE is a triad of sudden shortness of breath or dyspnea that is not related to activity; hemoptysis; and chest pain that is worse with a deep breath, cough, eating, or bending. While the other symptoms may occur with a fat embolism, they are not part of the classic triad of associated symptoms. B) The client with a fractured long bone, such as a femur, is at risk for fat emboli formed from lipid droplets from the marrow of the fractured bone. The classic clinical presentation of PE is a triad of sudden shortness of breath or dyspnea that is not related to activity; hemoptysis; and chest pain that is worse with a deep breath, cough, eating, or bending. While the other symptoms may occur with a fat embolism, they are not part of the classic triad of associated symptoms. C) The client with a fractured long bone, such as a femur, is at risk for fat emboli formed from lipid droplets from the marrow of the fractured bone. The classic clinical presentation of PE is a triad of sudden shortness of breath or dyspnea that is not related to activity; hemoptysis; and chest pain that is worse with a deep breath, cough, eating, or bending. While the other symptoms may occur with a fat embolism, they are not part of the classic triad of associated symptoms. D) The client with a fractured long bone, such as a femur, is at risk for fat emboli formed from lipid droplets from the marrow of the fractured bone. The classic clinical presentation of PE is a triad of sudden shortness of breath or dyspnea that is not related to activity; hemoptysis; and chest pain that is worse with a deep breath, cough, eating, or bending. While the other symptoms may occur with a fat embolism, they are not part of the classic triad of associated symptoms. Page Ref: 487 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 19.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of pulmonary vascular disorders and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of neoplastic, infectious, and pulmonary vascular lung disorders.

20) When admitting a client with Goodpasture syndrome, the nurse should focus assessments on which body systems? A) Renal and cardiovascular B) Pulmonary and gastrointestinal C) Cardiovascular and renal D) Pulmonary and renal Answer: D Explanation: A) Goodpasture syndrome is an antiglomerular basement antibody disease that targets the lungs and kidneys. B) Goodpasture syndrome is an antiglomerular basement antibody disease that targets the lungs and kidneys. C) Goodpasture syndrome is an antiglomerular basement antibody disease that targets the lungs and kidneys. D) Goodpasture syndrome is an antiglomerular basement antibody disease that targets the lungs and kidneys. Page Ref: 488 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 19.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of pulmonary vascular disorders and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of neoplastic, infectious, and pulmonary vascular lung disorders.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 20 Respiratory Failure 1) The nurse would expect to observe which characteristics in a patient with type II respiratory failure? A) Hypoxemia without hypercapnia B) Hypoxemia with hypercapnia C) Hypoxemia with hypocapnia D) Hyperventilation Answer: B Explanation: A) Type I respiratory failure, also called hypoxemic respiratory failure, is characterized by hypoxemia without hypercapnia. B) Type II respiratory failure, also called hypercapnic respiratory failure or ventilatory failure, results from inadequate alveolar ventilation, causing an increased level of carbon dioxide in the blood (hypercapnia) with or without a low level of oxygen in the blood (hypoxemia). C) Type II respiratory failure, also called hypercapnic respiratory failure or ventilatory failure, results from inadequate alveolar ventilation, causing an increased level of carbon dioxide in the blood (hypercapnia) with or without a low level of oxygen in the blood (hypoxemia). D) Type II respiratory failure is a result of hypoventilation. Page Ref: 495 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 20.1 Define respiratory failure, and describe the concepts related to respiratory failure. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of respiratory failure.

2) Which arterial blood gas values does the nurse anticipate in a patient with acute type II respiratory failure? A) Increased PaO2 B) Decreased PaCO2 C) Acidic pH D) Increased bicarbonate levels Answer: C Explanation: A) In type II respiratory failure, PaO2 is decreased, and PaCO2 increased to 50 mmHg or higher. B) In type II respiratory failure, PaO2 is decreased, and PaCO2 increased to 50 mmHg or higher. C) In acute type II failure, the bicarbonate levels are decreased, and the pH is acidic, but in chronic type II failure with renal compensation, the bicarbonate levels are increased to maintain the pH within normal limits but less than 7.4. D) In acute type II failure, the bicarbonate levels are decreased, and the pH is acidic, but in chronic type II failure with renal compensation, the bicarbonate levels are increased to maintain the pH within normal limits but less than 7.4. Page Ref: 500 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 20.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of type I and type II respiratory failure and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of respiratory failure.

3) What response should the nurse give a nursing student who asks why a patient with respiratory failure is being placed in the prone position? A) "The prone position reduces ventilation-perfusion matching." B) "The prone position reduces functional residual capacity." C) "The prone position reduces V-Q matching." D) "The prone position improves oxygenation." Answer: D Explanation: A) Positioning an individual in a decubitus upright or prone position facilitates breathing. Prone positioning improves the functional residual capacity, drainage of secretion, and V-Q matching and may improve oxygenation. B) Positioning an individual in a decubitus upright or prone position facilitates breathing. Prone positioning improves the functional residual capacity, drainage of secretion, and V-Q matching and may improve oxygenation. C) Positioning an individual in a decubitus upright or prone position facilitates breathing. Prone positioning improves the functional residual capacity, drainage of secretion, and V-Q matching and may improve oxygenation. D) Positioning an individual in a decubitus upright or prone position facilitates breathing. Prone positioning improves the functional residual capacity, drainage of secretion, and V-Q matching and may improve oxygenation. Page Ref: 501 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 20.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of type I and type II respiratory failure and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of respiratory failure to diagnosis and treatment.

4) When planning care to improve oxygenation for a patient with respiratory failure, the nursing plan includes turning and positioning the patient regularly. What rationale does the nurse give for this intervention? A) Turning reduces lung expansion. B) Turning maximizes the use of all lung zones. C) Turning reduces ventilation-perfusion matching. D) Turning reduces the work of breathing. Answer: B Explanation: A) Turning the patient regularly promotes expansion of different portions of the lungs. B) Turning the patient regularly rotates and maximizes lung zones to assist V-Q matching. C) Turning the patient regularly rotates and maximizes lung zones to assist V-Q matching. D) Turning does not reduce the work of breathing. Page Ref: 501 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 20.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of type I and type II respiratory failure and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of respiratory failure to diagnosis and treatment.

5) Which statement by a patient with respiratory failure indicates that more teaching is needed about use of the incentive spirometer, which promotes deep breathing? A) "The incentive spirometer helps me take deep breaths." B) "The incentive spirometer helps to open the alveoli in my lungs." C) "The incentive spirometer helps my lungs exchange oxygen and carbon dioxide more effectively." D) "The incentive spirometer improves retention of carbon dioxide." Answer: D Explanation: A) Deep breathing is a simple technique for improving breathing. Use of incentive spirometry assists in taking sustained inhalations to maximize diffusion and improve alveolar surface area. B) Deep breathing is a simple technique for improving breathing. Use of incentive spirometry assists in taking sustained inhalations to maximize diffusion and improve alveolar surface area. C) Deep breathing is a simple technique for improving breathing. Use of incentive spirometry assists in taking sustained inhalations to maximize diffusion and improve alveolar surface area, thereby improving exchange of gasses in the alveoli. D) Maximizing diffusion and improving alveolar surface area improves the movement of carbon dioxide out of the blood to be exhaled by the lungs. Page Ref: 501 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Evaluation | Learning Outcome: 20.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of type I and type II respiratory failure and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of respiratory failure to diagnosis and treatment.

6) Which measure should the nurse include in the care plan to loosen thick secretions in the patient with respiratory failure? A) Incentive spirometry B) Supplemental oxygen via face mask C) Chest percussion and vibration D) Pursed lip breathing Answer: C Explanation: A) Use of incentive spirometry assists in maximizing diffusion and improving alveolar surface area. B) Supplemental oxygen may help reduce hypoxemia, but will not help to loosen secretions. C) Chest percussion or vibration can be used to loosen thick, heavy secretions so that they can be coughed or suctioned out. D) Pursed lip breathing is beneficial to breathing in patients with chronic obstructive pulmonary disease, but it does not help to loosen secretions. Page Ref: 501 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 20.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of type I and type II respiratory failure and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of respiratory failure to diagnosis and treatment.

7) When planning care for a patient in the exudative phase of acute respiratory distress syndrome (ARDS), which concept should the nurse keep in mind? A) Microvascular endothelial damage only has occurred. B) Alveolar epithelial damage only has occurred. C) Both microvascular endothelial and alveolar epithelial damage have occurred. D) The alveolar-capillary membrane is still intact. Answer: C Explanation: A) The exudative phase, which develops 5-7 days after the initial injury, is characterized by damage to the alveolar-capillary membrane, which has two parts: the microvascular endothelium and the alveolar epithelium. B) The exudative phase, which develops 5-7 days after the initial injury, is characterized by damage to the alveolar-capillary membrane, which has two parts: the microvascular endothelium and the alveolar epithelium. C) The exudative phase, which develops 5-7 days after the initial injury, is characterized by damage to the alveolar-capillary membrane, which has two parts: the microvascular endothelium and the alveolar epithelium. D) The exudative phase, which develops 5-7 days after the initial injury, is characterized by damage to the alveolar-capillary membrane, which has two parts: the microvascular endothelium and the alveolar epithelium. Page Ref: 501-502 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 20.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders that cause respiratory failure and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of respiratory failure to diagnosis and treatment.

8) The nurse in intensive care is caring for a patient who is developing ARDS secondary to infection. When the patient develops hypoxemia, which intervention does the nurse anticipate? A) Intubation with mechanical ventilation B) Oxygen delivery via nasal cannula C) Oxygen delivery via Venturi mask D) Administration of surfactant Answer: A Explanation: A) Individuals with ARDS almost invariably require intubation and mechanical ventilation during their illness to manage the hypoxemia. Mechanical ventilation supports oxygenation by decreasing the work of breathing, providing increased levels of FIO2, recruiting atelectatic lung regions, and decreasing the venous return to the heart. B) A nasal cannula cannot deliver the FIO2 that the patient with ARDS needs and will not reduce the work of breathing. C) A Venturi mask delivers a specific oxygen concentration to patients on controlled oxygen therapy with adjustable levels of FIO2. D) Surfactant administration will not improve hypoxemia. The combination of surfactant therapy and mechanical ventilation with continuous positive airway pressure (CPAP) to prevent alveoli from collapsing has been a mainstay of treatment of IRDS. Page Ref: 504 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 20.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders that cause respiratory failure and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of respiratory failure to diagnosis and treatment.

9) When caring for an intubated patient on mechanical ventilation using positive end-expiratory pressure (PEEP), the nurse continually assesses for which potential complication? A) Lung injury due to barotraumas B) Pulmonary emboli C) Cor pulmonale D) Pulmonary edema Answer: A Explanation: A) Positive end-expiratory pressure (PEEP) is a method of ventilation in which airway pressure is maintained above atmospheric pressure at the end of exhalation during mechanical ventilation. Therefore, a higher pressure in the airways at the end of exhalation is expected. Despite the advantages, mechanical ventilation in ARDS may induce significant lung injury due to barotraumas and alveolar overdistention. B) Positive end-expiratory pressure (PEEP) is a method of ventilation in which airway pressure is maintained above atmospheric pressure at the end of exhalation during mechanical ventilation. Therefore, a higher pressure in the airways at the end of exhalation is expected. Despite the advantages, mechanical ventilation in ARDS may induce significant lung injury due to barotraumas and alveolar overdistention. C) Positive end-expiratory pressure (PEEP) is a method of ventilation in which airway pressure is maintained above atmospheric pressure at the end of exhalation during mechanical ventilation. Therefore, a higher pressure in the airways at the end of exhalation is expected. Despite the advantages, mechanical ventilation in ARDS may induce significant lung injury due to barotraumas and alveolar overdistention. D) Positive end-expiratory pressure (PEEP) is a method of ventilation in which airway pressure is maintained above atmospheric pressure at the end of exhalation during mechanical ventilation. Therefore, a higher pressure in the airways at the end of exhalation is expected. Despite the advantages, mechanical ventilation in ARDS may induce significant lung injury due to barotraumas and alveolar overdistention. Page Ref: 504-505 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 20.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders that cause respiratory failure and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of respiratory failure to diagnosis and treatment.

10) The nurse explains to the parents of a premature newborn that infant respiratory distress syndrome is caused by: A) infection. B) deficiency of surfactant. C) inflammation. D) trauma during birth. Answer: B Explanation: A) Infant respiratory distress syndrome (IRDS) arises from a deficiency of surfactant due to either the immature lung's inability to produce enough surfactant or a genetic mutation of the SP-B surfactant protein. B) Infant respiratory distress syndrome (IRDS) arises from a deficiency of surfactant due to either the immature lung's inability to produce enough surfactant or a genetic mutation of the SPB surfactant protein. C) Infant respiratory distress syndrome (IRDS) arises from a deficiency of surfactant due to either the immature lung's inability to produce enough surfactant or a genetic mutation of the SPB surfactant protein. D) Infant respiratory distress syndrome (IRDS) arises from a deficiency of surfactant due to either the immature lung's inability to produce enough surfactant or a genetic mutation of the SPB surfactant protein. Page Ref: 505 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 20.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders that cause respiratory failure and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of respiratory failure.

11) How should the nurse respond when the parent of a child with infant respiratory distress syndrome asks the nurse why surfactant is important? A) "Surfactant helps to keep the alveoli in the lungs expanded." B) "Surfactant stimulates the newborn to breath." C) "Surfactant protects the alveolar-capillary membranes from leaks." D) "Surfactant reduces inflammation in the lungs." Answer: A Explanation: A) Surfactant is important in maintaining alveolar compliance—the ability of tissue to stretch or distend. A lack of surfactant causes alveoli to collapse. B) Surfactant is important in maintaining alveolar compliance—the ability of tissue to stretch or distend. A lack of surfactant causes alveoli to collapse. It does not stimulate breathing. C) Surfactant is important in maintaining alveolar compliance—the ability of tissue to stretch or distend. A lack of surfactant causes alveoli to collapse. D) Surfactant is important in maintaining alveolar compliance—the ability of tissue to stretch or distend. A lack of surfactant causes alveoli to collapse. Page Ref: 505 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 20.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders that cause respiratory failure and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of respiratory failure.

12) When assessing the newborn, which finding should alert the nurse to a potential complication? A) A loud cry B) Respiratory rate of 40 breaths/minute C) Nasal flaring D) Acrocyanosis Answer: C Explanation: A) A loud cry is a sign of a healthy respiratory effort. B) A rate of 40 breaths/minute is normal in the newborn. C) Clinical manifestations of infant respiratory distress syndrome (IRDS) include obvious signs of respiratory distress such as nasal flaring, rapid breathing, shallow breathing, shortness of breath, and grunting with breathing. D) Acrocyanosis, cyanosis around the mouth and in the hands and feet, in the newborn is normal. Page Ref: 506 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 20.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders that cause respiratory failure and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of oxygen transport.

13) When assessing a newborn with infant respiratory distress syndrome, who is receiving surfactant therapy, which finding should alert the nurse of a complication of this medication? A) Pulmonary edema B) Development of a new heart murmur C) Bleeding into the lungs D) Decreased urinary output Answer: C Explanation: A) Surfactant therapy and mechanical ventilation with continuous positive airway pressure (CPAP) are a mainstay of treatment of IRDS since the 1990s. Typically, the newborn in distress breathes more easily within hours of surfactant therapy. Although there is a risk of bleeding into the lungs from surfactant replacement, complications are less likely and morbidity rates are much lower for newborns who receive timely therapy. B) Surfactant therapy and mechanical ventilation with continuous positive airway pressure (CPAP) are a mainstay of treatment of IRDS since the 1990s. Typically, the newborn in distress breathes more easily within hours of surfactant therapy. Although there is a risk of bleeding into the lungs from surfactant replacement, complications are less likely and morbidity rates are much lower for newborns who receive timely therapy. C) Surfactant therapy and mechanical ventilation with continuous positive airway pressure (CPAP) are a mainstay of treatment of IRDS since the 1990s. Typically, the newborn in distress breathes more easily within hours of surfactant therapy. Although there is a risk of bleeding into the lungs from surfactant replacement, complications are less likely and morbidity rates are much lower for newborns who receive timely therapy. D) Surfactant therapy and mechanical ventilation with continuous positive airway pressure (CPAP) are a mainstay of treatment of IRDS since the 1990s. Typically, the newborn in distress breathes more easily within hours of surfactant therapy. Although there is a risk of bleeding into the lungs from surfactant replacement, complications are less likely and morbidity rates are much lower for newborns who receive timely therapy. Page Ref: 506 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Assessment | Learning Outcome: 20.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders that cause respiratory failure and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of respiratory failure to diagnosis and treatment.

14) The nurse should keep which concept in mind when providing care to a patient with cardiogenic pulmonary edema? A) Increased left ventricular pressure is reflected back to the pulmonary capillary bed. B) This condition is caused by decreased oncotic pressure due to anemia. C) Capillary endothelial injury makes the capillaries leaky. D) Lymphatic blockage prevents drainage of interstitial fluid. Answer: A Explanation: A) There are four pathophysiologic mechanisms that cause the formation of pulmonary edema. The mechanism that causes cardiogenic pulmonary edema is left ventricular failure. The increased left ventricular pressure is reflected back into the pulmonary capillary bed. The increased pulmonary capillary pressure (wedge pressure > 20 mmHg) increases the hydrostatic drive for fluid to flow from the capillaries into the interstitial space. B) Pulmonary edema may also be caused by a decrease of oncotic pressure due to anemia or a decrease in plasma proteins. The pulmonary hydrostatic pressure is normal, but the oncotic pressure is not adequate to resorb normal amounts of fluid from the interstitial space. However, this is not cardiogenic pulmonary edema. C) Capillary endothelial injury makes capillaries "leaky" so more fluid leaks into the interstitial space can also lead to pulmonary edema. However, this is not cardiogenic pulmonary edema. D) Blockage of lymphatic drainage prevents the removal of excess fluid from the interstitial space and can lead to pulmonary edema. Normally, excess fluid in the lung interstitial space is collected at the periphery of acini to drain through the lymphatic system. However, this is not cardiogenic pulmonary edema. Page Ref: 506 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 20.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders that cause respiratory failure and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of respiratory failure.

15) Which manifestation would the nurse expect to find in the cardiac assessment of a patient with pulmonary edema? A) Accentuated pulmonic component of S2 B) S4 C) Accentuated S1 D) Diminished S1 Answer: A Explanation: A) On auscultation of the heart, an S3 and accentuated pulmonic component of S2 will be heard. B) On auscultation of the heart, an S3 and accentuated pulmonic component of S2 will be heard. C) On auscultation of the heart, an S3 and accentuated pulmonic component of S2 will be heard. D) On auscultation of the heart, an S3 and accentuated pulmonic component of S2 will be heard. Page Ref: 507 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 20.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders that cause respiratory failure and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of respiratory failure.

16) When assessing the patient with pulmonary edema, which pulmonary capillary wedge pressure does the nurse anticipate? A) <10 mmHg B) 10-14 mmHg C) 14-18 mmHg D) > 18 mmHg Answer: D Explanation: A) An elevated pulmonary wedge pressure that is greater than 18 mmHg indicates an increased left atrial pressure associated with heart failure and an increased pulmonary capillary permeability, which means that there is a greater hydrostatic pressure for filtration of fluid. B) An elevated pulmonary wedge pressure that is greater than 18 mmHg indicates an increased left atrial pressure associated with heart failure and an increased pulmonary capillary permeability, which means that there is a greater hydrostatic pressure for filtration of fluid. C) An elevated pulmonary wedge pressure that is greater than 18 mmHg indicates an increased left atrial pressure associated with heart failure and an increased pulmonary capillary permeability, which means that there is a greater hydrostatic pressure for filtration of fluid. D) An elevated pulmonary wedge pressure that is greater than 18 mmHg indicates an increased left atrial pressure associated with heart failure and an increased pulmonary capillary permeability, which means that there is a greater hydrostatic pressure for filtration of fluid. Page Ref: 507 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 20.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders that cause respiratory failure and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of respiratory failure.

17) When planning care for the patient with end-stage COPD, the nurse takes into consideration that the patient is at high risk for: A) type I respiratory failure. B) type II respiratory failure. C) Pulmonary edema. D) ARDS. Answer: B Explanation: A) Individuals with end-stage COPD are at high risk for type II respiratory failure. Damage to bronchioles increases the disruption of airflow, and hypoxemia occurs because of low alveolar ventilation that is uneven throughout the lung fields, resulting in V-Q mismatch. Type II respiratory failure can develop or worsen, as hypercapnia can increase rapidly with exacerbations. B) Individuals with end-stage COPD are at high risk for type II respiratory failure. Damage to bronchioles increases the disruption of airflow, and hypoxemia occurs because of low alveolar ventilation that is uneven throughout the lung fields, resulting in V-Q mismatch. Type II respiratory failure can develop or worsen, as hypercapnia can increase rapidly with exacerbations. C) Individuals with end-stage COPD are at high risk for type II respiratory failure. Damage to bronchioles increases the disruption of airflow, and hypoxemia occurs because of low alveolar ventilation that is uneven throughout the lung fields, resulting in V-Q mismatch. Type II respiratory failure can develop or worsen, as hypercapnia can increase rapidly with exacerbations. D) Individuals with end-stage COPD are at high risk for type II respiratory failure. Damage to bronchioles increases the disruption of airflow, and hypoxemia occurs because of low alveolar ventilation that is uneven throughout the lung fields, resulting in V-Q mismatch. Type II respiratory failure can develop or worsen, as hypercapnia can increase rapidly with exacerbations. Page Ref: 507 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 20.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders that cause respiratory failure and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of respiratory failure to diagnosis and treatment.

18) Which cardiac complication does the nurse anticipate in the patient with advanced COPD? A) Cor pulmonale B) Left-sided heart failure C) Pericarditis D) Hypertension Answer: A Explanation: A) Cor pulmonale (right heart failure) develops when the right ventricle is stretched or dilated to the point at which it can no longer effectively pump adequate blood through the pulmonary vasculature. B) Cor pulmonale (right heart failure) develops when the right ventricle is stretched or dilated to the point at which it can no longer effectively pump adequate blood through the pulmonary vasculature. C) Cor pulmonale (right heart failure) develops when the right ventricle is stretched or dilated to the point at which it can no longer effectively pump adequate blood through the pulmonary vasculature. D) Cor pulmonale (right heart failure) develops when the right ventricle is stretched or dilated to the point at which it can no longer effectively pump adequate blood through the pulmonary vasculature. Page Ref: 507 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 20.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders that cause respiratory failure and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of respiratory failure.

19) When assessing a patient with advanced COPD, which sputum characteristic indicates an acute exacerbation? A) Thin, dark-colored B) Thin, clear-colored C) Thick, dark-colored D) Frothy sputum Answer: C Explanation: A) Acute exacerbations of advanced COPD are characterized by increased dyspnea and/or cough, increased respiratory rate, and increased sputum volume or prevalence. The change in sputum is often an increased volume and a change in the character of the sputum (e.g., thicker consistency, darker color). B) Acute exacerbations of advanced COPD are characterized by increased dyspnea and/or cough, increased respiratory rate, and increased sputum volume or prevalence. The change in sputum is often an increased volume and a change in the character of the sputum (e.g., thicker consistency, darker color). C) Acute exacerbations of advanced COPD are characterized by increased dyspnea and/or cough, increased respiratory rate, and increased sputum volume or prevalence. The change in sputum is often an increased volume and a change in the character of the sputum (e.g., thicker consistency, darker color). D) Acute exacerbations of advanced COPD are characterized by increased dyspnea and/or cough, increased respiratory rate, and increased sputum volume or prevalence. The change in sputum is often an increased volume and a change in the character of the sputum (e.g., thicker consistency, darker color). Page Ref: 508 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 20.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders that cause respiratory failure and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of respiratory failure.

20) The nurse teaches a patient with advanced COPD to use pursed lip breathing. Which statement indicates that the patient understands the rationale for this type of breathing? A) "This will help me breathe in more oxygen." B) "This will help keep my small airways open." C) "This will help me use my accessory muscles for breathing." D) "This will help me cough up more sputum." Answer: B Explanation: A) Exhaling through pursed lips is thought to produce a back pressure that helps to support small airway patency during prolonged exhalation. B) Exhaling through pursed lips is thought to produce a back pressure that helps to support small airway patency during prolonged exhalation. C) Exhaling through pursed lips is thought to produce a back pressure that helps to support small airway patency during prolonged exhalation. D) Exhaling through pursed lips is thought to produce a back pressure that helps to support small airway patency during prolonged exhalation. Page Ref: 508 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Evaluation | Learning Outcome: 20.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders that cause respiratory failure and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of respiratory failure to diagnosis and treatment.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 21 Disorders of Oxygen Transport 1) Which laboratory assessment data indicates to the nurse that a patient has anemia? A) Reduced erythrocytes B) Elevated leukocytes C) Reduced thrombocytes D) Elevated neutrophils Answer: A Explanation: A) Anemia is a common clinical condition characterized by a reduction in the number of erythrocytes (red blood cells) or a decline in the ability of erythrocytes to carry oxygen. Elevated leukocytes (white blood cells), reduced thrombocytes (platelets), and elevated neutrophils (a type of white blood cell) are not characteristic of anemia. B) Anemia is a common clinical condition characterized by a reduction in the number of erythrocytes (red blood cells) or a decline in the ability of erythrocytes to carry oxygen. Elevated leukocytes (white blood cells), reduced thrombocytes (platelets), and elevated neutrophils (a type of white blood cell) are not characteristic of anemia. C) Anemia is a common clinical condition characterized by a reduction in the number of erythrocytes (red blood cells) or a decline in the ability of erythrocytes to carry oxygen. Elevated leukocytes (white blood cells), reduced thrombocytes (platelets), and elevated neutrophils (a type of white blood cell) are not characteristic of anemia. D) Anemia is a common clinical condition characterized by a reduction in the number of erythrocytes (red blood cells) or a decline in the ability of erythrocytes to carry oxygen. Elevated leukocytes (white blood cells), reduced thrombocytes (platelets), and elevated neutrophils (a type of white blood cell) are not characteristic of anemia. Page Ref: 514 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 21.1 Define anemia and discuss concepts related to the disorders of red blood cells. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of oxygen transport.

2) Which laboratory result confirms to the nurse that therapy for pernicious anemia has been effective? A) An increase in ferritin levels B) An increase in folate levels C) An increase in transferrin levels D) An increase in vitamin B12 levels Answer: D Explanation: A) Because decreased values of vitamin B12 indicate pernicious anemia, the nurse would expect vitamin B12 levels to rise with effective therapy. Ferritin and transferrin levels are not affected in pernicious anemia. Because folate levels may increase with pernicious anemia, folate levels should be reduced with effective therapy. B) Because decreased values of vitamin B12 indicate pernicious anemia, the nurse would expect vitamin B12 levels to rise with effective therapy. Ferritin and transferrin levels are not affected in pernicious anemia. Because folate levels may increase with pernicious anemia, folate levels should be reduced with effective therapy. C) Because decreased values of vitamin B12 indicate pernicious anemia, the nurse would expect vitamin B12 levels to rise with effective therapy. Ferritin and transferrin levels are not affected in pernicious anemia. Because folate levels may increase with pernicious anemia, folate levels should be reduced with effective therapy. D) Because decreased values of vitamin B12 indicate pernicious anemia, the nurse would expect vitamin B12 levels to rise with effective therapy. Ferritin and transferrin levels are not affected in pernicious anemia. Because folate levels may increase with pernicious anemia, folate levels should be reduced with effective therapy. Page Ref: 516 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Evaluation | Learning Outcome: 21.2 Describe the morphologic classification, etiology and pathogenesis, and clinical manifestations of anemia and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of oxygen transport.

3) Which vital signs would the nurse expect to find in a patient with anemia? A) Heart rate 88 beats/minute; respirations 16 breaths/minute B) Heart rate 74 beats/minute, respirations 20 breaths/minute C) Heart rate 108 beats/minute, respirations 26 breaths/minute D) Heart rate 120 beats/minute; respirations 16 breaths/minute Answer: C Explanation: A) In anemia, there is an attempt to compensate for the reduction in oxygen through both an increase in heart rate and an increased respiratory rate. B) In anemia, there is an attempt to compensate for the reduction in oxygen through both an increase in heart rate and an increased respiratory rate. C) In anemia, there is an attempt to compensate for the reduction in oxygen through both an increase in heart rate and an increased respiratory rate. D) In anemia, there is an attempt to compensate for the reduction in oxygen through both an increase in heart rate and an increased respiratory rate. Page Ref: 517 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 21.2 Describe the morphologic classification, etiology and pathogenesis, and clinical manifestations of anemia and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of oxygen transport.

4) Which instruction should be included in the teaching plan for a patient with hemochromatosis? A) Reduce intake of foods high in iron. B) Watch for signs and symptoms of infection. C) Report bleeding. D) Reduce intake of foods high in dietary fructose. Answer: A Explanation: A) Hemochromatosis is an autosomal recessive disorder that leads to an extremely high rate of iron absorption. Therefore, the client with this disorder should reduce the intake of iron in the diet. Hemochromatosis is not associated with increased risk of infection or bleeding. Because this disorder does not affect fructose, the client does not need to change intake of this nutrient. B) Hemochromatosis is an autosomal recessive disorder that leads to an extremely high rate of iron absorption. Therefore, the client with this disorder should reduce the intake of iron in the diet. Hemochromatosis is not associated with increased risk of infection or bleeding. Because this disorder does not affect fructose, the client does not need to change intake of this nutrient. C) Hemochromatosis is an autosomal recessive disorder that leads to an extremely high rate of iron absorption. Therefore, the client with this disorder should reduce the intake of iron in the diet. Hemochromatosis is not associated with increased risk of infection or bleeding. Because this disorder does not affect fructose, the client does not need to change intake of this nutrient. D) Hemochromatosis is an autosomal recessive disorder that leads to an extremely high rate of iron absorption. Therefore, the client with this disorder should reduce the intake of iron in the diet. Hemochromatosis is not associated with increased risk of infection or bleeding. Because this disorder does not affect fructose, the client does not need to change intake of this nutrient. Page Ref: 518 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 21.2 Describe the morphologic classification, etiology and pathogenesis, and clinical manifestations of anemia and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of oxygen transport to diagnosis and treatment.

5) The nurse is providing dietary instructions to a pregnant patient. The nurse recommends that the daily intake of iron should be: A) 8 mg/day. B) 15 mg/day. C) 22 mg/day. D) 27 mg/day. Answer: D Explanation: A) The RDA for iron varies considerably from 8 mg/day for adult men to 27 mg/day for pregnant women. B) The RDA for iron varies considerably from 8 mg/day for adult men to 27 mg/day for pregnant women. C) The RDA for iron varies considerably from 8 mg/day for adult men to 27 mg/day for pregnant women. D) The RDA for iron varies considerably from 8 mg/day for adult men to 27 mg/day for pregnant women. Page Ref: 521 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 21.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of nutritional anemias and approaches to diagnosis and treatment of those conditions. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and wellbeing, and self-care management | AACN Essential Competencies: IX.8. Implement evidencebased nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of oxygen transport to diagnosis and treatment.

6) To increase absorption of dietary iron, the nurse recommends that a patient with anemia drink which beverage with meals? A) Tea B) Orange juice C) Milk D) Water Answer: B Explanation: A) Nonheme iron absorption is enhanced by animal protein and a rich source of vitamin C (such as orange juice) at the same meal. However, this can be decreased by ingestion of tannins (a compound in tea) and calcium (found in milk). Drinking water does not affect the absorption of dietary iron. B) Nonheme iron absorption is enhanced by animal protein and a rich source of vitamin C (such as orange juice) at the same meal. However, this can be decreased by ingestion of tannins (a compound in tea) and calcium (found in milk). Drinking water does not affect the absorption of dietary iron. C) Nonheme iron absorption is enhanced by animal protein and a rich source of vitamin C (such as orange juice) at the same meal. However, this can be decreased by ingestion of tannins (a compound in tea) and calcium (found in milk). Drinking water does not affect the absorption of dietary iron. D) Nonheme iron absorption is enhanced by animal protein and a rich source of vitamin C (such as orange juice) at the same meal. However, this can be decreased by ingestion of tannins (a compound in tea) and calcium (found in milk). Drinking water does not affect the absorption of dietary iron. Page Ref: 521 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 21.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of nutritional anemias and approaches to diagnosis and treatment of those conditions. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of oxygen transport to diagnosis and treatment.

7) The plan of care for a patient with anemia due to alcoholism should include administration of which vitamin? A) Vitamin A B) B vitamins C) Vitamin C D) Vitamin D Answer: B Explanation: A) Alcohol abuse can contribute to a loss of several B vitamins that are necessary for erythrocyte maturation and function. B) Alcohol abuse can contribute to a loss of several B vitamins that are necessary for erythrocyte maturation and function. C) Alcohol abuse can contribute to a loss of several B vitamins that are necessary for erythrocyte maturation and function. D) Alcohol abuse can contribute to a loss of several B vitamins that are necessary for erythrocyte maturation and function. Page Ref: 522 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Planning | Learning Outcome: 21.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of nutritional anemias and approaches to diagnosis and treatment of those conditions. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of oxygen transport to diagnosis and treatment.

8) The nurse is counseling a couple who would like to start a family. The man has sickle cell disease and the woman does not have sickle cell disease or the sickle cell trait. Which statement by the man indicates an understanding of the transmission of the disease? A) "All our children will have the sickle cell trait." B) "Each child has a 50% chance of having the sickle cell trait." C) "Each child has a 50% chance of having sickle cell disease." D) "Each child has a 50% chance of not having the trait." Answer: A Explanation: A) Sickle cell disease occurs when an individual has inherited a mutated form of hemoglobin, referred to as hemoglobin S (HbS), from both parents; thus, the man in the couple must have two copies of HbS if he has sickle cell disease. When a mutated form is inherited from one parent (in this case, the father) and a normal copy (hemoglobin A) is inherited from the other (in this case, the mother), this is referred to as sickle cell trait. All offspring of such parents will have the trait. B) Each child will have a 50% chance of inheriting the trait if one parent has the trait and the other parent is normal. C) Each child will have a 50% chance of inheriting sickle cell disease when one parent has the disease and the other parent has the trait. D) If one parent has sickle cell trait and the other parent is normal, each child has a 50% chance of not having the trait or disease. Page Ref: 523 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Evaluation | Learning Outcome: 21.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hemolytic anemias and approaches to diagnosis and treatment of these conditions. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of oxygen transport to diagnosis and treatment.

9) A child with sickle cell anemia is admitted to the pediatric unit for erythrocytapheresis. The nursing plan of care should include preparing for which of the following treatments? A) Red blood cell exchange B) Platelet transfusion C) Chelation therapy D) Splenectomy Answer: A Explanation: A) A procedure known as erythrocytapheresis may be performed, in which red blood cells are exchanged with the intent of replacing damaged cells with cells free from the mutated form of hemoglobin (HbS) found in sickle cell disease. B) A platelet transfusion is not needed in sickle cell anemia because it does not remove and replace damaged red blood cells. C) Chelation therapy removes metals and minerals from the body, not damaged red blood cells. D) Spleen removal may be needed in sickle cell disease, but it does not replace damaged red cells with healthy ones. Page Ref: 525 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 21.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hemolytic anemias and approaches to diagnosis and treatment of these conditions. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of oxygen transport to diagnosis and treatment.

10) The nursing history indicates that a patient with sickle cell disease (SCD) has had numerous blood transfusions in the last three months. When assessing the patient, the nurse should be alert for which condition? A) Hypovolemia B) Iron overload C) Hypoxia D) Vaso-occlusion Answer: B Explanation: A) Because multiple blood transfusions have been given, the risk of hypovolemia is low. B) Clients with SCD may need multiple transfusions, placing them at risk for iron overload. C) Blood transfusions should decrease, not increase, the risk of hypoxia. D) The abnormally shaped sickle cells in SCD increase the risk of sickling and vaso-occlusion. Blood transfusions do not increase the risk because they involve giving the patient normal cells. Page Ref: 525 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Assessment | Learning Outcome: 21.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hemolytic anemias and approaches to diagnosis and treatment of these conditions. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of oxygen transport.

11) The nurse caring for a patient with anemia of chronic disease (ACD) would expect which of the following laboratory results? A) Increased serum iron level B) Reduced serum ferritin levels C) Hypochromic red blood cells D) Reduced transferrin saturation Answer: D Explanation: A) One of the major markers of ACD is a decrease in serum iron level accompanied by a drop in transferrin saturation. ACD is normochromic and normocytic, as the maturation of red blood cells has not been influenced. Ferritin is a protein that the body uses to aid in the storage of iron. Serum levels of ferritin rise as the body stores iron. B) One of the major markers of ACD is a decrease in serum iron level accompanied by a drop in transferrin saturation. ACD is normochromic and normocytic, as the maturation of red blood cells has not been influenced. Ferritin is a protein that the body uses to aid in the storage of iron. Serum levels of ferritin rise as the body stores iron. C) One of the major markers of ACD is a decrease in serum iron level accompanied by a drop in transferrin saturation. ACD is normochromic and normocytic, as the maturation of red blood cells has not been influenced. Ferritin is a protein that the body uses to aid in the storage of iron. Serum levels of ferritin rise as the body stores iron. D) One of the major markers of ACD is a decrease in serum iron level accompanied by a drop in transferrin saturation. ACD is normochromic and normocytic, as the maturation of red blood cells has not been influenced. Ferritin is a protein that the body uses to aid in the storage of iron. Serum levels of ferritin rise as the body stores iron. Page Ref: 528 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 21.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of anemia of chronic disease and approaches to diagnosis and treatment of the condition. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of oxygen transport.

12) Which of the following statements made by a patient with polycythemia indicates an understanding of the disease? A) "I have thin blood that will not clot." B) "I may need blood transfusions" C) "I have an overproduction of red cells from my bone marrow." D) "I have elevated iron levels." Answer: C Explanation: A) The clinical manifestations of polycythemia reflect the increased blood viscosity and blood volume that result from the increased number of red blood cells. The increased thickness of the blood places the patient at an increased risk for the development of thrombi, or blood clots. B) Therapeutic erythropheresis (also known as blood-letting) is often employed to reduce the number of red blood cells and to dilute the concentration within the bloodstream. Because the patient has an increased blood volume and number of red blood cells, transfusion should not be given. C) In polycythemia, there is an increase in the production of erythrocytes on the part of bone marrow. D) In polycythemia, iron counts are often decreased, owing to consumption of iron in the increased production of erythrocytes. Page Ref: 528 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 21.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of polycythemia vera and approaches to diagnosis and treatment of the condition. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of disorders of oxygen transport.

13) Which nursing intervention should be included in the plan of care for a patient with polycythemia vera? A) Explain the process of blood transfusion to the patient. B) Administer anticoagulants. C) Place the patient on a fluid restriction. D) Assess for hypotension. Answer: B Explanation: A) Therapeutic erythropheresis is removal of blood from the patient (also known as blood-letting) is often employed to reduce the number of red blood cells and to dilute the concentration within the bloodstream. Therefore, administering a blood transfusion would not be appropriate. B) Treatment of polycythemia vera involves the use of anticoagulation to prevent the development of thrombi. C) Because a goal of therapy in polycythemia vera is to dilute the concentrated blood, the client should not be placed on a fluid restriction, as this this would cause dehydration and an increase in the hematocrit. D) Because of the increased blood volume associated with polycythemia vera, the increased preload can manifest as hypertension. Page Ref: 529 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Planning | Learning Outcome: 21.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of polycythemia vera and approaches to diagnosis and treatment of the condition. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of oxygen transport to diagnosis and treatment.

14) During physical examination of a patient with sickle cell disease in a vaso-occlusive crisis, the nurse would be most likely to assess which hallmark finding? A) Pale extremities B) Dark urine C) Jaundice D) Acute pain Answer: D Explanation: A) Sickle cell disease is characterized by episodes of acute painful crises that are triggered by conditions that cause high oxygen demand. Although all of these findings may occur in the client with sickle cell diseases, acute pain is the hallmark of a vaso-occlusive crisis. B) Sickle cell disease is characterized by episodes of acute painful crises that are triggered by conditions that cause high oxygen demand. Although all of these findings may occur in the client with sickle cell diseases, acute pain is the hallmark of a vaso-occlusive crisis. C) Sickle cell disease is characterized by episodes of acute painful crises that are triggered by conditions that cause high oxygen demand. Although all of these findings may occur in the client with sickle cell diseases, acute pain is the hallmark of a vaso-occlusive crisis. D) Sickle cell disease is characterized by episodes of acute painful crises that are triggered by conditions that cause high oxygen demand. Although all of these findings may occur in the client with sickle cell diseases, acute pain is the hallmark of a vaso-occlusive crisis. Page Ref: 524 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 21.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hemolytic anemias and approaches to diagnosis and treatment of these conditions. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of oxygen transport.

15) The nurse is teaching health promotion and maintenance to a patient with aplastic anemia. Which action by the patient should be a priority? A) Avoiding crowds during flu season B) Eating foods high in iron C) Lowering levels of stress D) Using a safety razor Answer: A Explanation: A) The term aplastic refers to a decrease in all cell populations produced by the bone marrow. This includes erythrocytes, leukocytes, and platelets. The client with aplastic anemia is at risk for infection due to reduced leukocytes. Although all these interventions are helpful to the client with aplastic anemia, the risk of infection and, possibly, death is the highest priority. Proper nutrition, reducing stress, and avoiding bleeding while shaving are important, but not life-threatening. B) The term aplastic refers to a decrease in all cell populations produced by the bone marrow. This includes erythrocytes, leukocytes, and platelets. The client with aplastic anemia is at risk for infection due to reduced leukocytes. Although all these interventions are helpful to the client with aplastic anemia, the risk of infection and, possibly, death is the highest priority. Proper nutrition, reducing stress, and avoiding bleeding while shaving are important, but not lifethreatening. C) The term aplastic refers to a decrease in all cell populations produced by the bone marrow. This includes erythrocytes, leukocytes, and platelets. The client with aplastic anemia is at risk for infection due to reduced leukocytes. Although all these interventions are helpful to the client with aplastic anemia, the risk of infection and, possibly, death is the highest priority. Proper nutrition, reducing stress, and avoiding bleeding while shaving are important, but not lifethreatening. D) The term aplastic refers to a decrease in all cell populations produced by the bone marrow. This includes erythrocytes, leukocytes, and platelets. The client with aplastic anemia is at risk for infection due to reduced leukocytes. Although all these interventions are helpful to the client with aplastic anemia, the risk of infection and, possibly, death is the highest priority. Proper nutrition, reducing stress, and avoiding bleeding while shaving are important, but not lifethreatening. Page Ref: 526 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Implementation | Learning Outcome: 21.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hemolytic anemias and approaches to diagnosis and treatment of these conditions. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of oxygen transport to diagnosis and treatment.

16) The effectiveness of erythropoietin therapy in the patient with renal disease can be confirmed by which laboratory finding? A) Neutrophils 40-60% B) Leukocyte 6,000/mm3 C) Platelets 50,000/mm3 D) Erythrocytes 4.4 million/mm3 Answer: D Explanation: A) In individuals with renal disease, there may be a lack in the production of erythropoietin, which stimulates the release and maturation of red blood cells (erythrocytes). This lack of erythropoietin would cause anemia (low red blood cells and thus a low hematocrit). Erythropoietin may be administered to aid in the treatment of anemia from renal disease. The neutrophils, other leukocytes, and platelets are not affected by erythropoietin. B) In individuals with renal disease, there may be a lack in the production of erythropoietin, which stimulates the release and maturation of red blood cells (erythrocytes). This lack of erythropoietin would cause anemia (low red blood cells and thus a low hematocrit). Erythropoietin may be administered to aid in the treatment of anemia from renal disease. The neutrophils, other leukocytes, and platelets are not affected by erythropoietin. C) In individuals with renal disease, there may be a lack in the production of erythropoietin, which stimulates the release and maturation of red blood cells (erythrocytes). This lack of erythropoietin would cause anemia (low red blood cells and thus a low hematocrit). Erythropoietin may be administered to aid in the treatment of anemia from renal disease. The neutrophils, other leukocytes, and platelets are not affected by erythropoietin. D) In individuals with renal disease, there may be a lack in the production of erythropoietin, which stimulates the release and maturation of red blood cells (erythrocytes). This lack of erythropoietin would cause anemia (low red blood cells and thus a low hematocrit). Erythropoietin may be administered to aid in the treatment of anemia from renal disease. The neutrophils, other leukocytes, and platelets are not affected by erythropoietin. Page Ref: 517 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Evaluation | Learning Outcome: 21.2 Describe the morphologic classification, etiology and pathogenesis, and clinical manifestations of anemia and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of oxygen transport to diagnosis and treatment.

17) During the admission history of a patient with myelodysplastic syndrome, the nurse should question the patient about exposure to: A) radiation. B) tuberculosis. C) Lyme disease. D) asbestos. Answer: A Explanation: A) Myelodysplastic syndrome can be acquired through exposure to radiation and chemotherapeutic agents. It is not acquired through exposure to tuberculosis, Lyme disease, or asbestos. B) Myelodysplastic syndrome can be acquired through exposure to radiation and chemotherapeutic agents. It is not acquired through exposure to tuberculosis, Lyme disease, or asbestos. C) Myelodysplastic syndrome can be acquired through exposure to radiation and chemotherapeutic agents. It is not acquired through exposure to tuberculosis, Lyme disease, or asbestos. D) Myelodysplastic syndrome can be acquired through exposure to radiation and chemotherapeutic agents. It is not acquired through exposure to tuberculosis, Lyme disease, or asbestos. Page Ref: 518 Cognitive Level: Understanding Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Assessment | Learning Outcome: 21.2 Describe the morphologic classification, etiology and pathogenesis, and clinical manifestations of anemia and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of disorders of oxygen transport.

18) Which of the following should be included in the teaching plan for a child with sickle cell anemia? A) Encourage sedentary activity. B) Encourage vigorous activity at higher altitudes. C) Avoid activities in which falls may occur. D) Encourage intake of plenty of fluids. Answer: D Explanation: A) Supportive care for individuals with sickle cell disease includes the maintenance of adequate hydration. Because low levels of oxygen can precipitate a crisis, vigorous activity at higher altitudes should be avoided. Because the risk of bleeding is not present, the child does not need to avoid activities in which falls may occur. Nor does the child need to avoid exercises and engage only in sedentary activity. B) Supportive care for individuals with sickle cell disease includes the maintenance of adequate hydration. Because low levels of oxygen can precipitate a crisis, vigorous activity at higher altitudes should be avoided. Because the risk of bleeding is not present, the child does not need to avoid activities in which falls may occur. Nor does the child need to avoid exercises and engage only in sedentary activity. C) Supportive care for individuals with sickle cell disease includes the maintenance of adequate hydration. Because low levels of oxygen can precipitate a crisis, vigorous activity at higher altitudes should be avoided. Because the risk of bleeding is not present, the child does not need to avoid activities in which falls may occur. Nor does the child need to avoid exercises and engage only in sedentary activity. D) Supportive care for individuals with sickle cell disease includes the maintenance of adequate hydration. Because low levels of oxygen can precipitate a crisis, vigorous activity at higher altitudes should be avoided. Because the risk of bleeding is not present, the child does not need to avoid activities in which falls may occur. Nor does the child need to avoid exercises and engage only in sedentary activity. Page Ref: 525 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 21.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hemolytic anemias and approaches to diagnosis and treatment of these conditions. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of oxygen transport to diagnosis and treatment.

19) Which assessment data indicates to the nurse that a patient has a chronic iron deficiency? A) A gradual increase in hematocrit B) A gradual increase in hemoglobin C) Microcytic, hypochromic red blood cells D) Macrocytic, normochromic red blood cells Answer: C Explanation: A) Iron deficiency anemia is characterized at first by a gradual reduction in hematocrit and hemoglobin. As the loss of iron becomes more significant, the development of erythrocytes is affected, and the cells become microcytic in nature and hypochromic. B) Iron deficiency anemia is characterized at first by a gradual reduction in hematocrit and hemoglobin. As the loss of iron becomes more significant, the development of erythrocytes is affected, and the cells become microcytic in nature and hypochromic. C) Iron deficiency anemia is characterized at first by a gradual reduction in hematocrit and hemoglobin. As the loss of iron becomes more significant, the development of erythrocytes is affected, and the cells become microcytic in nature and hypochromic. D) Iron deficiency anemia is characterized at first by a gradual reduction in hematocrit and hemoglobin. As the loss of iron becomes more significant, the development of erythrocytes is affected, and the cells become microcytic in nature and hypochromic. Page Ref: 520 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 21.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of nutritional anemias and approaches to diagnosis and treatment of those conditions. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of oxygen transport.

20) Which response by the nurse is best when the mother states that she gives her 10-month-old baby 45 mg/day of iron? A) "Let's talk about safe levels of iron intake for a 10- month-old." B) "Lots of iron is important for your growing infant." C) "Iron supplements are important as babies are weaned from breastmilk." D) "Babies need more iron as they begin to crawl." Answer: A Explanation: A) Excess intake of iron, like that of many other elements, can be toxic. The DRIs contains a category known as the tolerable upper limit (TUL), which indicates the level at which chronic intake, if exceeded, may be dangerous. The TUL for iron ranges from 40 mg/day for healthy infants older than 7 months of age. An adequate iron intake is important to growing infants, but 45 mg/day is too high for a 10-month-old. Weaning from breastmilk and beginning to crawl are not indications to start iron supplementation. B) Excess intake of iron, like that of many other elements, can be toxic. The DRIs contains a category known as the tolerable upper limit (TUL), which indicates the level at which chronic intake, if exceeded, may be dangerous. The TUL for iron ranges from 40 mg/day for healthy infants older than 7 months of age. An adequate iron intake is important to growing infants, but 45 mg/day is too high for a 10-month-old. Weaning from breastmilk and beginning to crawl are not indications to start iron supplementation. C) Excess intake of iron, like that of many other elements, can be toxic. The DRIs contains a category known as the tolerable upper limit (TUL), which indicates the level at which chronic intake, if exceeded, may be dangerous. The TUL for iron ranges from 40 mg/day for healthy infants older than 7 months of age. An adequate iron intake is important to growing infants, but 45 mg/day is too high for a 10-month-old. Weaning from breastmilk and beginning to crawl are not indications to start iron supplementation. D) Excess intake of iron, like that of many other elements, can be toxic. The DRIs contains a category known as the tolerable upper limit (TUL), which indicates the level at which chronic intake, if exceeded, may be dangerous. The TUL for iron ranges from 40 mg/day for healthy infants older than 7 months of age. An adequate iron intake is important to growing infants, but 45 mg/day is too high for a 10-month-old. Weaning from breastmilk and beginning to crawl are not indications to start iron supplementation. Page Ref: 521 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 21.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of nutritional anemias and approaches to diagnosis and treatment of those conditions. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and wellbeing, and self-care management | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of disorders of oxygen transport. 20

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 22 Alterations of Hemostasis 1) Which statement by a patient at risk for excessive bleeding indicates that more teaching is needed? A) "I will brush my teeth with a soft toothbrush." B) "I need to avoid playing football with my children." C) "Stool softeners will help me avoid straining." D) "I have a new pair of sandals that I bought to wear this summer." Answer: D Explanation: A) Patients who are at risk of excessive bleeding need to be educated about their condition and provided with instructions about preventing bleeding. These are commonly called bleeding precautions and include such recommendations as using a soft toothbrush, wearing shoes at all times, avoiding contact sports, and using stool softeners to prevent straining. B) Patients who are at risk of excessive bleeding need to be educated about their condition and provided with instructions about preventing bleeding. These are commonly called bleeding precautions and include such recommendations as using a soft toothbrush, wearing shoes at all times, avoiding contact sports, and using stool softeners to prevent straining. C) Patients who are at risk of excessive bleeding need to be educated about their condition and provided with instructions about preventing bleeding. These are commonly called bleeding precautions and include such recommendations as using a soft toothbrush, wearing shoes at all times, avoiding contact sports, and using stool softeners to prevent straining. D) Patients who are at risk of excessive bleeding need to be educated about their condition and provided with instructions about preventing bleeding. These are commonly called bleeding precautions and include such recommendations as using a soft toothbrush, wearing shoes at all times, avoiding contact sports, and using stool softeners to prevent straining. Page Ref: 535 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Evaluation | Learning Outcome: 22.1 Define hemostasis, and discuss concepts related to coagulation. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and selfcare management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of alterations of hemostasis to diagnosis and treatment.

2) Which vitamin does the nurse teach is essential to the function of clotting factors? A) Vitamin D B) Vitamin E C) Vitamin C D) Vitamin K Answer: D Explanation: A) A number of clotting factors require vitamin K in order to function properly. B) A number of clotting factors require vitamin K in order to function properly. C) A number of clotting factors require vitamin K in order to function properly. D) A number of clotting factors require vitamin K in order to function properly. Page Ref: 535 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 22.1 Define hemostasis, and discuss concepts related to coagulation. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and selfcare management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of alterations of hemostasis.

3) Which of the following would the nurse explain to a patient with type 3 von Willebrand disease? A) The binding ability of von Willebrand factor is delayed. B) There is no production of von Willebrand factor. C) The binding ability of von Willebrand factor is enhanced. D) There is increased clearance of von Willebrand factor. Answer: B Explanation: A) There are several variants of type 2 Willebrand, in which the binding ability of the factor is either significantly enhanced or delayed, resulting in functional deficits. B) Type 3 Willebrand is a more severe form in which there is a complete absence of production of the factor. C) There are several variants of type 2 Willebrand, in which the binding ability of the factor is either significantly enhanced or delayed, resulting in functional deficits. D) Type 1 von Willebrand disease is characterized by either a failure to manufacture the factor or increased clearance. Page Ref: 542 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 22.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of primary disorders of hemostasis and approaches to diagnosis and treatment of those conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of alterations of hemostasis.

4) When assessing the laboratory values for patient with von Willebrand disease who is taking desmopressin (DDAVP), the nurse should be alert for: A) hypernatremia. B) hyponatremia. C) hypokalemia. D) hyperkalemia. Answer: B Explanation: A) The major adverse effects of DDAVP are facial flushing, headache, tachycardia, and hyponatremia. B) The major adverse effects of DDAVP are facial flushing, headache, tachycardia, and hyponatremia. C) The major adverse effects of DDAVP are facial flushing, headache, tachycardia, and hyponatremia. D) The major adverse effects of DDAVP are facial flushing, headache, tachycardia, and hyponatremia. Page Ref: 543 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Assessment | Learning Outcome: 22.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of primary disorders of hemostasis and approaches to diagnosis and treatment of those conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of alterations of hemostasis to diagnosis and treatment.

5) Which platelet value should the nurse report immediately to the physician? A) 9,000 uL B) 150,000/uL C) 200,000/uL D) 300,000/uL Answer: A Explanation: A) The normal range of circulating platelets is approximately 150,000-450,000/uL. An increased risk of bleeding rarely occurs until there are fewer than 80,000-100,000/uL, and there is a particularly high risk of spontaneous bleeding once the count drops below 10,000/uL. B) The normal range of circulating platelets is approximately 150,000-450,000/uL. An increased risk of bleeding rarely occurs until there are fewer than 80,000-100,000/uL, and there is a particularly high risk of spontaneous bleeding once the count drops below 10,000/uL. C) The normal range of circulating platelets is approximately 150,000-450,000/uL. An increased risk of bleeding rarely occurs until there are fewer than 80,000-100,000/uL, and there is a particularly high risk of spontaneous bleeding once the count drops below 10,000/uL. D) The normal range of circulating platelets is approximately 150,000-450,000/uL. An increased risk of bleeding rarely occurs until there are fewer than 80,000-100,000/uL, and there is a particularly high risk of spontaneous bleeding once the count drops below 10,000/uL. Page Ref: 544 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 22.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of primary disorders of hemostasis and approaches to diagnosis and treatment of those conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of hemostasis disorders.

6) Which sign would alert the nurse that a patient receiving low-molecular-weight heparin has developed type 1 heparin-induced thrombocytopenia (HIT)? A) Platelet clots develop upon initiation of heparin therapy. B) Platelet clots develop 2 weeks after initiating heparin therapy. C) Platelet count decreases modestly 2 days after beginning heparin therapy. D) Platelet count decreases significantly 2 days after beginning heparin therapy. Answer: C Explanation: A) Type 1 HIT involves a modest transient decrease in platelet count within the first 2-3 days after initiation of heparin therapy. Platelet counts return to normal spontaneously even if the drug is continued. B) Type 1 HIT involves a modest transient decrease in platelet count within the first 2-3 days after initiation of heparin therapy. Platelet counts return to normal spontaneously even if the drug is continued. C) Type 1 HIT involves a modest transient decrease in platelet count within the first 2-3 days after initiation of heparin therapy. Platelet counts return to normal spontaneously even if the drug is continued. D) Type 1 HIT involves a modest transient decrease in platelet count within the first 2-3 days after initiation of heparin therapy. Platelet counts return to normal spontaneously even if the drug is continued. Page Ref: 544 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Assessment | Learning Outcome: 22.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of primary disorders of hemostasis and approaches to diagnosis and treatment of those conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of alterations of hemostasis to diagnosis and treatment.

7) Which manifestations is the nurse most likely to assess in a patient with thrombocytopenia? A) Purpura and ecchymosis B) Nausea and vomiting C) Weakness and lethargy D) Malaise and chills Answer: A Explanation: A) The bleeding associated with thrombocytopenia is usually mucocutaneous innature– on the skin in the form of tiny pinprick hemorrhages called purpura or bruises called ecchymosis that may occur after relatively minor trauma. B) The bleeding associated with thrombocytopenia is usually mucocutaneous in nature–on the skin in the form of tiny pinprick hemorrhages called purpura or bruises called ecchymosis that may occur after relatively minor trauma. C) The bleeding associated with thrombocytopenia is usually mucocutaneous in nature–on the skin in the form of tiny pinprick hemorrhages called purpura or bruises called ecchymosis that may occur after relatively minor trauma. D) The bleeding associated with thrombocytopenia is usually mucocutaneous in nature–on the skin in the form of tiny pinprick hemorrhages called purpura or bruises called ecchymosis that may occur after relatively minor trauma. Page Ref: 545 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 22.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of primary disorders of hemostasis and approaches to diagnosis and treatment of those conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of hemostasis disorders.

8) Which laboratory value will most likely be abnormal in the patient undergoing diagnostic testing for hemophilia? A) Prothrombin time (PT) B) Partial thromboplastin time (PTT) C) Platelet count D) Bleeding time Answer: B Explanation: A) Diagnostically, individuals with hemophilia usually have prolonged PTT, with normal PT, platelet counts, and bleeding time or platelet function assay testing. B) Diagnostically, individuals with hemophilia usually have prolonged PTT, with normal PT, platelet counts, and bleeding time or platelet function assay testing. C) Diagnostically, individuals with hemophilia usually have prolonged PTT, with normal PT, platelet counts, and bleeding time or platelet function assay testing. D) Diagnostically, individuals with hemophilia usually have prolonged PTT, with normal PT, platelet counts, and bleeding time or platelet function assay testing. Page Ref: 546 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 22.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of secondary disorders of hemostasis and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of alterations of hemostasis to diagnosis and treatment.

9) How should the nurse respond when a woman, who is a carrier for hemophilia, asks about the risk of having a child with hemophilia? Her partner does not have the gene for hemophilia. A) "You have a 50% chance of passing the affected chromosome to your sons." B) "All your sons will have hemophilia." C) "Your daughters have a 50% chance of having hemophilia." D) "All your daughters will be carriers." Answer: A Explanation: A) The genes for both factor VIII and factor XI are on the X chromosome; therefore, the disorder primarily affects males, although females may be symptomatic carriers. All female offspring of affected males are carriers. Carrier females have a 50% chance of passing the affected chromosome to their male offspring. B) The genes for both factor VIII and factor XI are on the X chromosome; therefore, the disorder primarily affects males, although females may be symptomatic carriers. All female offspring of affected males are carriers. Carrier females have a 50% chance of passing the affected chromosome to their male offspring. C) The genes for both factor VIII and factor XI are on the X chromosome; therefore, the disorder primarily affects males, although females may be symptomatic carriers. All female offspring of affected males are carriers. Carrier females have a 50% chance of passing the affected chromosome to their male offspring. D) The genes for both factor VIII and factor XI are on the X chromosome; therefore, the disorder primarily affects males, although females may be symptomatic carriers. All female offspring of affected males are carriers. Carrier females have a 50% chance of passing the affected chromosome to their male offspring. Page Ref: 545 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 22.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of secondary disorders of hemostasis and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX. 2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of alterations of hemostasis.

10) When planning care for a trauma patient, the nurse understands that the response of the extrinsic coagulation pathway to tissue damage begins with the release of: A) factors VII and IX. B) platelet factor. C) factor III. D) factor VII. Answer: C Explanation: A) The intrinsic pathway begins with the activation of proenzymes exposed to collagen fibers at the injury site. This pathway proceeds with the assistance of platelet factor, a platelet factor released by aggregating platelets. After a series of linked reactions, activated clotting factors combine to form an enzyme complex capable of activating factor X. B) The intrinsic pathway begins with the activation of proenzymes exposed to collagen fibers at the injury site. This pathway proceeds with the assistance of platelet factor, a platelet factor released by aggregating platelets. After a series of linked reactions, activated clotting factors combine to form an enzyme complex capable of activating factor X. C) The extrinsic pathway begins with the release of tissue factor (factor III) by damaged endothelial cells or peripheral tissues. The greater the damage, the more tissue factor is released, and the faster clotting occurs. Tissue factor then combines with Ca2+ and another clotting factor to form an enzyme complex capable of activating factor X, the first step in the common pathway. D) The extrinsic pathway begins with the release of tissue factor (factor III) by damaged endothelial cells or peripheral tissues. The greater the damage, the more tissue factor is released, and the faster clotting occurs. Tissue factor then combines with Ca2+ and another clotting factor to form an enzyme complex capable of activating factor X, the first step in the common pathway. Page Ref: 537 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 22.1 Define hemostasis, and discuss concepts related to coagulation. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of alterations of hemostasis.

11) Which assessment findings would indicate to the nurse that a child with sickle cell disease is experiencing tissue ischemia? A) Pain in the legs and chest B) Bruising and nose bleed C) Pale skin and fatigue D) Fever and chills Answer: A Explanation: A) The hypoxia that can result from groups of sickle cells clumping together and obstructing blood flow often results in tissue ischemia, which can lead to the development of a significant level of pain in the back, chest, and extremities. The pain is accompanied by other signs of ischemic damage, such as swelling, tenderness, a rapid respiratory rate, and hypertension. B) The hypoxia that can result from groups of sickle cells clumping together and obstructing blood flow often results in tissue ischemia, which can lead to the development of a significant level of pain in the back, chest, and extremities. The pain is accompanied by other signs of ischemic damage, such as swelling, tenderness, a rapid respiratory rate, and hypertension. C) The hypoxia that can result from groups of sickle cells clumping together and obstructing blood flow often results in tissue ischemia, which can lead to the development of a significant level of pain in the back, chest, and extremities. The pain is accompanied by other signs of ischemic damage, such as swelling, tenderness, a rapid respiratory rate, and hypertension. D) The hypoxia that can result from groups of sickle cells clumping together and obstructing blood flow often results in tissue ischemia, which can lead to the development of a significant level of pain in the back, chest, and extremities. The pain is accompanied by other signs of ischemic damage, such as swelling, tenderness, a rapid respiratory rate, and hypertension. Page Ref: 546 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 22.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypercoagulopathy and approaches to diagnosis and treatment of the condition across the lifespan | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of hemostasis disorders.

12) Which laboratory value would the nurse expect to find in the patient with disseminated intravascular coagulation (DIC)? A) Low platelet count B) Elevated fibrinogen level C) Decreased D-dimer level D) Shortened PT level Answer: A Explanation: A) Diagnostically, as clotting factors are consumed in the patient with DIC, there are often low platelet and fibrinogen levels. There is a prolongation of PT and aPTT results, with an elevation in D-dimer values. These findings are consistent with prolongation of bleeding as a result of the consumption of clotting factors. B) Diagnostically, as clotting factors are consumed in the patient with DIC, there are often low platelet and fibrinogen levels. There is a prolongation of PT and aPTT results, with an elevation in D-dimer values. These findings are consistent with prolongation of bleeding as a result of the consumption of clotting factors. C) Diagnostically, as clotting factors are consumed in the patient with DIC, there are often low platelet and fibrinogen levels. There is a prolongation of PT and aPTT results, with an elevation in D-dimer values. These findings are consistent with prolongation of bleeding as a result of the consumption of clotting factors. D) Diagnostically, as clotting factors are consumed in the patient with DIC, there are often low platelet and fibrinogen levels. There is a prolongation of PT and aPTT results, with an elevation in D-dimer values. These findings are consistent with prolongation of bleeding as a result of the consumption of clotting factors. Page Ref: 547 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 22.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypercoagulopathy and approaches to diagnosis and treatment of the condition across the lifespan | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of hemostasis disorders.

13) Which platelet value is consistent with thrombocythemia? A) 100,000/mm3 or 100,000/uL B) 150,000/mm3 or 150,000/uL C) 350,000/mm3 or 350,000/uL D) 650,000/mm3 or 650,000/uL Answer: D Explanation: A) Thrombocythemia is a condition characterized by higher than expected numbers of thrombocytes. Typically, this is defined as an elevated platelet count greater than 600,000/mm3. B) Thrombocythemia is a condition characterized by higher than expected numbers of thrombocytes. Typically, this is defined as an elevated platelet count greater than 600,000/mm3. C) Thrombocythemia is a condition characterized by higher than expected numbers of thrombocytes. Typically, this is defined as an elevated platelet count greater than 600,000/mm3. D) Thrombocythemia is a condition characterized by higher than expected numbers of thrombocytes. Typically, this is defined as an elevated platelet count greater than 600,000/mm3. Page Ref: 547 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 22.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypercoagulopathy and approaches to diagnosis and treatment of the condition across the lifespan | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of hemostasis disorders.

14) When planning care for a patient with hypoxia, which concept about erythropoietin should the nurse keep in mind? A) Erythropoietin is released when renal blood flow increases. B) Erythropoietin is released when oxygen content in the lungs is high. C) Erythropoietin is released during anemic states. D) Erythropoietin is stimulated by kidney damage. Answer: C Explanation: A) Erythropoietin is released into the plasma when peripheral tissues, especially the kidneys, are exposed to low oxygen concentrations. Erythropoietin is released (1) during anemia; (2) when blood flow to the kidneys decreases; (3) when the oxygen content of air in the lungs decreases due to disease or high altitude; and (4) when the respiratory surfaces of the lungs are damaged. B) Erythropoietin is released into the plasma when peripheral tissues, especially the kidneys, are exposed to low oxygen concentrations. Erythropoietin is released (1) during anemia; (2) when blood flow to the kidneys decreases; (3) when the oxygen content of air in the lungs decreases due to disease or high altitude; and (4) when the respiratory surfaces of the lungs are damaged. C) Erythropoietin is released into the plasma when peripheral tissues, especially the kidneys, are exposed to low oxygen concentrations. Erythropoietin is released (1) during anemia; (2) when blood flow to the kidneys decreases; (3) when the oxygen content of air in the lungs decreases due to disease or high altitude; and (4) when the respiratory surfaces of the lungs are damaged. D) Erythropoietin is released into the plasma when peripheral tissues, especially the kidneys, are exposed to low oxygen concentrations. Erythropoietin is released (1) during anemia; (2) when blood flow to the kidneys decreases; (3) when the oxygen content of air in the lungs decreases due to disease or high altitude; and (4) when the respiratory surfaces of the lungs are damaged. Page Ref: 541 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 22.2 Describe major mechanisms involved in cellular regulation and function of coagulation pathways. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of alterations of hemostasis.

15) Which statement by a patient with primary thrombocytopenia indicates to the nurse that the patient understands the teaching about the disorder? A) "My disorder may be caused by a low number of platelets." B) "My platelets are not functioning properly." C) "I don't have enough coagulation factors." D) "My disorder is caused by liver disease." Answer: A Explanation: A) Primary disorders of hemostasis are associated with abnormalities in the number or function of platelets. A reduction in the number of platelets is referred to as thrombocytopenia and can lead to spontaneous bleeding. B) Primary disorders of hemostasis are associated with abnormalities in the number or function of platelets. A reduction in the number of platelets is referred to as thrombocytopenia and can lead to spontaneous bleeding. C) Secondary disorders of hemostasis are associated with a lack of, or reduction in, factors tied to coagulation. For example, a genetic lack of factor VIII leads to hemophilia. Liver disease can lead to secondary disorders, as the majority of proteins involved in coagulation are synthesized in the liver. D) Secondary disorders of hemostasis are associated with a lack of, or reduction in, factors tied to coagulation. For example, a genetic lack of factor VIII leads to hemophilia. Liver disease can lead to secondary disorders, as the majority of proteins involved in coagulation are synthesized in the liver. Page Ref: 535 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 22.1 Define hemostasis, and discuss concepts related to coagulation. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and selfcare management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of alterations of hemostasis.

16) When caring for a patient taking warfarin, which laboratory data would alert the nurse to the effectiveness of the medication? A) Partial thromboplastin time (PTT) B) Prothrombin time (PT) C) International normalization ratio (INR) D) Activated coagulation time Answer: C Explanation: A) Increased levels of partial thromboplastin time (PTT) indicate prolonged bleeding. Particularly prolonged bleeding is associated with changes in the levels of select clotting factors, primarily Factors II, V, IX, X, XI, and XII. B) Increased levels of prothrombin time (PT) indicate prolonger bleeding. Examines Factors II (prothrombin), V, VII, X, and fibrinogen. C) The international normalization ratio (INR) measures the therapeutic effectiveness of warfarin, a common oral anticoagulant. D) Activated coagulation time measures the number of seconds for clotting of whole blood on exposure to an activator of the intrinsic pathway. Page Ref: 542 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Assessment | Learning Outcome: 22.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of primary disorders of hemostasis and approaches to diagnosis and treatment of those conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of alterations of hemostasis to diagnosis and treatment.

17) Which prothrombin time (PT) would the nurse expect to assess in a patient with normal blood clotting? A) 10 seconds B) 13 seconds C) 14 seconds D) 16 seconds Answer: B Explanation: A) Prothrombin time (PT), which measures the functional ability of the extrinsic clotting pathway, is normally between 9.5 and 13.5 seconds. B) Prothrombin time (PT), which measures the functional ability of the extrinsic clotting pathway, is normally between 9.5 and 13.5 seconds. C) Prothrombin time (PT), which measures the functional ability of the extrinsic clotting pathway, is normally between 9.5 and 13.5 seconds. D) Prothrombin time (PT), which measures the functional ability of the extrinsic clotting pathway, is normally between 9.5 and 13.5 seconds. Page Ref: 543 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 22.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of primary disorders of hemostasis and approaches to diagnosis and treatment of those conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of hemostasis disorders.

18) Which instruction regarding thrombocytopenia would the nurse include in the teaching plan for a patient undergoing chemotherapy? A) The nadir for the platelet count occurs 3-5 days after treatment. B) The nadir for the platelet count occurs 5-8 days after treatment. C) The nadir for the platelet count occurs 7-10 days after treatment. D) The nadir for the platelet count occurs 10-13 days after treatment. Answer: C Explanation: A) Chemotherapy-associated thrombocytopenia is associated with decreases in other cell lines as well. With most chemotherapeutic agents, the nadir for the platelet count occurs 7-10 days after treatment, with recovery in 2-3 weeks. B) Chemotherapy-associated thrombocytopenia is associated with decreases in other cell lines as well. With most chemotherapeutic agents, the nadir for the platelet count occurs 7-10 days after treatment, with recovery in 2-3 weeks. C) Chemotherapy-associated thrombocytopenia is associated with decreases in other cell lines as well. With most chemotherapeutic agents, the nadir for the platelet count occurs 7-10 days after treatment, with recovery in 2-3 weeks. D) Chemotherapy-associated thrombocytopenia is associated with decreases in other cell lines as well. With most chemotherapeutic agents, the nadir for the platelet count occurs 7-10 days after treatment, with recovery in 2-3 weeks. Page Ref: 544 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Planning | Learning Outcome: 22.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of primary disorders of hemostasis and approaches to diagnosis and treatment of those conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of alterations of hemostasis to diagnosis and treatment.

19) When assessing a patient with thrombotic thrombocytopenia purpura (TTP), which clinical manifestations is the nurse likely to assess? A) Sickle cell anemia, thrombocytosis, renal insufficiency, fever, mental status changes B) Iron deficiency anemia, thrombocytopenia, hepatic failure, fever, mental status changes C) Pernicious anemia, thrombocytopenia, hepatic failure, fever, mental status changes D) Microangiopathic hemolytic anemia, thrombocytopenia, renal insufficiency, fever, mental status changes Answer: D Explanation: A) Five clinical manifestations of TTP, referred to as the pentad of TTP, are (1) microangiopathic hemolytic anemia, (2) thrombocytopenia, (3) renal insufficiency, (4) fever, and (5) mental status changes that can wax and wane (e.g., confusion, headache, fatigue, seizures, strokelike syndrome). B) Five clinical manifestations of TTP, referred to as the pentad of TTP, are (1) microangiopathic hemolytic anemia, (2) thrombocytopenia, (3) renal insufficiency, (4) fever, and (5) mental status changes that can wax and wane (e.g., confusion, headache, fatigue, seizures, strokelike syndrome). C) Five clinical manifestations of TTP, referred to as the pentad of TTP, are (1) microangiopathic hemolytic anemia, (2) thrombocytopenia, (3) renal insufficiency, (4) fever, and (5) mental status changes that can wax and wane (e.g., confusion, headache, fatigue, seizures, strokelike syndrome). D) Five clinical manifestations of TTP, referred to as the pentad of TTP, are (1) microangiopathic hemolytic anemia, (2) thrombocytopenia, (3) renal insufficiency, (4) fever, and (5) mental status changes that can wax and wane (e.g., confusion, headache, fatigue, seizures, strokelike syndrome). Page Ref: 545 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 22.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of primary disorders of hemostasis and approaches to diagnosis and treatment of those conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of hemostasis disorders.

20) Which laboratory values would the nurse expect in a patient with disseminated intravascular coagulation? A) Prolonged PT and aPTT, elevated D-dimer B) Prolonged PT and aPTT, reduced D-dimer C) Shortened PT and aPTT, elevated D-dimer D) Shortened PT and aPTT, reduced D-dimer Answer: A Explanation: A) As clotting factors are consumed in the patient with DIC, there are often low platelet and fibrinogen levels. There is a prolongation of PT and aPTT results, with an elevation in D-dimer values. These findings are consistent with prolongation of bleeding as a result of the consumption of clotting factors. B) As clotting factors are consumed in the patient with DIC, there are often low platelet and fibrinogen levels. There is a prolongation of PT and aPTT results, with an elevation in D-dimer values. These findings are consistent with prolongation of bleeding as a result of the consumption of clotting factors. C) As clotting factors are consumed in the patient with DIC, there are often low platelet and fibrinogen levels. There is a prolongation of PT and aPTT results, with an elevation in D-dimer values. These findings are consistent with prolongation of bleeding as a result of the consumption of clotting factors. D) As clotting factors are consumed in the patient with DIC, there are often low platelet and fibrinogen levels. There is a prolongation of PT and aPTT results, with an elevation in D-dimer values. These findings are consistent with prolongation of bleeding as a result of the consumption of clotting factors. Page Ref: 547 Cognitive Level: Applying Client Need & Sub: Physiological Integrity Standards: Nursing Process: Physiological Adaptation | Learning Outcome: 22.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypercoagulopathy and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of alterations of hemostasis to diagnosis and treatment.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 23 Vascular Disorders 1) When taking a history from a patient with peripheral vascular disease (PVD), the nurse would expect to find that the patient: A) is over age 50 years old. B) is female. C) leads an active lifestyle. D) eats a healthy diet. Answer: A Explanation: A) PVD primarily affects adults over age 50 years old. B) Men are affected by PVD more often than women. C) Risk factors for PVD are similar to those for other cardiovascular diseases. These include smoking, hypertension, coronary heart disease, high cholesterol, diabetes, family history of vascular disease, obesity, and sedentary lifestyle. D) Risk factors for PVD are similar to those for other cardiovascular diseases. These include smoking, hypertension, coronary heart disease, high cholesterol, diabetes, family history of vascular disease, obesity, and sedentary lifestyle. Page Ref: 553 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 23.1 Describe normal arterial and venous circulation, peripheral vascular diseases, and concepts related to alterations in vascular health. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of vascular disorders.

2) Which finding should the nurse expect when assessing a 30-year-old man with cardiovascular disease? A) History of smoking B) Lack of exercise C) Poor dietary habits D) Homozygous familial hypercholesterolemia Answer: D Explanation: A) Lifestyle factors associated with atherosclerosis include smoking, hypertension, heart disease, high levels of cholesterol and LDLs, diabetes, obesity, advanced age, and physical inactivity. Most lifestyle risk factors may be controlled by healthy dietary habits, regular exercise, and proper medical management. These risk factors do not typically lead to severe cardiovascular disease this early in life. People with homozygous familial hypercholesterolemia develop severe cardiovascular disease in childhood and often die by their mid-30s. B) Lifestyle factors associated with atherosclerosis include smoking, hypertension, heart disease, high levels of cholesterol and LDLs, diabetes, obesity, advanced age, and physical inactivity. Most lifestyle risk factors may be controlled by healthy dietary habits, regular exercise, and proper medical management. These risk factors do not typically lead to severe cardiovascular disease this early in life. People with homozygous familial hypercholesterolemia develop severe cardiovascular disease in childhood and often die by their mid-30s. C) Lifestyle factors associated with atherosclerosis include smoking, hypertension, heart disease, high levels of cholesterol and LDLs, diabetes, obesity, advanced age, and physical inactivity. Most lifestyle risk factors may be controlled by healthy dietary habits, regular exercise, and proper medical management. These risk factors do not typically lead to severe cardiovascular disease this early in life. People with homozygous familial hypercholesterolemia develop severe cardiovascular disease in childhood and often die by their mid-30s. D) The genetic nature of atherosclerosis is evidenced by people who inherit familial hypercholesterolemia, a condition in which the blood contains extremely high levels of cholesterol. People with homozygous familial hypercholesterolemia develop severe cardiovascular disease in childhood and often die by their mid-30s. Page Ref: 555 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 23.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of peripheral arterial disease and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of vascular disorders.

3) Which statement by a patient about lipid levels does the nurse need to clarify? A) "High levels of very low-density lipoproteins are good for me." B) "High levels of high-density lipoproteins are desirable for a healthy heart." C) "I want to raise my low-density lipoproteins as high as I can." D) "High levels of triglycerides are good for me." Answer: B Explanation: A) Almost all triglycerides are transported to adipose tissue for storage by very low-density lipoproteins (VLDL). Through a series of steps, the VLDLs are transformed into LDL molecules after the triglycerides have been transported to adipose tissue. Thus, high levels of VLDL lead to high levels of LDL, which are associated with increased risk of cardiovascular disease. B) High-density lipoproteins (HDLs) help to clear cholesterol from the arteries, transporting it to the liver for excretion. Therefore, higher levels of HDL are desirable. C) Elevated levels of low-density lipoproteins (LDLs) promote atherosclerosis because LDL deposits cholesterol on arterial walls. D) In addition to LDL and HDL, triglyceride levels are an important risk factor for cardiovascular disease. Page Ref: 555 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Evaluation | Learning Outcome: 23.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of peripheral arterial disease and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of vascular disorders.

4) When teaching a community health class on cardiac risk factor reduction, which serum cholesterol and triglyceride values does the nurse recommend as desirable? A) Total cholesterol <200 mg/dL, LDL 100-129 mg/dL, triglycerides <150 mg/dL B) Total cholesterol 200-239 mg/dL, LDL 130-159 mg/dL, triglycerides 150-199 mg/dL C) Total cholesterol >240, LDL 160-189 mg/dL, triglycerides 200-499 mg/dL D) LDL >190 mg/dL, triglycerides >500 mg/dL Answer: A Explanation: A) Desirable levels are total cholesterol <200 mg/dL, LDL 100-129 mg/dL, triglycerides <150 mg/dL. B) Borderline high risk is total cholesterol 200-239 mg/dL, LDL 130-159 mg/dL, triglycerides 150-199 mg/dL. C) High risk is total cholesterol >240, LDL 160-189 mg/dL, triglycerides 200-499 mg/dL D) Very high risk is LDL >190 mg/dL, triglycerides >500 mg/dL. Page Ref: 555 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 23.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of peripheral arterial disease and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of vascular disorders.

5) When assessing the ankle-brachial index in a patient with peripheral artery disease, the nurse: A) compares the strength of the pulses in the lower and upper extremities. B) compares the pulse rate in the upper and lower extremities. C) compares the blood pressure in the upper and lower extremities. D) compares sensation in the upper and lower extremities. Answer: C Explanation: A) A simple test used to help diagnose PAD is the ankle-brachial index (ABI). The ABI compares the blood pressure in the arms with the blood pressure in the ankles. An abnormal reading may indicate that circulation of the legs is diminished. B) A simple test used to help diagnose PAD is the ankle-brachial index (ABI). The ABI compares the blood pressure in the arms with the blood pressure in the ankles. An abnormal reading may indicate that circulation of the legs is diminished. C) A simple test used to help diagnose PAD is the ankle-brachial index (ABI). The ABI compares the blood pressure in the arms with the blood pressure in the ankles. An abnormal reading may indicate that circulation of the legs is diminished. D) A simple test used to help diagnose PAD is the ankle-brachial index (ABI). The ABI compares the blood pressure in the arms with the blood pressure in the ankles. An abnormal reading may indicate that circulation of the legs is diminished. Page Ref: 557 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 23.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of peripheral arterial disease and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of vascular disorders to diagnosis and treatment.

6) To evaluate the effectiveness of atorvastatin (Lipitor®) in reducing the risk of heart disease, the nurse would expect to see: A) higher serum total cholesterol levels. B) lower serum HDL levels. C) lower serum LDL levels. D) higher serum triglyceride levels. Answer: C Explanation: A) The primary medications used to lower cholesterol levels are called statins. Statins such as atorvastatin (Lipitor®) block a critical enzyme in the synthesis of cholesterol in the liver and can dramatically lower LDL levels as well as total cholesterol and triglyceride levels. B) The primary medications used to lower cholesterol levels are called statins. Statins such as atorvastatin (Lipitor®) block a critical enzyme in the synthesis of cholesterol in the liver and can dramatically lower LDL levels as well as total cholesterol and triglyceride levels. C) The primary medications used to lower cholesterol levels are called statins. Statins such as atorvastatin (Lipitor®) block a critical enzyme in the synthesis of cholesterol in the liver and can dramatically lower LDL levels as well as total cholesterol and triglyceride levels. D) The primary medications used to lower cholesterol levels are called statins. Statins such as atorvastatin (Lipitor®) block a critical enzyme in the synthesis of cholesterol in the liver and can dramatically lower LDL levels as well as total cholesterol and triglyceride levels. Page Ref: 555, 558 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Evaluation | Learning Outcome: 23.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of peripheral arterial disease and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of vascular disorders to diagnosis and treatment.

7) Which patient statement indicates to the nurse that more teaching is needed about preventing episodes of Raynaud disease? A) "I should stay away from people who are smoking." B) "Warm weather triggers attacks." C) "I should try to reduce the stress in my life." D) "I should talk to my doctor about treating my sinus congestion without vasoconstricting drugs." Answer: B Explanation: A) Smoke from cigarettes can trigger an attack of Raynaud disease. B) Raynaud attacks are often triggered by cold weather and emotional stress. C) Raynaud attacks are often triggered by cold weather and emotional stress. D) Medications such as beta blockers, antimigraine drugs, sinus decongestants, and chemotherapy agents can cause blood vessels to constrict and can trigger an attack in Raynaud disease. Page Ref: 559 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Evaluation | Learning Outcome: 23.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of peripheral arterial disease and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of vascular disorders to diagnosis and treatment.

8) The nurse should expect which finding in a patient with thoracic outlet syndrome (TOS)? A) A difference in blood pressure between the upper and lower extremities B) Positive ankle-brachial index C) Positive Adson maneuver D) Manifestations of Turner syndrome Answer: C Explanation: A) A higher blood pressure in the upper extremities compared to the lower extremities may indicate that circulation of the legs is diminished. B) The ankle-brachial index is used to diagnose peripheral arterial disease, not TOS. C) The Adson maneuver (movement of the shoulder joint) helps identify the cause of pain and decreased blood flow due to TOS. D) Children with Turner syndrome are at risk for coarctation of the aorta, not TOS. Page Ref: 559 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 23.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of peripheral arterial disease and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of vascular disorders to diagnosis and treatment.

9) Which statement by a patient with chronic venous insufficiency indicates that more teaching is needed about measures to prevent varicose veins? A) "Exercise will aggravate the condition." B) "I should wear compression stockings." C) "I'll need to lose some weight because I am obese." D) "I need to stop smoking." Answer: A Explanation: A) Exercise is important in preventing varicose veins, as good muscle tone decreases blood pooling in the veins. B) Wearing compression (support) hosiery can help prevent varicose veins. C) Maintaining a healthy weight is important for all types of venous disease because obesity increases the pressure in the veins and makes it harder to return blood to the heart. D) Smoking increases the risk for venous disease. Page Ref: 562 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Evaluation | Learning Outcome: 23.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of chronic venous disease and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of vascular disorders to diagnosis and treatment.

10) Which direction should the nurse give to a pregnant woman who has developed varicose veins in her legs? A) Maintain complete bedrest. B) Keep legs in a dependent position. C) Avoid support stockings. D) Change positions frequently. Answer: D Explanation: A) Pregnancy is a major risk factor for varicose veins, which may occur in the vulva as well as the legs. Pregnant women should take opportunities to elevate their legs, change position frequently, and wear compression socks or support pantyhose as preventive measures. B) Pregnancy is a major risk factor for varicose veins, which may occur in the vulva as well as the legs. Pregnant women should take opportunities to elevate their legs, change position frequently, and wear compression socks or support pantyhose as preventive measures. C) Pregnancy is a major risk factor for varicose veins, which may occur in the vulva as well as the legs. Pregnant women should take opportunities to elevate their legs, change position frequently, and wear compression socks or support pantyhose as preventive measures. D) Pregnancy is a major risk factor for varicose veins, which may occur in the vulva as well as the legs. Pregnant women should take opportunities to elevate their legs, change position frequently, and wear compression socks or support pantyhose as preventive measures. Page Ref: 562 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 23.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of chronic venous disease and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of vascular disorders to diagnosis and treatment.

11) Following the guidelines from the American College of Chest Physicians, the nursing care plan for a patient with deep vein thrombosis should include teaching the patient about taking which of the following medications? A) Aspirin B) Warfarin (Coumadin®) C) Heparin D) Rivaroxaban (Xarelto®) Answer: D Explanation: A) The American College of Chest Physicians now recommends 3-month therapy with dabigatran (Pradaxa®), rivaroxaban (Xarelto®), apixaban (Eliquis®), or edoxaban (Savaysa®) as initial treatment for venous thromboembolism. B) The American College of Chest Physicians now recommends 3-month therapy with dabigatran (Pradaxa®), rivaroxaban (Xarelto®), apixaban (Eliquis®), or edoxaban (Savaysa®) as initial treatment for venous thromboembolism. C) The American College of Chest Physicians now recommends 3-month therapy with dabigatran (Pradaxa®), rivaroxaban (Xarelto®), apixaban (Eliquis®), or edoxaban (Savaysa®) as initial treatment for venous thromboembolism. D) The American College of Chest Physicians now recommends 3-month therapy with dabigatran (Pradaxa®), rivaroxaban (Xarelto®), apixaban (Eliquis®), or edoxaban (Savaysa®) as initial treatment for venous thromboembolism. Page Ref: 562 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Planning | Learning Outcome: 23.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of chronic venous disease and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of vascular disorders to diagnosis and treatment.

12) When counseling a patient, the nurse explains that according to the 2017 American Heart Association guidelines his blood pressure of 135/85 is a diagnosis of: A) normal blood pressure. B) elevated blood pressure. C) stage 1 hypertension. D) stage 2 hypertension. Answer: C Explanation: A) The 2017 American Heart Association guidelines specify that Stage I hypertension is a systolic BP from 130-139 or a diastolic BP from 80-89. B) The 2017 American Heart Association guidelines specify that Stage I hypertension is a systolic BP from 130-139 or a diastolic BP from 80-89. C) The 2017 American Heart Association guidelines specify that Stage I hypertension is a systolic BP from 130-139 or a diastolic BP from 80-89. D) The 2017 American Heart Association guidelines specify that Stage I hypertension is a systolic BP from 130-139 or a diastolic BP from 80-89. Page Ref: 563 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 23.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypertension and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of vascular disorders to diagnosis and treatment.

13) The nurse anticipates that a patient without comorbidities and a blood pressure of 125/75 mmHg will be most likely be treated: A) with lifestyle modifications. B) with lifestyle modifications and one antihypertensive medication. C) with lifestyle modifications and more than one antihypertensive medication. D) with lifestyle modifications and higher doses of more than one antihypertensive medications. Answer: A Explanation: A) A person with a BP of 125/75 mm Hg has elevated hypertension. A person who has elevated blood pressure generally can manage the disease without medication by implementing positive lifestyle changes such as a healthier diet, increased physical exercise, and weight management. B) A person with stage 1 or stage 2 HTN has a clear risk for experiencing health consequences from the disorder, and lifestyle changes combined with antihypertensive medications are usually prescribed. C) The higher the blood pressure, the more aggressive will be the management of the disease, such as prescribing higher doses or several different medications for the HTN. D) The higher the blood pressure, the more aggressive will be the management of the disease, such as prescribing higher doses or several different medications for the HTN. Page Ref: 566 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Implementation | Learning Outcome: 23.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypertension and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of vascular disorders to diagnosis and treatment.

14) An assessment of the patient with hypertensive crisis will most likely reveal: A) diastolic > 100 mmHg. B) systolic > 160 mm Hg. C) diastolic > 120 mmHg. D) systolic > 170 mm Hg. Answer: C Explanation: A) A hypertensive crisis is a relatively rare condition that occurs when systolic pressure exceeds 180 and/or diastolic pressure exceeds 120 mmHg. It was formerly called malignant hypertension or hypertensive emergency. B) A hypertensive crisis is a relatively rare condition that occurs when systolic pressure exceeds 180 and/or diastolic pressure exceeds 120 mmHg. It was formerly called malignant hypertension or hypertensive emergency. C) A hypertensive crisis is a relatively rare condition that occurs when systolic pressure exceeds 180 and/or diastolic pressure exceeds 120 mmHg. It was formerly called malignant hypertension or hypertensive emergency. D) A hypertensive crisis is a relatively rare condition that occurs when systolic pressure exceeds 180 and/or diastolic pressure exceeds 120 mmHg. It was formerly called malignant hypertension or hypertensive emergency. Page Ref: 563, 565 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 23.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypertension and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of vascular disorders.

15) Which statement by a patient with hypertension indicates to the nurse that more teaching is needed? A) "Lots of rest will help lower my blood pressure." B) "I need to achieve an optimal weight." C) "I should lower my alcohol intake." D) "I should follow a low saturated fat diet." Answer: A Explanation: A) The first step in treating chronic HTN is to implement therapeutic lifestyle changes. These changes are the same as those for other cardiovascular disorders and may include the following: restricting sodium consumption, limiting alcohol consumption, smoking cessation, maintaining an optimal weight, reducing intake of saturated fat and cholesterol, increasing consumption of fruits and vegetables, increasing physical activity, and reducing stress levels. B) The first step in treating chronic HTN is to implement therapeutic lifestyle changes. These changes are the same as those for other cardiovascular disorders and may include the following: restricting sodium consumption, limiting alcohol consumption, smoking cessation, maintaining an optimal weight, reducing intake of saturated fat and cholesterol, increasing consumption of fruits and vegetables, increasing physical activity, and reducing stress levels. C) The first step in treating chronic HTN is to implement therapeutic lifestyle changes. These changes are the same as those for other cardiovascular disorders and may include the following: restricting sodium consumption, limiting alcohol consumption, smoking cessation, maintaining an optimal weight, reducing intake of saturated fat and cholesterol, increasing consumption of fruits and vegetables, increasing physical activity, and reducing stress levels. D) The first step in treating chronic HTN is to implement therapeutic lifestyle changes. These changes are the same as those for other cardiovascular disorders and may include the following: restricting sodium consumption, limiting alcohol consumption, smoking cessation, maintaining an optimal weight, reducing intake of saturated fat and cholesterol, increasing consumption of fruits and vegetables, increasing physical activity, and reducing stress levels. Page Ref: 566 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Evaluation | Learning Outcome: 23.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypertension and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of heart failure.

16) Which of the following antihypertensive medications does the nurse anticipate administering for a patient newly diagnosed with hypertension? A) Propranolol (Inderal®) B) Furosemide (Lasix®) C) Hydrochlorothiazide (Microzide®) D) Lisinopril (Prinivil®) Answer: D Explanation: A) Beta-blockers, such as propranolol, are no longer first-line treatment for hypertension. B) For many decades, diuretics, especially the thiazide class, were the preferred drugs for the initial treatment of HTN. Diuretics lower blood pressure by increasing urine output and reducing blood volume. They are safe and effective medications that are still widely prescribed. However, with the discovery of the importance of the RAAS in controlling blood pressure, medications were developed to block aspects of this pathway in hypertensive patients. Drugs blocking the RAAS have become first-line drugs in treating both HTN and heart failure. C) For many decades, diuretics, especially the thiazide class, were the preferred drugs for the initial treatment of HTN. Diuretics lower blood pressure by increasing urine output and reducing blood volume. They are safe and effective medications that are still widely prescribed. However, with the discovery of the importance of the RAAS in controlling blood pressure, medications were developed to block aspects of this pathway in hypertensive patients. Drugs blocking the RAAS have become first-line drugs in treating both HTN and heart failure. D) With the discovery of the importance of the RAAS in controlling blood pressure, medications were developed to block aspects of this pathway in hypertensive patients. Drugs blocking the RAAS have become first-line drugs in treating both HTN and heart failure. The primary medications in this class block angiotensin-converting enzyme (ACE). Lisinopril (Prinivil®) is a widely prescribed medication in this drug class. Page Ref: 566 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Implementation | Learning Outcome: 23.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypertension and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of vascular disorders to diagnosis and treatment.

17) What is the best explanation the nurse should give when a patient asks how his Zestorectic® works? A) This medication works as a diuretic. B) This medication is an ACE inhibitor. C) This medication combines a diuretic and an ACE inhibitor. D) This medication inhibits activation of the sympathetic nervous system. Answer: C Explanation: A) Zestorectic® combines a diuretic (hydrochlorothiazide) with an ACE inhibitor (lisinopril). Using two drugs allows for lower doses of each drug and a reduced potential for adverse effects. A greater reduction in blood pressure may also be obtained by combining two drugs that treat HTN by different mechanisms of action. B) Zestorectic® combines a diuretic (hydrochlorothiazide) with an ACE inhibitor (lisinopril). Using two drugs allows for lower doses of each drug and a reduced potential for adverse effects. A greater reduction in blood pressure may also be obtained by combining two drugs that treat HTN by different mechanisms of action. C) Zestorectic® combines a diuretic (hydrochlorothiazide) with an ACE inhibitor (lisinopril). Using two drugs allows for lower doses of each drug and a reduced potential for adverse effects. A greater reduction in blood pressure may also be obtained by combining two drugs that treat HTN by different mechanisms of action. D) Zestorectic® combines a diuretic (hydrochlorothiazide) with an ACE inhibitor (lisinopril). Using two drugs allows for lower doses of each drug and a reduced potential for adverse effects. A greater reduction in blood pressure may also be obtained by combining two drugs that treat HTN by different mechanisms of action. Page Ref: 567 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Implementation | Learning Outcome: 23.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypertension and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of vascular disorders to diagnosis and treatment.

18) When assessing a patient with a venous ulcer due to chronic venous insufficiency, the nurse would expect the ulcer to be located: A) on the calf. B) on a toe. C) on the heel. D) on a pressure point. Answer: A Explanation: A) Venous ulcers are usually located from the mid-calf to just below the malleoli. B) Arterial ulcers occur more commonly on the toes, heels, and pressure points on the foot. C) Arterial ulcers occur more commonly on the toes, heels, and pressure points on the foot. D) Arterial ulcers occur more commonly on the toes, heels, and pressure points on the foot. Page Ref: 560 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 23.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of chronic venous disease and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of vascular disorders.

19) When assessing a patient with long-standing claudication, the nurse is most likely to assess: A) sharp shooting leg pain in the area of arterial stenosis. B) leg pain that is relieved by walking. C) leg pain at rest. D) a reddened, warm area over the calf. Answer: C Explanation: A) When blood flow to skeletal muscle is insufficient, the patient may experience claudication, a cramping muscle pain in the region of the narrowing. At first, claudication may be intermittent and occur only during exercise, but it may progress to pain even when at rest. B) When blood flow to skeletal muscle is insufficient, the patient may experience claudication, a cramping muscle pain in the region of the narrowing. At first, claudication may be intermittent and occur only during exercise, but it may progress to pain even when at rest. C) When blood flow to skeletal muscle is insufficient, the patient may experience claudication, a cramping muscle pain in the region of the narrowing. At first, claudication may be intermittent and occur only during exercise, but it may progress to pain even when at rest. D) Redness and warmth occur with inflammation of a vein. Page Ref: 556 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 23.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of peripheral arterial disease and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of vascular disorders.

20) Which manifestation is the nurse likely to assess in the patient with chronic venous insufficiency (CVI)? A) Sacral edema B) Thinning of the skin on the calves C) Leg pain that worsens with elevation D) Pain in the legs that worsens with standing Answer: D Explanation: A) General symptoms occurring with CVI include leg cramps and pain that worsens on standing, edema of the leg or ankle, thickening or discoloration of the skin on the calves, and heaviness or weakness in the legs. B) General symptoms occurring with CVI include leg cramps and pain that worsens on standing, edema of the leg or ankle, thickening or discoloration of the skin on the calves, and heaviness or weakness in the legs. C) General symptoms occurring with CVI include leg cramps and pain that worsens on standing, edema of the leg or ankle, thickening or discoloration of the skin on the calves, and heaviness or weakness in the legs. D) General symptoms occurring with CVI include leg cramps and pain that worsens on standing, edema of the leg or ankle, thickening or discoloration of the skin on the calves, and heaviness or weakness in the legs. Page Ref: 560 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 23.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of chronic venous disease and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of vascular disorders.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 24 Coronary Circulation Disorders 1) When assessing patient with reduced cerebral perfusion, the nurse should be alert for which early finding? A) Angina B) Claudication C) Altered mental status D) Dyspnea Answer: C Explanation: A) Angina describes the chest pain, discomfort, pressure, and squeezing symptoms of CAD when the heart is not receiving enough perfusion of blood. B) Claudication, leg pain that is induced by exercise, is a type of cardiovascular disease typically caused by decreased arterial blood flow and limb ischemia. C) Clinical signs or symptoms of ischemia can be seen when the cerebral perfusion pressure drops below the lower limit of autoregulation. Altered mental status is an early symptom of decreased cerebral blood flow. D) Reduced blood flow to the lungs may produce dyspnea, including dyspnea at rest. Page Ref: 573 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 24.1 Describe coronary artery disease, acute coronary syndromes, and concepts related to disorders of coronary circulation. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of coronary circulation disorders.

2) To obtain information about a patient's major modifiable risk factors for coronary artery disease, which question should the nurse ask? A) "How much alcohol do you drink?" B) "Do you have sleep apnea?" C) "Do you smoke cigarettes?" D) "Do you suffer from depression?" Answer: C Explanation: A) In addition to the major modifiable risk factors, other modifiable risk factors are sleep apnea, stress, depression, heavy alcohol use, and air pollution. B) In addition to the major modifiable risk factors, other modifiable risk factors are sleep apnea, stress, depression, heavy alcohol use, and air pollution. C) Major modifiable risk factors that contribute to a risk of CAD include smoking and tobacco use, lack of physical activity, poor nutrition, overweight, obesity, hypertension, dyslipidemias, insulin resistance, and metabolic syndrome. D) In addition to the major modifiable risk factors, other modifiable risk factors are sleep apnea, stress, depression, heavy alcohol use, and air pollution. Page Ref: 575 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 24.2 Outline the epidemiology and risk factors related to coronary artery disease as well as methods of preventing coronary artery disease. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of coronary circulation disorders.

3) Which characteristics in an adult patient would the nurse assess as having poor cardiovascular health using the American Heart Association's Life's Simple 7? A) Blood glucose 126 mg/dL, lack of physical activity, current smoker B) 60 minutes/week of moderate physical activity, weight of 26 kg/m2, quit 9 smoking months ago C) Cholesterol 150 mg/dL, quit smoking cigarettes 15 months ago, weight of 24 kg/m2 D) Systolic blood pressure 124 mm Hg, blood glucose 105 mg/dL, 3 healthy diet components Answer: A Explanation: A) These are characteristics of a person in poor cardiovascular health, according to the American Heart Association's Life's Simple 7. B) These are characteristics of a person in intermediate cardiovascular health, according to the American Heart Association's Life's Simple 7. C) These are characteristics of a person in ideal cardiovascular health, according to the American Heart Association's Life's Simple 7. D) These are characteristics of a person in intermediate cardiovascular health, according to the American Heart Association's Life's Simple 7. Page Ref: 575-576 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 24.2 Outline the epidemiology and risk factors related to coronary artery disease as well as methods of preventing coronary artery disease. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of coronary circulation disorders.

4) Which of the following teaching points about atherosclerosis would the school nurse include when speaking to parents of middle school-aged children? A) Atherosclerotic buildup begins in middle adulthood. B) Early eating habits do not affect adult risk of atherosclerosis. C) A healthy blood pressure in childhood reduces the risk of heart disease as adults. D) A healthy lifestyle should be started by age 40 years old to reduce risk of atherosclerosis as adults. Answer: C Explanation: A) Children and young adults are not immune to atherosclerosis, which is the leading cause of death in developed and developing countries. B) Interventions to promote a healthy lifestyle such as maintaining a healthy weight and blood pressure and abstaining from smoking are necessary to prevent atherosclerosis or to regress developed and developing atheromas at any age before they cause CAD. C) Interventions to promote a healthy lifestyle such as maintaining a healthy weight and blood pressure and abstaining from smoking are necessary to prevent atherosclerosis or to regress developed and developing atheromas at any age before they cause CAD. D) Interventions to promote a healthy lifestyle such as maintaining a healthy weight and blood pressure and abstaining from smoking are necessary to prevent atherosclerosis or to regress developed and developing atheromas at any age before they cause CAD. Page Ref: 580 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 24.3 Outline the pathophysiology, diagnosis, and treatment of coronary artery disease. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and wellbeing, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of coronary circulation disorders.

5) Which explanation of cardiac risk assessment should the nurse give to a patient asking about his risk for heart disease? A) "Risk assessment will tell us if you will have a heart attack." B) "If you reduce your risk for heart disease, you will prevent heart disease." C) "Risk assessment takes into consideration accumulated long-term exposure to risk factors." D) "Risk assessment can guide us in helping you reduce your risk for heart disease." Answer: D Explanation: A) A risk assessment is an important first step in screening for CAD or any CVDs. However, risk prediction is an imperfect science, and current algorithms do not incorporate accumulated long term exposure to risk factors; thus, they leading to overestimation or underestimation of risk estimates. B) A risk assessment is an important first step in screening for CAD or any CVDs. However, risk prediction is an imperfect science, and current algorithms do not incorporate accumulated long term exposure to risk factors; thus, they leading to overestimation or underestimation of risk estimates. C) A risk assessment is an important first step in screening for CAD or any CVDs. However, risk prediction is an imperfect science, and current algorithms do not incorporate accumulated long term exposure to risk factors; thus, they leading to overestimation or underestimation of risk estimates. D) A risk assessment is an important first step in screening for CAD or any CVDs. However, risk prediction is an imperfect science, and current algorithms do not incorporate accumulated long term exposure to risk factors; thus, they leading to overestimation or underestimation of risk estimates. Page Ref: 575, 580 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 24.3 Outline the pathophysiology, diagnosis, and treatment of coronary artery disease. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of coronary circulation disorders.

6) Which electrocardiographic change would the emergency department nurse expect to observe in a patient experiencing subendocardial cardiac injury? A) ST-segment elevation B) ST-segment depression C) Shortened PR interval D) Prolonged PR interval Answer: B Explanation: A) Transmural (epicardial) injury extends from the endocardium to epicardium and is characterized by ST-segment elevation. B) Subendocardial injury is characterized by ST-segment depression. C) A shortened PR interval is not an indication of ischemia. D) A prolonged PR interval is not an indication of ischemia. Page Ref: 588-592 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 24.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of myocardial ischemia and infarction and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of coronary circulation disorders to diagnosis and treatment.

7) Which medications should the nurse anticipate administering in the patient with an initial diagnosis of stable angina? A) Antiplatelet, long-acting nitrate B) Beta blocker, ACE inhibitor C) Antiplatelet, beta blocker D) ACE inhibitor, long-acting nitrate Answer: C Explanation: A) Medical therapy includes the use of an antiplatelet such as aspirin. Beta blockers may be used as initial therapy for relief of symptoms, and calcium channel blockers or a long-acting nitrate is used when beta blockers are contraindicated or not tolerated by the patient. Other medications such as ACE inhibitors may be considered for patients with comorbidities such as diabetes, hypertension, chronic kidney disease, and/or left ventricle dysfunction. B) Medical therapy includes the use of an antiplatelet such as aspirin. Beta blockers may be used as initial therapy for relief of symptoms, and calcium channel blockers or a long-acting nitrate is used when beta blockers are contraindicated or not tolerated by the patient. Other medications such as ACE inhibitors may be considered for patients with comorbidities such as diabetes, hypertension, chronic kidney disease, and/or left ventricle dysfunction. C) Medical therapy includes the use of an antiplatelet such as aspirin. Beta blockers may be used as initial therapy for relief of symptoms, and calcium channel blockers or a long-acting nitrate is used when beta blockers are contraindicated or not tolerated by the patient. Other medications such as ACE inhibitors may be considered for patients with comorbidities such as diabetes, hypertension, chronic kidney disease, and/or left ventricle dysfunction. D) Medical therapy includes the use of an antiplatelet such as aspirin. Beta blockers may be used as initial therapy for relief of symptoms, and calcium channel blockers or a long-acting nitrate is used when beta blockers are contraindicated or not tolerated by the patient. Other medications such as ACE inhibitors may be considered for patients with comorbidities such as diabetes, hypertension, chronic kidney disease, and/or left ventricle dysfunction. Page Ref: 586 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Implementation | Learning Outcome: 24.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of myocardial ischemia and infarction and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of coronary circulation disorders to diagnosis and treatment.

8) Which manifestation would the nurse expect in a patient with stable angina? A) Pain that is relieved with oxygen administration B) Pain that is relieved by a long-acting nitrate C) Pain that persists with rest D) Pain that is relieved with short-acting nitroglycerin Answer: D Explanation: A) The resolution of angina pectoris with rest or the use of short-acting nitroglycerin can be diagnostic and treatment for stable angina. B) The resolution of angina pectoris with rest or the use of short-acting nitroglycerin can be diagnostic and treatment for stable angina. C) The resolution of angina pectoris with rest or the use of short-acting nitroglycerin can be diagnostic and treatment for stable angina. D) The resolution of angina pectoris with rest or the use of short-acting nitroglycerin can be diagnostic and treatment for stable angina. Page Ref: 16 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 24.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of myocardial ischemia and infarction and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of coronary circulation disorders.

9) Which laboratory finding is expected in the patient experiencing unstable angina? A) Normal cardiac troponin levels B) Elevated creatine kinase MB C) Elevated myoglobin D) Elevated creatine kinase Answer: A Explanation: A) A major difference between unstable angina and non-ST-segment elevation myocardial infarction (NSTEMI) is whether damage is significant enough to release biomarkers (such as cardiac troponin levels, creatine kinase MB, and myoglobin) indicating myocardial necrosis (diagnostic for acute MI). The presence of elevated biomarkers indicating significant myocardial necrosis is diagnostic for NSTEMI, and the absence of biomarkers confirms the diagnosis of unstable angina. B) A major difference between unstable angina and non-ST-segment elevation myocardial infarction (NSTEMI) is whether damage is significant enough to release biomarkers (such as cardiac troponin levels, creatine kinase MB, and myoglobin) indicating myocardial necrosis (diagnostic for acute MI). The presence of elevated biomarkers indicating significant myocardial necrosis is diagnostic for NSTEMI, and the absence of biomarkers confirms the diagnosis of unstable angina. C) A major difference between unstable angina and non-ST-segment elevation myocardial infarction (NSTEMI) is whether damage is significant enough to release biomarkers (such as cardiac troponin levels, creatine kinase MB, and myoglobin) indicating myocardial necrosis (diagnostic for acute MI). The presence of elevated biomarkers indicating significant myocardial necrosis is diagnostic for NSTEMI, and the absence of biomarkers confirms the diagnosis of unstable angina. D) A major difference between unstable angina and non-ST-segment elevation myocardial infarction (NSTEMI) is whether damage is significant enough to release biomarkers indicating myocardial necrosis (diagnostic for acute MI). The presence of elevated biomarkers indicating significant myocardial necrosis is diagnostic for NSTEMI, and the absence of biomarkers confirms the diagnosis of unstable angina. Page Ref: 590 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 24.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of specific acute coronary syndromes and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of coronary circulation disorders to diagnosis and treatment.

10) Which of the following interventions would the emergency department nurse anticipate in a patient being treated for a non-ST-segment elevation myocardial infarction (NSTEMI)? A) Sublingual nitroglycerin for up to three doses 5 minute apart B) Intravenous nitroglycerin, if the patient has recently used a phosphodiesterase inhibitor drug C) Enteric-coated aspirin D) Intravenous beta blocker Answer: A Explanation: A) Short-acting sublingual nitroglycerin (in a dose of 0.3-0.4 mg) should be administered under the patient's tongue every 5 minutes for up to three doses. B) If ischemic chest pain continues, intravenous nitroglycerin may be considered, especially in the presence of hypertension. However, nitrates (sublingual nitroglycerin or intravenous) are contraindicated if the patient has recently used a phosphodiesterase inhibitor such as sildenafil (Viagra) or tadalafil (Cialis). C) Non-enteric-coated chewable aspirin should be given at presentation of symptoms and continued throughout the patient's life because of its antiplatelet function in preventing future thrombosis and coronary artery occlusion. D) Oral, not intravenous, beta blockers are initiated within the first 24 hours if the patient does not have contraindications such as signs of heart failure or low cardiac output, risk for cardiogenic shock, heart block without a pacemaker, and asthma or reactive airway disease. Page Ref: 590 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Implementation | Learning Outcome: 24.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of specific acute coronary syndromes and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of coronary circulation disorders to diagnosis and treatment.

11) The plan of care for a patient with a STEMI, treated in a non-percutaneous coronary intervention capable (PCI) hospital, includes: A) evaluation in the cardiac catheterization lab within 90 minutes of non-PCI hospital arrival. B) transfer to a PCI-capable hospital within 3 hours. C) fibrinolytic therapy if transfer causes a delay of more than 120 minutes for door to balloon. D) stabilizing patient for 24 hours, then transferring to a PCI-capable hospital. Answer: C Explanation: A) If first seen at a non-PCI-capable hospital, the patient should be transferred quickly so that the time from door to balloon is no more than 120 minutes. B) If first seen at a non-PCI-capable hospital, the patient should be transferred quickly so that the time from door to balloon is no more than 120 minutes. C) Unless contraindicated, the patient who arrives at non-PCI-capable hospital with a STEMI should receive fibrinolytic therapy if the transfer is expected to cause a delay of more than 120 minutes for door to balloon. If medical therapy is chosen as the reperfusion strategy, it should be administered within 30 minutes ("door to drug") of the patient's arrival at the hospital. D) If first seen at a non-PCI-capable hospital, the patient should be transferred quickly so that the time from door to balloon is no more than 120 minutes. Page Ref: 593 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 24.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of specific acute coronary syndromes and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of coronary circulation disorders to diagnosis and treatment.

12) How should the nurse interpret the electrocardiogram (ECG) of a patient which shows an atrial rate of 300-600 bpm, ventricular rate of 100-180 bpm, irregularly irregular rhythm, variable P:QRS, and PR interval that cannot be measured? A) Atrial flutter B) Atrial fibrillation C) Paroxysmal supraventricular tachycardia D) Sinus tachycardia Answer: B Explanation: A) The ECG in atrial flutter shows atrial rate of 240-360 bpm; ventricular rate depends on degree of atrioventricular block and usually is <150 bpm; atrial rhythm, regular; ventricular rhythm, usually regular; P:QRS: 2:1, 4:1, 6:1; PR interval: not measured; QRS complex: 0.6-0.10 sec. B) In atrial fibrillation, the ECG reveals an atrial rate of 300-600 bpm, a ventricular rate of 100180 bpm, an irregularly irregular rhythm, a variable P:QRS, and a PR interval that cannot be measured. C) In paroxysmal supraventricular tachycardia, the ECG reveals a rate of 100-280 bpm (usually 150-200 bpm), regular rhythm; P waves often not identifiable; PR interval not measured, QRS complex 0.6-0.10 sec. D) In sinus tachycardia, the ECG reveals a rate of 101-150 bpm; regular rhythm; 1:1 P:QRS; PR interval 0.12-0.20 sec., QRS complex 0.6-0.10 sec. Page Ref: 595-596 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 24.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of complications of acute coronary syndromes and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of coronary circulation disorders to diagnosis and treatment.

13) Which patient statement indicates that more teaching about the Zio Patch arrhythmia monitor is needed? A) "It is very convenient that I don't have a bulky monitor to carry around." B) "This will record my heart rhythm over two weeks." C) "My doctor will call me if I have an arrhythmia while I am wearing this monitor." D) "There are no wires to for me to worry about coming loose." Answer: C Explanation: A) Recent FDA approval of the Zio Patch, which is a wire-free monitor that is worn as a lightweight adhesive patch, allows long-term monitoring over 14 days. The Zio Patch has been found to detect more events than the Holter monitor, does not require implantation, and is less bulky. The Zio Patch is not monitored while the patient is wearing it. It is analyzed once the monitoring period is over. B) Recent FDA approval of the Zio Patch, which is a wire-free monitor that is worn as a lightweight adhesive patch, allows long-term monitoring over 14 days. The Zio Patch has been found to detect more events than the Holter monitor, does not require implantation, and is less bulky. The Zio Patch is not monitored while the patient is wearing it. It is analyzed once the monitoring period is over. C) Recent FDA approval of the Zio Patch, which is a wire-free monitor that is worn as a lightweight adhesive patch, allows long-term monitoring over 14 days. The Zio Patch has been found to detect more events than the Holter monitor, does not require implantation, and is less bulky. The Zio Patch is not monitored while the patient is wearing it. It is analyzed once the monitoring period is over. D) Recent FDA approval of the Zio Patch, which is a wire-free monitor that is worn as a lightweight adhesive patch, allows long-term monitoring over 14 days. The Zio Patch has been found to detect more events than the Holter monitor, does not require implantation, and is less bulky. The Zio Patch is not monitored while the patient is wearing it. It is analyzed once the monitoring period is over. Page Ref: 600 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Evaluation | Learning Outcome: 24.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of complications of acute coronary syndromes and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of coronary circulation disorders to diagnosis and treatment.

14) When performing cardiopulmonary resuscitation, in which order should the nurse perform the steps? A) Airway, breathing, compressions B) Breathing, airway, compressions C) Compressions, breathing, airway D) compressions, airway, breathing Answer: D Explanation: A) In the acute situation, basic life support is performed in accordance to the AHA guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care. Trained professionals and laypeople can carry out activities to resuscitate the patient in cardiac arrest using the acronym CAB, which stands for compressions, airway, and breathing. B) In the acute situation, basic life support is performed in accordance to the AHA guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care. Trained professionals and laypeople can carry out activities to resuscitate the patient in cardiac arrest using the acronym CAB, which stands for compressions, airway, and breathing. C) In the acute situation, basic life support is performed in accordance to the AHA guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care. Trained professionals and laypeople can carry out activities to resuscitate the patient in cardiac arrest using the acronym CAB, which stands for compressions, airway, and breathing. D) In the acute situation, basic life support is performed in accordance to the AHA guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care. Trained professionals and laypeople can carry out activities to resuscitate the patient in cardiac arrest using the acronym CAB, which stands for compressions, airway, and breathing. Page Ref: 600 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 24.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of complications of acute coronary syndromes and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of coronary circulation disorders to diagnosis and treatment.

15) Which physical assessment findings would the nurse expect in a patient with a left ventricular aneurysm? A) S3 B) Apical impulse displaced to right C) Diastolic murmur D) Opening snap Answer: A Explanation: A) With a ventricular aneurysm, a third or fourth heart sound may be present on physical examination, and the apical impulse may be displaced to left of the midclavicular line. B) With a ventricular aneurysm, a third or fourth heart sound may be present on physical examination, and the apical impulse may be displaced to left of the midclavicular line. C) With a ventricular aneurysm, a systolic murmur may be auscultated related to coexisting mitral regurgitation. D) An opening snap is heard in mitral stenosis. With a ventricular aneurysm a systolic murmur may be auscultated related to coexisting mitral regurgitation. Page Ref: 601, 604 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 24.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of complications of acute coronary syndromes and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of coronary circulation disorders.

16) The nurse is assessing for pulsus paradoxus in a patient who was in a car accident. Which of the following results suggest the patient is developing cardiac tamponade? A) A decrease of 10 mm Hg in systolic blood pressure during inspiration B) An increase of 10 mm Hg in systolic blood pressure during inspiration C) A decrease of 10 mm Hg in diastolic blood pressure during inspiration D) An increase of 10 mm Hg in diastolic blood pressure during inspiration Answer: A Explanation: A) Pulsus paradoxus is a characteristic finding of cardiac tamponade in which there is an abnormal decrease of more than 10 mmHg in systolic blood pressure during inspiration. Pulsus paradoxus is measured by using a stethoscope and manual sphygmomanometer to estimate hemodynamic impairment associated with pericardial effusion, which is more detrimental if the pericardial effusion is evolving rapidly. B) Pulsus paradoxus is a characteristic finding of cardiac tamponade in which there is an abnormal decrease of more than 10 mmHg in systolic blood pressure during inspiration. C) Pulsus paradoxus is a characteristic finding of cardiac tamponade in which there is an abnormal decrease of more than 10 mmHg in systolic blood pressure during inspiration. D) Pulsus paradoxus is a characteristic finding of cardiac tamponade in which there is an abnormal decrease of more than 10 mmHg in systolic blood pressure during inspiration. Page Ref: 602 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 24.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of complications of acute coronary syndromes and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of coronary circulation disorders.

17) The nurse is caring for a patient with cardiac tamponade who underwent pericardiocentesis to remove fluid. What findings would indicate to the nurse that the procedure has been effective? A) Hear rate 92 bpm B) Respiratory rate 34 breaths/minute C) Jugular venous distention D) Pulsus paradoxus of 14 mm Hg Answer: A Explanation: A) Systemic and pulmonary hypoperfusion symptoms may be present and include dyspnea, edema, oliguria (low urine output), jugular venous distention, tachypnea, and tachycardia as a compensatory mechanism to maintain cardiac output. A heart rate of 92 is within normal limits. B) Systemic and pulmonary hypoperfusion symptoms may be present and include dyspnea, edema, oliguria (low urine output), jugular venous distention, tachypnea, and tachycardia as a compensatory mechanism to maintain cardiac output. A respiratory rate of 34 breaths/minute is considered tachypneic. C) Systemic and pulmonary hypoperfusion symptoms may be present and include dyspnea, edema, oliguria (low urine output), jugular venous distention, tachypnea, and tachycardia as a compensatory mechanism to maintain cardiac output. D) A pulsus paradoxus of 14 mm Hg is a finding of cardiac tamponade. Page Ref: 595, 602-603 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 24.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of complications of acute coronary syndromes and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of coronary circulation disorders to diagnosis and treatment.

18) When auscultating the heart of a patient with mitral stenosis, the nurse is most likely to hear which sounds? A) Diastolic murmur and opening snap. B) Holosystolic murmur C) Systolic click murmur D) Loud, harsh holosystolic murmur Answer: A Explanation: A) In mitral stenosis, a diastolic heart murmur and opening snap are heard on auscultation. B) In mitral regurgitation, a holosystolic murmur may be heard on auscultation. C) In mitral valve prolapse, a systolic click murmur may be heard on auscultation. D) In ventricular septal rupture, a loud, harsh holosystolic murmur may be auscultated. Page Ref: 604-605 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 24.7 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of valvular disorders and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of coronary circulation disorders.

19) Which finding is the nurse likely to assess in a patient with pericarditis? A) Pain that worsens on exhalation B) Pain that worsens on sitting upright C) Pain that worsens when lying prone D) Pain that worsens with deep inspiration Answer: D Explanation: A) Pericarditis often causes pleuritic chest pain as irritated layers rub against one another. The pain is worse with deep inspiration, coughing, swallowing, or lying in supine position and may radiate. B) Pericarditis often causes pleuritic chest pain as irritated layers rub against one another. The pain is worse with deep inspiration, coughing, swallowing, or lying in supine position and may radiate. C) Pericarditis often causes pleuritic chest pain as irritated layers rub against one another. The pain is worse with deep inspiration, coughing, swallowing, or lying in supine position and may radiate. D) Pericarditis often causes pleuritic chest pain as irritated layers rub against one another. The pain is worse with deep inspiration, coughing, swallowing, or lying in supine position and may radiate. Page Ref: 601 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 24.7 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of valvular disorders and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of coronary circulation disorders.

20) How should the nurse respond when a patient with coronary artery disease asks why Creactive protein (CRP) levels are being drawn for laboratory analysis? A) "An elevated CRP level is a predictor of coronary artery disease." B) "An elevated CRP level means you will have a heart attack." C) "CRP is released from the heart during a heart attack." D) "CRP is released from atherosclerotic plaques." Answer: A Explanation: A) C-reactive protein (CRP) is a biomarker and mediator of the inflammatory process in the development of atherosclerosis. An elevated plasma or serum CRP level is strongly associated with atherosclerosis and CAD and is predictive of cardiovascular events such as MI, stroke, peripheral artery disease, and sudden cardiac death. B) C-reactive protein (CRP) is a biomarker and mediator of the inflammatory process in the development of atherosclerosis. An elevated plasma or serum CRP level is strongly associated with atherosclerosis and CAD and is predictive of cardiovascular events such as MI, stroke, peripheral artery disease, and sudden cardiac death. C) C-reactive protein (CRP) is a biomarker and mediator of the inflammatory process in the development of atherosclerosis. An elevated plasma or serum CRP level is strongly associated with atherosclerosis and CAD and is predictive of cardiovascular events such as MI, stroke, peripheral artery disease, and sudden cardiac death. D) C-reactive protein (CRP) is a biomarker and mediator of the inflammatory process in the development of atherosclerosis. An elevated plasma or serum CRP level is strongly associated with atherosclerosis and CAD and is predictive of cardiovascular events such as MI, stroke, peripheral artery disease, and sudden cardiac death. Page Ref: 575 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 24.2 Outline the epidemiology and risk factors related to coronary artery disease as well as methods of preventing coronary artery disease. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of coronary circulation disorders.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 25 Cardiac Structural Disorders 1) What is the best response for the nurse to make when the parents of an infant, born with a congenital heart defect, ask the cause of the condition? A) "It is caused by a genetic defect." B) "It is caused by environmental factors." C) "The cause is multifactorial." D) "The cause is not known." Answer: C Explanation: A) It is commonly accepted now that the development of congenital heart defects is multifactorial, a combination of environment and genetics. B) It is commonly accepted now that the development of congenital heart defects is multifactorial, a combination of environment and genetics. C) It is commonly accepted now that the development of congenital heart defects is multifactorial, a combination of environment and genetics. D) It is commonly accepted now that the development of congenital heart defects is multifactorial, a combination of environment and genetics. Page Ref: 613 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 25.1 Discuss the statistics related to structural heart defects, the impact of the environment on their etiology, and concepts related to structural heart defects. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of cardiac structural disorders.

2) When teaching a prenatal class, the nurse tells the class that the first fetal heart beat occurs: A) on day 12. B) on day 22. C) on day 32. D) at the end of the first trimester. Answer: B Explanation: A) The fusion of the heart tube occurs on days 21 and 22, leading to the first "heart" beat on day 22. B) The fusion of the heart tube occurs on days 21 and 22, leading to the first "heart" beat on day 22. C) The fusion of the heart tube occurs on days 21 and 22, leading to the first "heart" beat on day 22. D) The fusion of the heart tube occurs on days 21 and 22, leading to the first "heart" beat on day 22. Page Ref: 615 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 25.2 Outline the structure of the pediatric cardiovascular system. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of cardiac structural disorders.

3) What response should the nurse give, while teaching a prenatal class, when asked when cardiac defects occur? A) "They may occur any time during gestation." B) "They occur by the end of the ninth week." C) "They occur before implantation has occurred." D) "They occur shortly before birth." Answer: B Explanation: A) By the end of 9 weeks gestation, the main structures are developed, and any structural defects have already occurred. B) By the end of 9 weeks gestation, the main structures are developed, and any structural defects have already occurred. C) Once implantation of the embryo has occurred, around the 12th day of human development, the cells begin to undergo mitosis, resulting in differentiation of cell types. By the 17th day of human development, the primary heart field has developed. Heart structures do not begin to form before implantation. D) By the end of 9 weeks gestation, the main structures are developed, and any structural defects have already occurred. Page Ref: 615 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 25.2 Outline the structure of the pediatric cardiovascular system. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of cardiac structural disorders.

4) An experienced labor and delivery nurse is orienting nurses new to labor and delivery. Which of the following does the experienced nurse teach about fetal circulation? A) Oxygenated blood is carried to the fetus via the umbilical artery. B) Oxygenated blood enters the right atrium. C) Most of the blood in the right atrium crosses the foramen ovale into the left atrium. D) Blood entering the right ventricle is pumped to the lungs. Answer: C Explanation: A) In the fetus, oxygenated blood enters through the umbilical vein and travels to the heart via the ductus venosus bypassing the liver. B) Oxygenated blood from the umbilical vein combines with deoxygenated blood in the inferior vena cava, mixes with deoxygenated blood in the superior vena cava, and then empties into the right atrium. C) Blood in the right atrium shunts through the foramen ovale from the right atrium to the left atrium as a result of the high right atrial pressures and the lower left atrial pressures. D) Some blood does travel from the right atrium to the right ventricle via the pulmonary trunk; however, this blood is shunted across the ductus arteriosus to the aorta as a result of the very high pulmonary pressures. Page Ref: 615 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 25.3 Describe prenatal and postnatal hemodynamics and the screening used to detect critical congenital heart defects in newborns. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of cardiac structural disorders.

5) When assessing a newborn immediately after birth, which concept should the nurse keep in mind? A) Pulmonary pressures rise. B) Left atrial pressure rises. C) Right atrial pressure rises. D) Systemic vascular resistance falls. Answer: B Explanation: A) At birth, the infant takes its first breath, which reduces the pulmonary pressures as the pulmonary vasculature dilates in response to the change in the partial pressure of oxygen. Pulmonary blood flow increases as pulmonary pressure decreases, as does the increased blood flow to the left atrium as the left atrial pressure increases. After the umbilical cord has been cut, systemic vascular resistance increases in response to the decrease in the right atrial pressures. B) At birth, the infant takes its first breath, which reduces the pulmonary pressures as the pulmonary vasculature dilates in response to the change in the partial pressure of oxygen. Pulmonary blood flow increases as pulmonary pressure decreases, as does the increased blood flow to the left atrium as the left atrial pressure increases. After the umbilical cord has been cut, systemic vascular resistance increases in response to the decrease in the right atrial pressures. C) At birth, the infant takes its first breath, which reduces the pulmonary pressures as the pulmonary vasculature dilates in response to the change in the partial pressure of oxygen. Pulmonary blood flow increases as pulmonary pressure decreases, as does the increased blood flow to the left atrium as the left atrial pressure increases. After the umbilical cord has been cut, systemic vascular resistance increases in response to the decrease in the right atrial pressures. D) At birth, the infant takes its first breath, which reduces the pulmonary pressures as the pulmonary vasculature dilates in response to the change in the partial pressure of oxygen. Pulmonary blood flow increases as pulmonary pressure decreases, as does the increased blood flow to the left atrium as the left atrial pressure increases. After the umbilical cord has been cut, systemic vascular resistance increases in response to the decrease in the right atrial pressures. Page Ref: 615 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 25.3 Describe prenatal and postnatal hemodynamics and the screening used to detect critical congenital heart defects in newborns. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of cardiac structural disorders.

6) When performing a screening for critical congenital heart disease (CCHD), where should the nurse obtain the preductal pulse oximeter reading? A) From the right hand B) From the left hand C) From the right foot D) From the left foot Answer: A Explanation: A) Pulse oximetry readings are taken on the right hand (preductal) and either foot (postductal). B) Pulse oximetry readings are taken on the right hand (preductal) and either foot (postductal). C) Pulse oximetry readings are taken on the right hand (preductal) and either foot (postductal). D) Pulse oximetry readings are taken on the right hand (preductal) and either foot (postductal). Page Ref: 616 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 25.3 Describe prenatal and postnatal hemodynamics and the screening used to detect critical congenital heart defects in newborns. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of cardiac structural disorders to diagnosis and treatment.

7) What is the best response by the nurse when the mother of a 24-hour-old newborn asks why her baby is being screened for congenital heart disease? A) "We don't trust you to notice possible heart problems in your baby." B) "This is a routine mandatory newborn screening." C) "Your baby's skin color is a little red." D) "The doctor heard a heart murmur which is not normal at this stage after delivery." Answer: B Explanation: A) Many cases of congenital heart disease (CHD) are asymptomatic, and the parents may not notice anything wrong. This is why screening is routinely done on healthy babies to look for evidence of problems before the baby is sent home from the hospital. B) Critical congenital heart disease (CCHD) is a term used to refer to a group of serious congenital heart defects that usually require surgical correction within the first year of life. In September 2011, the U.S. Secretary of Health and Human Services publicly recommended that routine screening of newborns for CCHD be added to the current state-mandated newborn screenings. C) A red complexion is not unusual for a 24-hour-old newborn. D) A heart murmur may be heard at one day after delivery because the ductus arteriosus begins to close within 1- to 15 hours after birth, with permanent closure resulting by 21 days of life. Page Ref: 616 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 25.3 Describe prenatal and postnatal hemodynamics and the screening used to detect critical congenital heart defects in newborns. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of cardiac structural disorders to diagnosis and treatment.

8) Which finding would alert the nurse to a potential problem in a newborn undergoing critical congenital heart disease testing? A) An SpO2 of 94% on room air on the right hand and right foot B) An SpO2 of 98% on room air on the right hand and right foot C) An SpO2 of 96% on room air on the right hand with less than a 3% difference on the left foot D) An SpO2 of 98% on room air on the right hand and left foot Answer: A Explanation: A) A negative CCHD screening includes pulse oximeter readings of greater than 95% on room air on the right hand (preductal) and either foot (postductal) or less than a 3% difference between the preductal and postductal readings. A positive CCHD screening would be SpO2 of 90-94% in the hand and foot or a hand-foot absolute difference greater than 3%. If the first CCHD screening results in a positive result, the test is repeated after 1 hour up to three times. A confirmed positive result, that is, SpO2 of less than 90% in hand or foot or three repeated positive screens, results in referral of the infant for an echocardiogram and further medical evaluation. B) A negative CCHD screening includes pulse oximeter readings of greater than 95% on room air on the right hand (preductal) and either foot (postductal) or less than a 3% difference between the preductal and postductal readings. A positive CCHD screening would be SpO2 of 90-94% in the hand and foot or a hand-foot absolute difference greater than 3%. If the first CCHD screening results in a positive result, the test is repeated after 1 hour up to three times. A confirmed positive result, that is, SpO2 of less than 90% in hand or foot or three repeated positive screens, results in referral of the infant for an echocardiogram and further medical evaluation. C) A negative CCHD screening includes pulse oximeter readings of greater than 95% on room air on the right hand (preductal) and either foot (postductal) or less than a 3% difference between the preductal and postductal readings. A positive CCHD screening would be SpO2 of 90-94% in the hand and foot or a hand-foot absolute difference greater than 3%. If the first CCHD screening results in a positive result, the test is repeated after 1 hour up to three times. A confirmed positive result, that is, SpO2 of less than 90% in hand or foot or three repeated positive screens, results in referral of the infant for an echocardiogram and further medical evaluation. D) A negative CCHD screening includes pulse oximeter readings of greater than 95% on room air on the right hand (preductal) and either foot (postductal) or less than a 3% difference between the preductal and postductal readings. A positive CCHD screening would be SpO2 of 90-94% in the hand and foot or a hand-foot absolute difference greater than 3%. If the first CCHD screening results in a positive result, the test is repeated after 1 hour up to three times. A confirmed positive result, that is, SpO2 of less than 90% in hand or foot or three repeated positive screens, results in referral of the infant for an echocardiogram and further medical evaluation. Page Ref: 616 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance

Standards: Nursing Process: Assessment | Learning Outcome: 25.3 Describe prenatal and postnatal hemodynamics and the screening used to detect critical congenital heart defects in newborns. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of cardiac structural disorders to diagnosis and treatment. 9) The nurse is explaining the goals of the Congenital Heart Disease Genetic Network Study (CHD GENES) to a couple considering genetic screening for congenital defects. Which statement by a parent indicates that more teaching is needed? A) "There is a strong genetic role in the development of congenital heart disease." B) "A goal of this study is to identify how genetics affects clinical outcomes." C) "This study will help develop new therapies." D) "This study has positively identified ways to prevent congenital heart disease." Answer: D Explanation: A) Through population-based studies around the world, the CHD GENES study has concluded that epidemiologic evidence clearly indicates a very strong genetic role in the pathogenesis of CCHD. B) The CHD GENES study seeks to identify the influence of genetics on the clinical outcomes and enabling development of new therapies and possibly approaches for prevention, such as newborn genetic screening. C) The CHD GENES study seeks to identify the influence of genetics on the clinical outcomes and enabling development of new therapies and possibly approaches for prevention, such as newborn genetic screening. D) The CHD GENES study seeks to identify the influence of genetics on the clinical outcomes and enabling development of new therapies and possibly approaches for prevention, such as newborn genetic screening. Page Ref: 617 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Evaluation | Learning Outcome: 25.4 Differentiate the relationships among genetic factors, clinical features, and outcomes in individuals with congenital heart defects. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of cardiac structural disorders.

10) The nurse is performing a cardiac assessment on a newborn. Which findings would the nurse expect in a grade 4 murmur? A) Murmur is barely audible. B) Murmur is loud, but without a thrill. C) Murmur is loud with a palpable thrill. D) Murmur is audible without a stethoscope. Answer: C Explanation: A) Murmurs are graded on a six-point scale to indicate intensity and pitch. A grade 1 murmur is barely audible, a grade 2 murmur is louder, and a grade 3 murmur is loud but not accompanied by a thrill. A grade 4 murmur is loud and associated with a palpable thrill. A grade 5 murmur is associated with a thrill, and the murmur can be heard with the stethoscope partially off the chest. A grade 6 murmur is audible without a stethoscope. B) Murmurs are graded on a six-point scale to indicate intensity and pitch. A grade 1 murmur is barely audible, a grade 2 murmur is louder, and a grade 3 murmur is loud but not accompanied by a thrill. A grade 4 murmur is loud and associated with a palpable thrill. A grade 5 murmur is associated with a thrill, and the murmur can be heard with the stethoscope partially off the chest. A grade 6 murmur is audible without a stethoscope. C) Murmurs are graded on a six-point scale to indicate intensity and pitch. A grade 1 murmur is barely audible, a grade 2 murmur is louder, and a grade 3 murmur is loud but not accompanied by a thrill. A grade 4 murmur is loud and associated with a palpable thrill. A grade 5 murmur is associated with a thrill, and the murmur can be heard with the stethoscope partially off the chest. A grade 6 murmur is audible without a stethoscope. D) Murmurs are graded on a six-point scale to indicate intensity and pitch. A grade 1 murmur is barely audible, a grade 2 murmur is louder, and a grade 3 murmur is loud but not accompanied by a thrill. A grade 4 murmur is loud and associated with a palpable thrill. A grade 5 murmur is associated with a thrill, and the murmur can be heard with the stethoscope partially off the chest. A grade 6 murmur is audible without a stethoscope. Page Ref: 620 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 25.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of the four categories of congenital heart defects. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of cardiac structural disorders.

11) When assessing a baby for a murmur caused by an atrial septal defect, where should the nurse place the stethoscope? A) Upper left sternal border B) Upper right sternal border C) Lower left sternal border D) Apex Answer: A Explanation: A) An atrial septal defect is a hole in the wall (septum) between the atria that allows oxygenated blood from the left atrium to flow (shunt) to the right atrium, whereupon it moves through the tricuspid valve to the right ventricle and on to the pulmonary system, producing a murmur heard best in the upper left sternal border. B) An atrial septal defect is a hole in the wall (septum) between the atria that allows oxygenated blood from the left atrium to flow (shunt) to the right atrium, whereupon it moves through the tricuspid valve to the right ventricle and on to the pulmonary system, producing a murmur heard best in the upper left sternal border. C) An atrial septal defect is a hole in the wall (septum) between the atria that allows oxygenated blood from the left atrium to flow (shunt) to the right atrium, whereupon it moves through the tricuspid valve to the right ventricle and on to the pulmonary system, producing a murmur heard best in the upper left sternal border. D) An atrial septal defect is a hole in the wall (septum) between the atria that allows oxygenated blood from the left atrium to flow (shunt) to the right atrium, whereupon it moves through the tricuspid valve to the right ventricle and on to the pulmonary system, producing a murmur heard best in the upper left sternal border. Page Ref: 620 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 25.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of the four categories of congenital heart defects. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of cardiac structural disorders.

12) To improve ventricular contractility in a child with a ventricular septal defect, the nurse would expect to administer: A) a diuretic. B) a cardiac glycoside. C) an ACE inhibitor. D) an aldosterone receptor blocker. Answer: B Explanation: A) Medical management of the VSD is aimed at reducing afterload. Afterload is the resistance the heart must overcome to eject the volume of blood from the ventricle and is expressed as total peripheral resistance. Medical management includes a diuretic to help decrease pulmonary volume, an afterload reducing agent such as an ACE inhibitor or aldosterone receptor blocker, and possibly digoxin, a cardiac glycoside agent that improves contractility of the ventricle. B) Medical management of the VSD is aimed at reducing afterload. Afterload is the resistance the heart must overcome to eject the volume of blood from the ventricle and is expressed as total peripheral resistance. Medical management includes a diuretic to help decrease pulmonary volume, an afterload reducing agent such as an ACE inhibitor or aldosterone receptor blocker, and possibly digoxin, a cardiac glycoside agent that improves contractility of the ventricle. C) Medical management of the VSD is aimed at reducing afterload. Afterload is the resistance the heart must overcome to eject the volume of blood from the ventricle and is expressed as total peripheral resistance. Medical management includes a diuretic to help decrease pulmonary volume, an afterload reducing agent such as an ACE inhibitor or aldosterone receptor blocker, and possibly digoxin, a cardiac glycoside agent that improves contractility of the ventricle. D) Medical management of the VSD is aimed at reducing afterload. Afterload is the resistance the heart must overcome to eject the volume of blood from the ventricle and is expressed as total peripheral resistance. Medical management includes a diuretic to help decrease pulmonary volume, an afterload reducing agent such as an ACE inhibitor or aldosterone receptor blocker, and possibly digoxin, a cardiac glycoside agent that improves contractility of the ventricle. Page Ref: 620 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Implementation | Learning Outcome: 25.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of the four categories of congenital heart defects. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of cardiac structural disorders to diagnosis and treatment.

13) Which compensatory position will the nurse observe in a child with tetralogy of Fallot (TOF) who is experiencing a hypercyanotic spell? A) In a high-Fowler position B) Supine with the legs elevated C) With knees pulled up to chest D) On the left side Answer: C Explanation: A) Infants with TOF have hypercyanotic spells, also known as Tet spells, when crying or with exertion. During a Tet spell, the infants pull their knees up to their chest, the effect being a reduction of systemic venous return and an increase in systemic vascular pressure. This compensatory movement helps to decrease the cyanosis for the time being. B) Infants with TOF have hypercyanotic spells, also known as Tet spells, when crying or with exertion. During a Tet spell, the infants pull their knees up to their chest, the effect being a reduction of systemic venous return and an increase in systemic vascular pressure. This compensatory movement helps to decrease the cyanosis for the time being. C) Infants with TOF have hypercyanotic spells, also known as Tet spells, when crying or with exertion. During a Tet spell, the infants pull their knees up to their chest, the effect being a reduction of systemic venous return and an increase in systemic vascular pressure. This compensatory movement helps to decrease the cyanosis for the time being. D) Infants with TOF have hypercyanotic spells, also known as Tet spells, when crying or with exertion. During a Tet spell, the infants pull their knees up to their chest, the effect being a reduction of systemic venous return and an increase in systemic vascular pressure. This compensatory movement helps to decrease the cyanosis for the time being. Page Ref: 623 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 25.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of the four categories of congenital heart defects. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.8. Implement evidencebased nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of cardiac structural disorders to diagnosis and treatment.

14) Which medication would the nurse give to prevent renal reabsorption of sodium and chloride in the infant with pulmonary congestion secondary to congenital heart disease? A) Prostaglandin B) Loop diuretic C) Inotropes D) ACE inhibitors Answer: B Explanation: A) Prostaglandins are given to produce dilation of ductus arteriosus in ductal dependent lesions. B) Loop diuretics are used to treat pulmonary congestion by preventing the reabsorption of Na+ and Cl- in the loop of Henle. C) Through activation of adrenergic receptors, heart rate and force of cardiac contraction increase, inotropes result in an increase in cardiac output and an increase in blood pressure in heart failure and shock. D) ACE inhibitors inhibit conversion of angiotensin I to angiotensin II, resulting in a decrease in systemic pressure, resulting in decreased cardiac afterload and increased cardiac output. These drugs also dilate veins, which decrease preload, thereby decreasing pulmonary congestion. They are indicated for high systemic or central pressures. Page Ref: 628 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Implementation | Learning Outcome: 25.6 Link the pathophysiology of congenital heart defects to the diagnosis and treatment of the disorders in infants. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of cardiac structural disorders to diagnosis and treatment.

15) When assessing a patient with Ebstein anomaly, the nurse should assess for an anomaly of which heart valve? A) Pulmonic valve B) Mitral valve C) Aortic valve D) Tricuspid valve Answer: D Explanation: A) In Ebstein anomaly, the tricuspid valve forms within the right ventricle, and the right ventricle is underdeveloped. B) In Ebstein anomaly, the tricuspid valve forms within the right ventricle, and the right ventricle is underdeveloped. C) In Ebstein anomaly, the tricuspid valve forms within the right ventricle, and the right ventricle is underdeveloped. D) In Ebstein anomaly, the tricuspid valve forms within the right ventricle, and the right ventricle is underdeveloped. Page Ref: 630 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 25.7 Link the pathophysiology of congenital heart disorders to the diagnosis and treatment of the disorders in adults. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of cardiac structural disorders to diagnosis and treatment.

16) Which finding would the nurse expect to auscultate in a patient with rheumatic heart disease causing mitral stenosis? A) Loud S1, split S2 B) S3 and S4 heart sounds C) Loud high-pitched rumbling murmur D) Murmur on diastole Answer: A Explanation: A) In mitral stenosis, a loud S1, split S2, and a mitral opening snap may be heard on auscultation. B) In aortic stenosis and aortic regurgitation, S3 and S4 heart sounds may be heard. C) In mitral regurgitation, a loud high-pitched rumbling murmur may be auscultated. D) In aortic regurgitation, a murmur may be heard on diastole. Page Ref: 632 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 25.8 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of noncongenital structural heart defects. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of cardiac structural disorders.

17) The nurse, assessing a patient with endocarditis, notes small red painful growths on the fingers and toe pads. The nurse documents these findings as: A) Osler nodes. B) Janeway lesions. C) Roth spots. D) Ebstein anomaly. Answer: A Explanation: A) Manifestations of endocarditis caused by microemboli include microhemorrhages, petechiae, Osler nodes (small red painful growths on the finger and toe pads), Janeway lesions (small nonpainful purple lesions on the palms of the hands and soles of the feet), and Roth spots (small white spots seen on the retinas). B) Manifestations of endocarditis caused by microemboli include microhemorrhages, petechiae, Osler nodes (small red painful growths on the finger and toe pads), Janeway lesions (small nonpainful purple lesions on the palms of the hands and soles of the feet), and Roth spots (small white spots seen on the retinas). C) Manifestations of endocarditis caused by microemboli include microhemorrhages, petechiae, Osler nodes (small red painful growths on the finger and toe pads), Janeway lesions (small nonpainful purple lesions on the palms of the hands and soles of the feet), and Roth spots (small white spots seen on the retinas). D) In Ebstein anomaly, the tricuspid valve forms within the right ventricle, and the right ventricle is underdeveloped. Page Ref: 632 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 25.8 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of noncongenital structural heart defects. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of cardiac structural disorders.

18) Which information should the nurse include in the teaching plan for a patient receiving a biologic valve replacement? A) Anticoagulation will be necessary. B) An audible click may be heard. C) There is a low risk of thromboemboli. D) The valve may need to be replaced in the future. Answer: D Explanation: A) Biologic valves are provided from a pig, calf, or human cadaver. This type of replacement does not require long-term anticoagulation. Infections are much easier to treat, and there is a low risk of thromboembolism. This type of valve replacement often requires frequent replacement. B) Biologic valves are provided from a pig, calf, or human cadaver. This type of replacement does not require long-term anticoagulation. Infections are much easier to treat, and there is a low risk of thromboembolism. This type of valve replacement often requires frequent replacement. C) Biologic valves are provided from a pig, calf, or human cadaver. This type of replacement does not require long-term anticoagulation. Infections are much easier to treat, and there is a low risk of thromboembolism. This type of valve replacement often requires frequent replacement. D) Biologic valves are provided from a pig, calf, or human cadaver. This type of replacement does not require long-term anticoagulation. Infections are much easier to treat, and there is a low risk of thromboembolism. This type of valve replacement often requires frequent replacement. Page Ref: 633 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 25.9 Link the pathophysiology of noncongenital structural heart defects to the diagnosis and treatment of the disorders. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of cardiac structural disorders to diagnosis and treatment.

19) Which intervention should the nurse anticipate performing first after the birth of an infant with hypoplastic left heart syndrome? A) Preparing the infant for surgery B) Administering a prostaglandin infusion C) Placing the infant on the transplant list D) Preparing the parents for the death of the infant Answer: B Explanation: A) Surgery may be performed through several staged repairs, but immediately after birth, the priority action is to maintain a patent ductus arteriosus. B) Infants who are born with hypoplastic left heart syndrome require the ductus arteriosus to remain patent. Treatment begins with a prostaglandin infusion to maintain the ductus arteriosus to allow for any oxygenated systemic blood flow. This infusion is necessary to provide oxygenated blood to flow to the body and should be started immediately. C) Although staged surgical procedures improve the systemic perfusion, they are not curative, and these children will have lifelong complications and may require a heart transplant. Placing the infant on the heart transplant list will be done at the time the decision is made to pursue this course of treatment. It is not done immediately after birth. D) The overall 5-year survivability after staged surgical repairs is approximately 70%. Page Ref: 625 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 25.6 Link the pathophysiology of congenital heart defects to the diagnosis and treatment of the disorders in infants. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of cardiac structural disorders to diagnosis and treatment.

20) Which finding should the nurse anticipate in an infant with coarctation of the aorta? A) Higher right ventricular pressure than left ventricular pressure B) Lower blood pressure in the lower extremities than the upper extremities C) Higher blood pressure in the upper extremities than the lower extremities D) Higher blood pressure in the left arm tan the right arm Answer: B Explanation: A) The infant with coarctation of the aorta will have high left ventricular pressures and low systemic pressures, especially in the legs, where the pressures are usually 10-15% lower than those in the upper extremities. B) The infant with coarctation of the aorta will have high left ventricular pressures and low systemic pressures, especially in the legs, where the pressures are usually 10-15% lower than those in the upper extremities. C) The infant with coarctation of the aorta will have high left ventricular pressures and low systemic pressures, especially in the legs, where the pressures are usually 10-15% lower than those in the upper extremities. D) The infant with coarctation of the aorta will have high left ventricular pressures and low systemic pressures, especially in the legs, where the pressures are usually 10-15% lower than those in the upper extremities. Page Ref: 625 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 25.6 Link the pathophysiology of congenital heart defects to the diagnosis and treatment of the disorders in infants. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of cardiac structural disorders.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 26 Heart Failure 1) When planning care for a patient with heart failure, which concept should the nurse keep in mind? A) The sympathetic nervous system is activated when cardiac output drops. B) The renin-angiotensin-aldosterone system is inhibited when cardiac output drops. C) Heart muscle demonstrates excessive contractility. D) Inflammatory mediators inhibit heart muscle repair and remodeling. Answer: A Explanation: A) Heart failure manifests itself in volume overload and fatigue, which occur in response to a cascade of compensatory mechanisms set into motion by decreased cardiac output. In response to decreased CO, the renin-angiotensin-aldosterone system (RAAS) and the sympathetic nervous system (SNS) are activated. Ideally, these compensatory mechanisms will maintain adequate CO. B) Heart failure manifests itself in volume overload and fatigue, which occur in response to a cascade of compensatory mechanisms set into motion by decreased cardiac output. In response to decreased CO, the RAAS and the SNS are activated. Ideally, these compensatory mechanisms will maintain adequate CO. C) Heart failure is a condition caused by an inability of the heart to pump an adequate amount of blood to meet the body's metabolic needs. This can be caused either by a problem with muscular contraction, causing decreased ejection of the blood out of the heart; by a problem with muscular relaxation, thereby not allowing the heart to fill adequately with blood prior to contraction; or a combination of both. D) In heart failure, the heart cannot contract normally, and its pumping capacity is reduced. Compensatory mechanisms are activated to maintain left ventricular function within a range that preserves or slightly reduces the functional capacity of the patient. This includes activation of the SNS, the RAAS, and inflammatory mediators. The inflammatory mediators are responsible for cardiac repair and remodeling. Page Ref: 638 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 26.1 Describe the prevalence of heart failure and concepts related to heart failure. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of heart failure.

2) When assessing a patient with heart failure affecting only the left ventricle, the nurse would expect which of the following conditions? A) Systemic venous congestion B) Elevated jugular venous pressure C) Peripheral edema D) Pulmonary venous congestion Answer: D Explanation: A) Systemic venous congestion occurs as a result of right ventricular failure. When the left ventricle fails, pulmonary venous congestion increases the work of the right ventricle, which must generate more force to overcome the increased pressure from venous congestion. As venous congestion progresses backward in the circulatory system, systemic venous congestion occurs, leading to elevated jugular venous pressure, liver congestion, and peripheral edema. B) Elevated jugular venous pressure occurs as a result of right ventricular failure. When the left ventricle fails, pulmonary venous congestion increases the work of the right ventricle, which must generate more force to overcome the increased pressure from venous congestion. As venous congestion progresses backward in the circulatory system, systemic venous congestion occurs, leading to elevated jugular venous pressure, liver congestion, and peripheral edema. C) Peripheral edema occurs as a result of right ventricular failure. When the left ventricle fails, pulmonary venous congestion increases the work of the right ventricle, which must generate more force to overcome the increased pressure from venous congestion. As venous congestion progresses backward in the circulatory system, systemic venous congestion occurs, leading to elevated jugular venous pressure, liver congestion, and peripheral edema. D) Left-sided heart failure typically causes volume overload and venous congestion in the lungs, leading to fatigue and shortness of breath. Page Ref: 636-637 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 26.2 Outline the classification and staging of heart failure. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of heart failure.

3) Which of the following is the best response given to a patient by the nurse when a patient with heart failure asks for an explanation of his ejection fraction? A) "It is the amount of blood pumped from the heart with each beat." B) "It is the percentage of blood pumped by the heart with each beat." C) "It is the amount of blood the heart pumps each minute." D) "It is the amount of blood the heart pumps each minute divided by the body surface area." Answer: B Explanation: A) Stroke volume is the amount of blood pumped out of the heart with each beat in milliliters. B) Ejection fraction is a measurement of the percentage of blood ejected from the left ventricle with each contraction. C) Cardiac output is the amount of blood pumped out of the heart in liters per minute. D) Cardiac index refers to the value obtained when the cardiac output is divided by the body surface area. Page Ref: 640 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 26.2 Outline the classification and staging of heart failure. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of heart failure.

4) When assessing the patient with high-output heart failure, the nurse is most likely to find: A) vasoconstriction and hypotension. B) vasoconstriction and hypertension. C) vasodilation and hypotension. D) vasodilation and hypertension. Answer: C Explanation: A) In high-output heart failure, heart failure syndrome exists even though the heart is pumping a large amount of blood, more than 8 liters per minute. This condition is usually seen when there is vasodilation of the systemic blood vessels and blood pressure is decreased. When the blood pressure decreases, the sympathetic nervous system is activated, and the neurohormonal effects of heart failure emerge. Therefore, even though the CO is elevated, the heart failure syndrome exists. B) In high-output heart failure, heart failure syndrome exists even though the heart is pumping a large amount of blood, more than 8 liters per minute. This condition is usually seen when there is vasodilation of the systemic blood vessels and blood pressure is decreased. When the blood pressure decreases, the sympathetic nervous system is activated, and the neurohormonal effects of heart failure emerge. Therefore, even though the CO is elevated, the heart failure syndrome exists. C) In high-output heart failure, heart failure syndrome exists even though the heart is pumping a large amount of blood, more than 8 liters per minute. This condition is usually seen when there is vasodilation of the systemic blood vessels and blood pressure is decreased. When the blood pressure decreases, the sympathetic nervous system is activated, and the neurohormonal effects of heart failure emerge. Therefore, even though the CO is elevated, the heart failure syndrome exists. D) In high-output heart failure, heart failure syndrome exists even though the heart is pumping a large amount of blood, more than 8 liters per minute. This condition is usually seen when there is vasodilation of the systemic blood vessels and blood pressure is decreased. When the blood pressure decreases, the sympathetic nervous system is activated, and the neurohormonal effects of heart failure emerge. Therefore, even though the CO is elevated, the heart failure syndrome exists. Page Ref: 640 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 26.2 Outline the classification and staging of heart failure. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of heart failure.

5) Which statement by a patient with chronic heart failure indicates to the nurse that more teaching is needed? A) "The disease will be marked by periods of exacerbations." B) "I will need to make lifestyle modifications to control the disease." C) "If I follow strict self-care, I can cure the disease." D) "Any type of stress can cause a worsening of the disease." Answer: C Explanation: A) Patients with chronic heart failure may develop acute heart failure, also called acute decompensated heart failure (ADHF) manifested by worsening of heart failure symptoms to a level such that hospitalization is required. B) In a patient with stable chronic heart failure, dietary indiscretion, medication nonadherence, or poor decision making (failure to act on symptoms, for example), high blood pressure, myocardial ischemia, alcohol intake, or various endocrine disorders may also precipitate ADHF. C) Even with strict adherence to the medical regimen and lifestyle modifications, heart failure progresses, with 50% of individuals succumbing to this disease within 5 years of diagnosis. D) In a patient with stable chronic heart failure, any stress, such as infection, could result in decompensation. Page Ref: 640 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 26.2 Outline the classification and staging of heart failure. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of heart failure to diagnosis and treatment.

6) A patient with heart failure reports some shortness of breathing with activity, such as cleaning the house or grocery shopping, but no shortness of breath at rest. According to the New York Heart Association staging system, the nurse would classify this patient as: A) Class I. B) Class II. C) Class III. D) Class IV. Answer: B Explanation: A) In class I, individuals have heart disease that does not affect their daily activities. B) In class II, individuals with cardiac disease are comfortable when resting, but results in slight limitations of activity. In this case, the patient experiences shortness of breath while cleaning the house and grocery shopping, but not when resting. C) In class III, individuals with heart disease are markedly limited by physical activity although they are still comfortable at rest. D) In class IV, individuals with heart disease experience symptoms with any level of activity and even sometimes at rest. Page Ref: 640-641 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 26.2 Outline the classification and staging of heart failure. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of heart failure.

7) A patient with heart failure reports some shortness of breathing with activity, such as cleaning the house or grocery shopping, but no shortness of breath at rest. According to the American College of Cardiology (ACC)/American Heart Association (AHA) staging, the nurse would classify this patient as: A) Stage A. B) Stage B. C) Stage C. D) Stage D. Answer: C Explanation: A) In stage A of the ACC/AHA stages of heart failure, the patient is at high risk for heart failure but without structural heart disease or symptoms of heart failure. B) In stage B of the ACC/AHA stages of heart failure, the patient has structural heart disease but without signs or symptoms of heart failure. C) In stage C of the ACC/AHA stages of heart failure, the patient has structural heart disease with prior or current symptoms of heart failure. D) In stage D of the ACC/AHA stages of heart failure, the patient has refractory heart failure requiring specialized interventions. Page Ref: 640 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 26.2 Outline the classification and staging of heart failure. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of heart failure.

8) When caring for a patient with heart failure, which concept about cardiac output should the nurse keep in mind? A) A faster heart rate increases the cardiac output. B) A slower heart rate increases cardiac output. C) Preload is the volume of blood in the ventricle after contraction. D) Afterload is the pressure of the heart during ventricular filling. Answer: A Explanation: A) Cardiac output is determined by the heart rate and stroke volume. Faster heart rates typically increase CO, and slower heart rates typically decrease CO. B) Cardiac output is determined by the heart rate and stroke volume. Faster heart rates typically increase CO, and slower heart rates typically decrease CO. C) Preload is the amount of blood in the ventricle before contraction, at the end of diastole. D) Afterload is the amount of pressure the heart needs to generate to pump blood out of the ventricle. Page Ref: 642-643 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 26.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of systolic heart failure and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of heart failure.

9) Which action would the intensive care nurse take to measure the preload of a patient with heart failure? A) Take the patient's blood pressure. B) Calculate the mean arterial pressure. C) Measure the pulmonary artery pressure. D) Calculate the systemic vascular resistance. Answer: C Explanation: A) The blood pressure reading does not determine preload. B) The mean arterial pressure reading does not determine preload. C) Preload can be measured using a pulmonary artery catheter. In this procedure, a small catheter is inserted into the jugular vein and advanced through the right atrium and right ventricle of the heart and into the pulmonary artery. The tip of the catheter is continuous with pressurized tubing and a pressure transducer so that pressure in the pulmonary artery can be measured. D) Systemic vascular resistance is the resistance to forward flow of blood generated by the blood vessels in the systemic circulation. It is calculated by taking into account the mean arterial blood pressure, the right atrial pressure, and the cardiac output. Page Ref: 643 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 26.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of systolic heart failure and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of heart failure.

10) Which data in a patient undergoing pulmonary heart catheterization confirms a diagnosis of systolic heart failure? A) Decreased right atrial pressure B) Elevated pulmonary artery wedge pressure C) Increased cardiac index D) Decreased pulmonary artery pressure Answer: B Explanation: A) Pulmonary artery catheterization may be helpful in making the diagnosis of systolic heart failure and in determining the treatment. Typically, patients with systolic heart failure have elevated right atrial pressures, pulmonary artery pressures, and pulmonary arterial wedge pressures, owing to the fluid retention and venous hypertension. Cardiac output and index may also be reduced. B) Pulmonary artery catheterization may be helpful in making the diagnosis of systolic heart failure and in determining the treatment. Typically, patients with systolic heart failure have elevated right atrial pressures, pulmonary artery pressures, and pulmonary arterial wedge pressures, owing to the fluid retention and venous hypertension. Cardiac output and index may also be reduced. C) Pulmonary artery catheterization may be helpful in making the diagnosis of systolic heart failure and in determining the treatment. Typically, patients with systolic heart failure have elevated right atrial pressures, pulmonary artery pressures, and pulmonary arterial wedge pressures, owing to the fluid retention and venous hypertension. Cardiac output and index may also be reduced. D) Pulmonary artery catheterization may be helpful in making the diagnosis of systolic heart failure and in determining the treatment. Typically, patients with systolic heart failure have elevated right atrial pressures, pulmonary artery pressures, and pulmonary arterial wedge pressures, owing to the fluid retention and venous hypertension. Cardiac output and index may also be reduced. Page Ref: 646 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 26.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of systolic heart failure and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of heart failure to diagnosis and treatment.

11) Which information should the nurse include in a teaching care plan for a patient with systolic heart failure? A) Monitor weight once a week. B) Restrict salt intake. C) Ensure sufficient bedrest. D) Drink plenty of fluids with meals. Answer: B Explanation: A) Patients with heart failure should participate in self-care activities to maintain their relative health and to manage their disease. Specific tasks include monitoring their heart failure symptoms, their weight, and their vital signs. Weight should be monitored daily so that the diuretic dose can be changed to avoid worsening heart failure. B) Patients are also expected to follow a low-sodium diet and avoid alcohol, and they may be instructed to limit their fluid intake. C) Routine exercise, as tolerated, is advised for patients with heart failure. D) Patients may be instructed to limit their fluid intake if fluid retention and overload is a problem. Page Ref: 648 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 26.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of systolic heart failure and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of heart failure to diagnosis and treatment.

12) Which statement made by a patient with a biventricular pacemaker indicates that more teaching is needed? A) "My right ventricle contracts at the same time as the left ventricle." B) "This type of pacemaker mimics normal cardiac function." C) "Biventricular pacing decreases regurgitation of my mitral valve." D) "This pacemaker can deliver a shock if I develop a life-threatening heart rhythm." Answer: D Explanation: A) Biventricular pacemakers may improve cardiac function by synchronizing the contraction of the right and left ventricles, mimicking normal cardiac function, and decreasing mitral valve regurgitation. B) Biventricular pacemakers may improve cardiac function by synchronizing the contraction of the right and left ventricles, mimicking normal cardiac function, and decreasing mitral valve regurgitation. C) Biventricular pacemakers may improve cardiac function by synchronizing the contraction of the right and left ventricles, mimicking normal cardiac function, and decreasing mitral valve regurgitation. D) A biventricular pacemaker paces the ventricles but does not cardiovert or defibrillate. Page Ref: 649 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 26.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of systolic heart failure and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of heart failure to diagnosis and treatment.

13) Which finding would the nurse expect when assessing a patient with diastolic heart failure? A) Lack of peripheral edema B) Dyspnea at rest C) Normal ejection fraction D) Increased urinary output Answer: C Explanation: A) The kidneys are particularly susceptible to the hemodynamic effects of diastolic heart failure, also known as heart failure with preserved ejection function (HFpEF), and fluid retention is very problematic. B) Decreased cardiac output activates the renin-angiotensin-aldosterone system (RAAS), leading to fluid retention, pulmonary and hepatic congestion, and dyspnea. Because of the normal ejection fraction, patients with HFpEF typically experience dyspnea only with exercise, as cardiac output may not be sufficient during increased demand. C) Diastolic heart failure is seen in patients with normal contractility but abnormal relaxation of the heart. This type of heart failure is called heart failure with preserved ejection fraction (HFpEF), as these patients have heart failure in the presence of a normal ejection fraction. D) The kidneys are particularly susceptible to the hemodynamic effects of HFpEF, and fluid retention is very problematic. The exact mechanism may be due to decreased CO, the effects of RAAS activation, or pressure exerted on the kidneys by fluid overload itself. When fluid is retained, urinary output decreases. Page Ref: 651-652 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 26.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of diastolic heart failure and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of heart failure.

14) When assessing a patient, which finding by the nurse would support a diagnosis of left-sided heart failure? A) Hepatic engorgement B) Nausea and vomiting C) Elevated jugular venous pressure D) Paroxysmal nocturnal dyspnea Answer: D Explanation: A) In right-sided heart failure, sodium and water retention occur, leading to right ventricular dilation and elevated right ventricular preload. The right upper quadrant of the abdomen may become tender as the liver enlarges and swells. B) In right-sided heart failure, sodium and water retention occur, leading to right ventricular dilation and elevated right ventricular preload. Patients may complain of nausea, vomiting, and early satiety as the liver enlarges and causes pressure on the stomach. C) In right-sided heart failure, there may be elevated jugular venous pressure and distended neck veins. D) As left ventricular preload increases, pressure is increased in the organs immediately preceding the left ventricle in the circulatory circuit, or the lungs. Pulmonary venous pressure increases, leading to paroxysmal nocturnal dyspnea (sudden shortness of breath while sleeping). Page Ref: 653-654 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 26.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of left-sided heart failure and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of heart failure.

15) Which first-line medication would the nurse anticipate being in the plan of care for a patient with systolic heart failure to reduce vasoconstriction and afterload? A) Diuretics B) Nitrates C) Beta blocker D) ACE inhibitor Answer: D Explanation: A) Diuretics, such as the loop diuretic furosemide, reduce sodium resorption in the kidneys, thereby promoting diuresis and relieving symptoms related to congestion. Diuretics are not first-line therapy for heart failure. B) Vasodilators, such as nitrates, directly relax vascular smooth muscle, leading to vasodilation. Nitrates typically affect the venous system, reducing preload. Vasodilators are not first-line therapy for heart failure. C) Beta blockers are used in the treatment of systolic heart failure to block the effects of betaadrenergic stimulation on the heart and blood vessels. Blocking the beta receptors helps to reduce vasoconstriction and heart rates, reducing blood pressure and allowing more time for ventricular filling. They are not first-line therapy for heart failure. D) Treatment of systolic heart failure is aimed at reducing symptoms by decreasing fluid retention and counteracting the neurohormonal effects of heart failure. ACE inhibitors are considered first-line therapy in the treatment of systolic heart failure. ACE inhibitors block the conversion of angiotensin I to angiotensin II, thereby decreasing vasoconstriction and reducing afterload. Page Ref: 646 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 26.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of systolic heart failure and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of heart failure to diagnosis and treatment.

16) Which manifestation does the nurse expect a patient to exhibit in high-output heart failure? A) Cool skin B) Strong peripheral pulses C) Flat neck veins D) Dry, scaly skin Answer: B Explanation: A) Unlike patients with systolic heart failure, patients with high-output heart failure are typically warm with strong distal pulses. B) Unlike patients with systolic heart failure, patients with high-output heart failure are typically warm with strong distal pulses. C) Patients with high-output heart failure develop signs of volume overload such as hepatic congestion, elevated jugular venous pressure, and peripheral edema. D) Patients with high-output heart failure develop signs of volume overload such as hepatic congestion, elevated jugular venous pressure, and peripheral edema. Dry scaly skin is a sin of dehydration, not fluid overload. Page Ref: 655 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 26.7 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of high-output heart failure and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of heart failure.

17) Which of the following medications would the nurse anticipate administering to a patient with systolic heart failure to reduce fluid volume and relieve congestion? A) Diuretics B) Inotropes C) Nitrates D) Beta blockers Answer: A Explanation: A) Diuretics are used to reduce fluid volume overload and venous congestion. B) Inotropic medications are administered in heart failure to increase the contractility of the left ventricle, resulting in an increase in cardiac output. C) Nitrates act as vasodilators by relaxing smooth muscle. D) Beta blockers are used to block the sympathetic nervous system, controlling heart rate. Page Ref: 646-648 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Implementation | Learning Outcome: 26.2 Outline the classification and staging of heart failure. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of heart failure to diagnosis and treatment.

18) What response should the nurse give when a patient with heart failure asks what the physician meant by saying his left ventricular assist device (LVAD) was destination therapy? A) "Your LVAD will support your heart until a heart is available for transplant." B) "Your LVAD will support your heart because you are not a candidate for heart transplant." C) "Your LVAD will allow your heart to rest and recover." D) "Your LVAD takes the place of your heart." Answer: B Explanation: A) LVADs are implanted pumps that support the heart, draining blood from the left ventricle and pumping it into the ascending aorta. Bridge-to-transplant LVAD recipients have their LVAD in place until a suitable heart donor is identified, at which time they receive cardiac transplantation. B) LVADs are implanted pumps that support the heart, draining blood from the left ventricle and pumping it into the ascending aorta. Patients who receive destination therapy LVADs are not candidates for heart transplant and will likely have the LVAD until their death. C) LVADs are implanted pumps that support the heart, draining blood from the left ventricle and pumping it into the ascending aorta. LVADs can be used as destination therapy or as a bridge to transplant. Heart failure is a chronic condition in which the heart will not recover. D) LVADs are implanted pumps that support the heart, draining blood from the left ventricle and pumping it into the ascending aorta. An LVAD does not take over the heart's function. Page Ref: Page 649 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 26.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of systolic heart failure and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of heart failure to diagnosis and treatment.

19) When caring for a patient who has advanced from stage C to stage D of the American College of Cardiology (ACC)/American Heart Association (AHA) heart failure classification system, the nurse instructs the patient and family that this stage includes the addition of: A) lifestyle modification and management of underlying disorder. B) ACE inhibitors, angiotensin receptor blockers (ARBs), blood pressure control, or beta blockers. C) diuretics, aldosterone blockers, or vasodilators. D) interventional therapy with left ventricular assist device or heart transplantation. Answer: D Explanation: A) Patients in ACC/AHA stage A heart failure are at risk for the development of heart failure but do not yet have heart disease. Interventions for patients in stage A include lifestyle modification or therapies designed to manage the underlying disorder. B) Patients in stage B heart failure have heart disease but have yet to develop symptoms. Medical interventions for patients in stage B include angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers, blood pressure control, or beta blockers if there is a history of myocardial infarction. C) Targeted interventions for patients in this stage include the interventions noted for stage B with the addition of diuretics, aldosterone blockers, or vasodilators such as isosorbide and hydralazine. D) Interventions for patients in this stage include heart transplant, left ventricular assist devices (LVADs), or continuous intravenous inotropes. Page Ref: 641 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 26.2 Outline the classification and staging of heart failure. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of heart failure to diagnosis and treatment.

20) To effectively care for patients with heart disease, the staff development nurse is teaching new nurses hired for the intensive care unit about the Frank-Starling law. Which concept will the instructor teach? A) Increasing preload causes an increase in left ventricular contractility. B) Increasing preload causes a decrease in left ventricular contractility. C) Increasing afterload causes a decrease in left ventricular contractility. D) Increasing afterload causes an increase in left ventricular contractility. Answer: A Explanation: A) Generally speaking, increasing preload (or increasing cardiomyocyte stretch) produces an increase in the strength of ventricular contraction. This is known as the FrankStarling law. B) Generally speaking, increasing preload (or increasing cardiomyocyte stretch) produces an increase in the strength of ventricular contraction. This is known as the Frank-Starling law. C) Generally speaking, increasing preload (or increasing cardiomyocyte stretch) produces an increase in the strength of ventricular contraction. This is known as the Frank-Starling law. D) Generally speaking, increasing preload (or increasing cardiomyocyte stretch) produces an increase in the strength of ventricular contraction. This is known as the Frank-Starling law. Page Ref: 643 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 26.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of systolic heart failure and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of heart failure.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 27 Disorders of Circulation Within the CNS 1) Which information should the nurse include in a teaching care plan for a patient with moyamoya disease? A) It may be an inherited genetic disorder. B) It is caused by an arteriovenous fistula. C) It is caused by the inflammatory process. D) It is caused by a narrowing of the cerebral arteries. Answer: A Explanation: A) Moyamoya is a rare, progressive cerebrovascular disorder caused by blocked arteries at the base of the brain in the basal ganglia. It most often affects children but can occur in adults and tends to be familial, so it may be an inherited genetic disorder. B) Moyamoya is a rare, progressive cerebrovascular disorder caused by blocked arteries at the base of the brain in the basal ganglia. It most often affects children but can occur in adults and tends to be familial, so it may be an inherited genetic disorder. C) Moyamoya is a rare, progressive cerebrovascular disorder caused by blocked arteries at the base of the brain in the basal ganglia. It most often affects children but can occur in adults and tends to be familial, so it may be an inherited genetic disorder. D) Moyamoya is a rare, progressive cerebrovascular disorder caused by blocked arteries at the base of the brain in the basal ganglia. It most often affects children but can occur in adults and tends to be familial, so it may be an inherited genetic disorder. Page Ref: 661 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 27.1 Describe the function of the central nervous system and concepts related to disorders of circulation within the central nervous system. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of disorders of circulation within the CNS.

2) When performing an assessment of the central nervous system, which concept should the nurse keep in mind? A) White matter uses 94% of the cerebral oxygen. B) Gray matter uses only 6% of cerebral oxygen. C) The brain receives about 15% of the cardiac output. D) The brain weighs 25% of total body mass. Answer: C Explanation: A) Although the brain weighs only 2.5% of total body mass, it receives approximately 15% of cardiac output, which is used to supply adequate oxygen and nutrients to cells of the CNS. Although the white matter of the CNS makes up 60% of brain mass, it uses only 6% of cerebral oxygen, whereas the gray matter of the brain utilizes 94% of cerebral oxygen, owing to its high metabolic demand. B) Although the brain weighs only 2.5% of total body mass, it receives approximately 15% of cardiac output, which is used to supply adequate oxygen and nutrients to cells of the CNS. Although the white matter of the CNS makes up 60% of brain mass, it uses only 6% of cerebral oxygen, whereas the gray matter of the brain utilizes 94% of cerebral oxygen, owing to its high metabolic demand. C) Although the brain weighs only 2.5% of total body mass, it receives approximately 15% of cardiac output, which is used to supply adequate oxygen and nutrients to cells of the CNS. Although the white matter of the CNS makes up 60% of brain mass, it uses only 6% of cerebral oxygen, whereas the gray matter of the brain utilizes 94% of cerebral oxygen, owing to its high metabolic demand. D) Although the brain weighs only 2.5% of total body mass, it receives approximately 15% of cardiac output, which is used to supply adequate oxygen and nutrients to cells of the CNS. Although the white matter of the CNS makes up 60% of brain mass, it uses only 6% of cerebral oxygen, whereas the gray matter of the brain utilizes 94% of cerebral oxygen, owing to its high metabolic demand. Page Ref: 662 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 27.2 Outline the vascular supply of the brain and spinal cord. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of disorders of circulation within the CNS.

3) Which statement by the mother of a baby with hydrocephalus indicates that the mother understands this condition? A) "My baby had a stroke." B) "My baby has too much fluid in his brain." C) "My baby has a collection of blood around his brain." D) "My baby has swelling of the brain." Answer: B Explanation: A) Conditions that impair the flow of CSF through the ventricles or disrupt the ability of the arachnoid villi to resorb CSF can result in hydrocephalus, an excessive accumulation of CSF in the brain that can cause increased pressure within the skull. B) Conditions that impair the flow of CSF through the ventricles or disrupt the ability of the arachnoid villi to resorb CSF can result in hydrocephalus, an excessive accumulation of CSF in the brain that can cause increased pressure within the skull. C) Conditions that impair the flow of CSF through the ventricles or disrupt the ability of the arachnoid villi to resorb CSF can result in hydrocephalus, an excessive accumulation of CSF in the brain that can cause increased pressure within the skull. D) Conditions that impair the flow of CSF through the ventricles or disrupt the ability of the arachnoid villi to resorb CSF can result in hydrocephalus, an excessive accumulation of CSF in the brain that can cause increased pressure within the skull. Page Ref: 664 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 27.3 Distinguish the normal flow of cerebrospinal fluid through the brain and spinal cord in contrast with the circulation of blood. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of disorders of circulation within the CNS.

4) When administering medications, which concept pertaining to the blood-brain barrier must the nurse understand? A) Highly lipophilic medications cross the blood-brain barrier directly. B) Highly lipophilic medications cannot cross the blood-brain barrier. C) Highly lipophilic medications cross the blood-brain barrier by simple diffusion. D) Highly lipophilic medications cross into the brain where there is no blood-brain barrier. Answer: A Explanation: A) Highly lipophilic substances are able to cross the membrane directly and enter the brain, and water can cross the membrane by simple diffusion. Most nutrients cross the barrier by facilitated diffusion through mechanisms that couple the movement of the nutrient with movement of an ion that is moving down its concentration gradient. B) Highly lipophilic substances are able to cross the membrane directly and enter the brain, and water can cross the membrane by simple diffusion. Most nutrients cross the barrier by facilitated diffusion through mechanisms that couple the movement of the nutrient with movement of an ion that is moving down its concentration gradient. C) Highly lipophilic substances are able to cross the membrane directly and enter the brain, and water can cross the membrane by simple diffusion. Most nutrients cross the barrier by facilitated diffusion through mechanisms that couple the movement of the nutrient with movement of an ion that is moving down its concentration gradient. D) Highly lipophilic substances are able to cross the membrane directly and enter the brain, and water can cross the membrane by simple diffusion. Most nutrients cross the barrier by facilitated diffusion through mechanisms that couple the movement of the nutrient with movement of an ion that is moving down its concentration gradient. Page Ref: 665 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Planning | Learning Outcome: 27.4 Summarize the protective role of the blood-brain barrier. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of disorders of circulation within the CNS.

5) A history and assessment of a patient with normal pressure hydrocephalus will most likely reveal: A) no change in mental status. B) acute dementia. C) bowel incontinence. D) an older adult. Answer: D Explanation: A) Normal pressure hydrocephalus (NPH) is an abnormal accumulation of CSF in the ventricles or cavities that places pressure on the brain tissue. NPH can develop at any age but is most common in older adults. Symptoms of NPH include progressive mental impairment and dementia, instability particularly with walking, and bladder incontinence. B) Normal pressure hydrocephalus (NPH) is an abnormal accumulation of CSF in the ventricles or cavities that places pressure on the brain tissue. NPH can develop at any age but is most common in older adults. Symptoms of NPH include progressive mental impairment and dementia, instability particularly with walking, and bladder incontinence. C) Normal pressure hydrocephalus (NPH) is an abnormal accumulation of CSF in the ventricles or cavities that places pressure on the brain tissue. NPH can develop at any age but is most common in older adults. Symptoms of NPH include progressive mental impairment and dementia, instability particularly with walking, and bladder incontinence. D) Normal pressure hydrocephalus (NPH) is an abnormal accumulation of CSF in the ventricles or cavities that places pressure on the brain tissue. NPH can develop at any age but is most common in older adults. Symptoms of NPH include progressive mental impairment and dementia, instability particularly with walking, and bladder incontinence. Page Ref: 668 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 27.5 Predict the influence of cerebral autoregulation on the blood vessels that supply the central nervous system. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of circulation within the CNS.

6) The nurse instructs a patient who had a TIA to take which action if he experiences symptoms of a TIA in the future? A) No action is needed if the symptoms resolve immediately. B) Wait 24 hours to see if symptoms resolve before seeking medical care. C) Seek urgent medical care. D) Make an appointment with healthcare provider if symptoms recur. Answer: C Explanation: A) Although there is controversy about the need for hospitalization for TIA, all patients who have experienced a TIA (even if the symptoms resolve) should receive urgent evaluation, risk stratification, and initiation of stroke prevention therapy. B) Although there is controversy about the need for hospitalization for TIA, all patients who have experienced a TIA should receive urgent evaluation and not wait 24 hours. C) Although there is controversy about the need for hospitalization for TIA, all patients who have experienced a TIA should receive urgent evaluation, risk stratification, and initiation of stroke prevention therapy. D) Although there is controversy about the need for hospitalization for TIA, all patients who have experienced a TIA should receive urgent evaluation, risk stratification, and initiation of stroke prevention therapy. Page Ref: 670 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 27.7 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of transient ischemic attack and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of circulation within the CNS to diagnosis and treatment.

7) When caring for a patient with increased intracranial pressure, which laboratory value trend requires immediate action by the nurse? A) A falling PaCO2 level B) A rising PaCO2 level C) A falling PaO2 level D) A rising PaO2 level Answer: B Explanation: A) The partial pressure of carbon dioxide (PaCO2) in arterial blood influences cerebral autoregulation more significantly than the partial pressure of oxygen (PaO2) does. Cerebral blood flow increases or decreases briskly in response to changes in PaCO2; cerebral vessels constrict as PaCO2 levels fall and dilate to increase blood flow when PaCO2 levels rise, increasing intracranial pressure. B) The partial pressure of carbon dioxide (PaCO2) in arterial blood influences cerebral autoregulation more significantly than the partial pressure of oxygen (PaO2) does. Cerebral blood flow increases or decreases briskly in response to changes in PaCO2; cerebral vessels constrict as PaCO2 levels fall and dilate to increase blood flow when PaCO2 levels rise, increasing intracranial pressure. C) Although the physician should be notified with any change laboratory values, a rising PaCO2 level can quickly increase intracranial pressure. D) Although the physician should be notified with any change laboratory values, a rising PaCO2 level can quickly increase intracranial pressure. Page Ref: 667 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 27.5 Predict the influence of cerebral autoregulation on the blood vessels that supply the central nervous system. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of circulation within the CNS.

8) When assessing a patient with traumatic brain injury, which cerebral blood flow would the nurse consider normal? A) 750 milliliters of blood/minute B) 1000 milliliters of blood/minute C) 1500 milliliters of blood/minute D) 2000 milliliters of blood/minute Answer: A Explanation: A) The brain normally receives approximately 750 milliliters of blood per minute, or 15% of the cardiac output, and uses 20% of the body's oxygen consumption. B) The brain normally receives approximately 750 milliliters of blood per minute, or 15% of the cardiac output, and uses 20% of the body's oxygen consumption. C) The brain normally receives approximately 750 milliliters of blood per minute, or 15% of the cardiac output, and uses 20% of the body's oxygen consumption. D) The brain normally receives approximately 750 milliliters of blood per minute, or 15% of the cardiac output, and uses 20% of the body's oxygen consumption. Page Ref: 669 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 27.6 Explain the cellular events that follow from ischemia and hypoxia of the brain and spinal cord. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of disorders of circulation within the CNS.

9) The nurse is developing a community program about stroke risk factor reduction. Which would the nurse explain is a non-modifiable risk factor? A) Poor nutrition B) Prior stroke or TIA C) Diabetes D) High levels of homocysteine Answer: B Explanation: A) Nonmodifiable risk factors for a stroke include age, family history, prior TIA or stroke, race, sex, and sickle cell disease. Poor nutrition is a modifiable risk factor. B) Nonmodifiable risk factors for a stroke include age, family history, prior TIA or stroke, race, sex, and sickle cell disease. C) Nonmodifiable risk factors for a stroke include age, family history, prior TIA or stroke, race, sex, and sickle cell disease. Diabetes is a modifiable risk factor. D) Nonmodifiable risk factors for a stroke include age, family history, prior TIA or stroke, race, sex, and sickle cell disease. High levels of homocysteine is a modifiable risk factor. Page Ref: 671 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 27.7 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of transient ischemic attack and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of disorders of circulation within the CNS.

10) The nurse should expect to assess which findings in a patient with a right anterior cerebral artery stroke? A) Diplopia, dysarthria, and nystagmus B) Right cerebellar ataxia and Horner syndrome C) Aphasia and neglect D) Paresis and sensory loss of the left leg and foot Answer: D Explanation: A) A stroke involving the basilar artery produces diplopia, dysarthria, and nystagmus. B) Ipsilateral cerebellar ataxia and Horner syndrome occur when the vertebral artery is involved. C) Aphasia and neglect are the result of ischemia arising in the middle cerebral artery. D) Ischemia of the anterior cerebral artery produces paresis and sensory loss of contralateral leg and foot. Page Ref: 674 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 27.8 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of ischemic and hemorrhagic strokes and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of circulation within the CNS.

11) A patient with an ischemic stroke has a blood pressure of 200/110 mmHg. Which action should the nurse anticipate? A) Administering antihypertensives to lower the blood pressure as quickly as possible. B) Administering antihypertensives if the blood pressure exceeds 220/120 mmHg. C) Administering antihypertensives to lower blood pressure by 25% over 24 hours. D) Administering antihypertensives to lower the blood pressure to less than 140/80 mmHg. Answer: B Explanation: A) Antihypertensive therapy may be used in these patients when the blood pressure is higher than 220/120 mmHg, but care must be taken not to lower the blood pressure too quickly. A reasonable goal is to lower the blood pressure by 15% over the first 24 hours after the onset of stroke. B) Antihypertensive therapy may be used in these patients when the blood pressure is higher than 220/120 mmHg, but care must be taken not to lower the blood pressure too quickly. A reasonable goal is to lower the blood pressure by 15% over the first 24 hours after the onset of stroke. C) Antihypertensive therapy may be used in these patients when the blood pressure is higher than 220/120 mmHg, but care must be taken not to lower the blood pressure too quickly. A reasonable goal is to lower the blood pressure by 15% over the first 24 hours after the onset of stroke. D) Antihypertensive therapy may be used in these patients when the blood pressure is higher than 220/120 mmHg, but care must be taken not to lower the blood pressure too quickly. A reasonable goal is to lower the blood pressure by 15% over the first 24 hours after the onset of stroke. Page Ref: 673 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 27.8 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of ischemic and hemorrhagic strokes and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of circulation within the CNS to diagnosis and treatment.

12) When checking the orders for a patient with hemorrhagic stroke, which order would be a cause for concern for the nurse? A) Monitoring blood pressure B) Monitoring blood glucose levels C) Administering an osmotic diuretic D) Administering aspirin Answer: D Explanation: A) The priority of care for a hemorrhagic stroke depends on adequate ventilation and management of blood pressure. Osmotic diuretics may be used to decrease intracranial pressure. Glucose levels should be monitored, and normoglycemia should be maintained. B) The priority of care for a hemorrhagic stroke depends on adequate ventilation and management of blood pressure. Osmotic diuretics may be used to decrease intracranial pressure. Glucose levels should be monitored, and normoglycemia should be maintained. C) The priority of care for a hemorrhagic stroke depends on adequate ventilation and management of blood pressure. Osmotic diuretics may be used to decrease intracranial pressure. Glucose levels should be monitored, and normoglycemia should be maintained. D) Aspirin 325 mg orally given within 24-48 hours of ischemic stroke onset provides a modest benefit in ischemic stroke outcomes. It is not given for a hemorrhagic stroke, as it increases the risk of bleeding. Page Ref: 673 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 27.8 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of ischemic and hemorrhagic strokes and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of circulation within the CNS to diagnosis and treatment.

13) A patient on warfarin fell and hit his head on an icy sidewalk and has been diagnosed with a subdural hematoma. Which intervention should be included in the nursing plan of care this patient? A) Administer aspirin B) Administer protamine C) Administer vitamin K D) Administer thrombolytic therapy Answer: C Explanation: A) Aspirin and thrombolytic therapy should not be administered because they increase the risk of further subdural bleeding. B) To reduce the risk of further bleeding following a subdural hematoma, heparin may need to be reversed with protamine, and patients receiving warfarin are given vitamin K to reverse its effects. C) To reduce the risk of further bleeding following a subdural hematoma, heparin may need to be reversed with protamine, and patients receiving warfarin are given vitamin K to reverse its effects. D) Aspirin and thrombolytic therapy should not be administered because they increase the risk of further subdural bleeding. Page Ref: 675 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Planning | Learning Outcome: 27.9 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of subdural and spinal cord hemorrhage and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of circulation within the CNS to diagnosis and treatment.

14) Which finding would the nurse expect when assessing a patient with a spinal subarachnoid hemorrhage? A) Neck stiffness and photosensitivity B) Quadriparesis C) Loss of sphincter control D) Sensory loss below the lesion Answer: A Explanation: A) Patients with spinal cord hemorrhage typically present with sudden, severe, localized back pain with or without radiculopathy. If the hemorrhage is intramedullary, the patient may experience hemiparesis, paraparesis, or quadriparesis; sensory loss below the lesion; and loss of sphincter control. A patient with spinal subarachnoid hemorrhage may have headache, neck stiffness, and photosensitivity. B) Patients with spinal cord hemorrhage typically present with sudden, severe, localized back pain with or without radiculopathy. If the hemorrhage is intramedullary, the patient may experience hemiparesis, paraparesis, or quadriparesis; sensory loss below the lesion; and loss of sphincter control. A patient with spinal subarachnoid hemorrhage may have headache, neck stiffness, and photosensitivity. C) Patients with spinal cord hemorrhage typically present with sudden, severe, localized back pain with or without radiculopathy. If the hemorrhage is intramedullary, the patient may experience hemiparesis, paraparesis, or quadriparesis; sensory loss below the lesion; and loss of sphincter control. A patient with spinal subarachnoid hemorrhage may have headache, neck stiffness, and photosensitivity. D) Patients with spinal cord hemorrhage typically present with sudden, severe, localized back pain with or without radiculopathy. If the hemorrhage is intramedullary, the patient may experience hemiparesis, paraparesis, or quadriparesis; sensory loss below the lesion; and loss of sphincter control. A patient with spinal subarachnoid hemorrhage may have headache, neck stiffness, and photosensitivity. Page Ref: 675 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 27.9 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of subdural and spinal cord hemorrhage and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of circulation within the CNS.

15) A baby has been brought to the emergency department unresponsive. The parent reports that the baby was in a motor vehicle accident, but the nurse notes no physical signs of trauma. A physical examination reveals retinal hemorrhages. Which diagnosis does the nurse suspect? A) Ischemic stroke B) Hemorrhagic stroke C) Spinal cord hemorrhage D) Shaken baby syndrome Answer: D Explanation: A) Child abuse or shaken baby syndrome can result in subdural hematoma, retinal hemorrhages, and cerebral edema. This occurs when an infant or child's head is shaken violently with or without deceleration. B) Child abuse or shaken baby syndrome can result in subdural hematoma, retinal hemorrhages, and cerebral edema. This occurs when an infant or child's head is shaken violently with or without deceleration. C) Child abuse or shaken baby syndrome can result in subdural hematoma, retinal hemorrhages, and cerebral edema. This occurs when an infant or child's head is shaken violently with or without deceleration. D) Child abuse or shaken baby syndrome can result in subdural hematoma, retinal hemorrhages, and cerebral edema. This occurs when an infant or child's head is shaken violently with or without deceleration. Page Ref: 675 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Analysis | Learning Outcome: 27.9 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of subdural and spinal cord hemorrhage and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of circulation within the CNS to diagnosis and treatment.

16) Which cardiac arrhythmia is the nurse most likely to assess in a patient with an embolic stroke? A) Sinus tachycardia B) Atrial fibrillation C) First degree heart block D) Ventricular tachycardia Answer: B Explanation: A) Embolic strokes occur as a result of a moving clot that can form in anywhere in the body. Most cerebral embolisms are of cardiac origin, usually caused by atrial fibrillation or breakage of an atherosclerotic plaque from a carotid artery, which lodges in a cerebral vessel. B) Embolic strokes occur as a result of a moving clot that can form in anywhere in the body. Most cerebral embolisms are of cardiac origin, usually caused by atrial fibrillation or breakage of an atherosclerotic plaque from a carotid artery, which lodges in a cerebral vessel. C) Embolic strokes occur as a result of a moving clot that can form in anywhere in the body. Most cerebral embolisms are of cardiac origin, usually caused by atrial fibrillation or breakage of an atherosclerotic plaque from a carotid artery, which lodges in a cerebral vessel. D) Embolic strokes occur as a result of a moving clot that can form in anywhere in the body. Most cerebral embolisms are of cardiac origin, usually caused by atrial fibrillation or breakage of an atherosclerotic plaque from a carotid artery, which lodges in a cerebral vessel. Page Ref: 672 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 27.8 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of ischemic and hemorrhagic strokes and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of disorders of circulation within the CNS.

17) When assessing a patient with manifestations of a stroke, the nurse keeps in mind that embolic strokes most commonly occur in which artery? A) Vertebral artery B) Basilar artery C) Middle cerebral artery D) Posterior cerebral artery Answer: C Explanation: A) Emboli that pass through the carotid arteries commonly occlude the middle cerebral artery, which carries more than 80% of blood flow to the cerebral hemisphere. Emboli that travel to the vertebral or basilar arteries can lodge at the apex of the basilar artery or in the posterior cerebral arteries. B) Emboli that pass through the carotid arteries commonly occlude the middle cerebral artery, which carries more than 80% of blood flow to the cerebral hemisphere. Emboli that travel to the vertebral or basilar arteries can lodge at the apex of the basilar artery or in the posterior cerebral arteries. C) Emboli that pass through the carotid arteries commonly occlude the middle cerebral artery, which carries more than 80% of blood flow to the cerebral hemisphere. Emboli that travel to the vertebral or basilar arteries can lodge at the apex of the basilar artery or in the posterior cerebral arteries. D) Emboli that pass through the carotid arteries commonly occlude the middle cerebral artery, which carries more than 80% of blood flow to the cerebral hemisphere. Emboli that travel to the vertebral or basilar arteries can lodge at the apex of the basilar artery or in the posterior cerebral arteries. Page Ref: 672 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 27.8 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of ischemic and hemorrhagic strokes and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of disorders of circulation within the CNS.

18) When a patient is suspected of having a brain arteriovenous malformation (AVM), which of the following may be auscultated? A) A cerebral bruit B) A carotid bruit C) An aortic arch bruit D) An abdominal aortic bruit Answer: A Explanation: A) The turbulent blood flow through the AVM can cause cerebral bruits. B) The turbulent blood flow through the AVM can cause cerebral bruits. C) The turbulent blood flow through the AVM can cause cerebral bruits. D) The turbulent blood flow through the AVM can cause cerebral bruits. Page Ref: 673 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 27.8 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of ischemic and hemorrhagic strokes and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of circulation within the CNS.

19) The nurse would expect to assess third nerve palsy in patient with an ischemic stroke involving which artery? A) Anterior cerebral artery B) Basilar artery C) Proximal posterior cerebral artery D) Distal posterior cerebral artery Answer: C Explanation: A) A stroke involving the anterior cerebral artery may cause paresis and sensory loss of contralateral leg and foot. B) A stroke involving the basilar artery may cause hemiparesis or quadriparesis, hemi or crossed sensory loss, nystagmus, vertigo, diplopia, gaze palsies, dysarthria, ipsilateral cerebellar ataxia, Horner syndrome, and coma. C) A stroke involving the proximal posterior cerebral artery may cause contralateral hemiparesis, sensory loss, ataxia, third nerve palsy, vertical gaze palsy, hemiballismus, choreoathetosis, and impaired consciousness. D) A stroke involving the distal posterior cerebral artery may cause contralateral homonymous hemianopia, dyslexia without agraphia, visual hallucinations and distortions, memory defect, and cortical blindness (if bilateral occlusion). Page Ref: 674 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 27.8 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of ischemic and hemorrhagic strokes and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of circulation within the CNS.

20) When assessing a patient following an aneurysmal subarachnoid hemorrhage, the nurse should be alert for delayed cerebral ischemia during which time period? A) In the first 2 hours B) In 3 to 5 days C) In 3 to 14 days D) After 6 weeks Answer: C Explanation: A) Delayed cerebral ischemia (DCI) is a clinical syndrome of focal neurologic deficits, cognitive deficits, or both that occurs in approximately 30% of patients during the initial 3-14 days following hemorrhage. B) Delayed cerebral ischemia (DCI) is a clinical syndrome of focal neurologic deficits, cognitive deficits, or both that occurs in approximately 30% of patients during the initial 3-14 days following hemorrhage. C) Delayed cerebral ischemia (DCI) is a clinical syndrome of focal neurologic deficits, cognitive deficits, or both that occurs in approximately 30% of patients during the initial 3-14 days following hemorrhage. D) Delayed cerebral ischemia (DCI) is a clinical syndrome of focal neurologic deficits, cognitive deficits, or both that occurs in approximately 30% of patients during the initial 3-14 days following hemorrhage. Page Ref: 673 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 27.8 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of ischemic and hemorrhagic strokes and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of circulation within the CNS.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 28 Shock and Multiple Organ Dysfunction Syndrome 1) The emergency department nurse is assessing a client in shock. The nurse understands that shock can be caused by which conditions? Select all that apply. A) Psychological distress B) Obstruction of blood flow C) Failure of the heart to pump D) Inflammatory vascular disease E) Low blood volume Answer: B, C, D, E Explanation: A) Types of shock are named according to the underlying cause. Psychological distress is not a cause of shock. B) Types of shock are named according to the underlying cause. Shock caused by obstruction of blood flow is obstructive shock. Failure of the heart to pump is cardiogenic shock. C) Types of shock are named according to the underlying cause. Failure of the heart to pump is cardiogenic shock. D) Types of shock are named according to the underlying cause. Shock due to inflammatory vascular response to infection is septic shock or anaphylactic shock. E) Types of shock are named according to the underlying cause. Low blood volume is hypovolemic shock. Page Ref: 681 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Pathophysiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 28.1 Describe the prevalence of shock, its multisystem effects on the body, and concepts related to shock. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of shock and multiple organ dysfunction syndrome to diagnosis and treatment.

2) The critical care nurse is assessing a client for clinical signs of shock. Which assessment finding does the nurse understand to be a clinical sign of shock? A) Polydipsia B) Headache C) Nausea D) Cold, clammy skin Answer: D Explanation: A) Polydipsia, headache, and nausea are not considered clinical signs of shock. B) Polydipsia, headache, and nausea are not considered clinical signs of shock. C) Polydipsia, headache, and nausea are not considered clinical signs of shock. D) Clinical signs of tissue hypoperfusion are evident in cold, clammy skin as a result of vasoconstriction and cyanosis in a client experiencing shock. Page Ref: 681 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Pathophysiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 28.1 Describe the prevalence of shock, its multisystem effects on the body, and concepts related to shock. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of shock and multiple organ dysfunction syndrome to diagnosis and treatment.

3) The nurse is providing discharge instructions to a client hospitalized with a bacterial infection. Which statement will the nurse include in the education? A) "An unresolved infection may result in septic shock." B) "Infections can cause a failure of the heart to pump, resulting in obstructive shock." C) "Bacterial buildup may cause abnormal redistribution of blood, resulting in hypovolemic shock." D) "The inflammatory vascular response in infections can lead to cardiogenic shock." Answer: A Explanation: A) Septic shock and anaphylactic shock can be due to an inflammatory vascular response to infection. Failure of the heart to pump is cardiogenic shock, not obstructive shock. Shock due to low blood volume is hypovolemic shock, and is not related to bacterial buildup. B) Failure of the heart to pump is cardiogenic shock, not obstructive shock. C) Shock due to low blood volume is hypovolemic shock, and is not related to bacterial buildup. D) Shock due to an inflammatory vascular response to infection is septic shock or anaphylactic shock. Page Ref: 681 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pathophysiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 28.1 Describe the prevalence of shock, its multisystem effects on the body, and concepts related to shock. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of shock and multiple organ dysfunction syndrome to diagnosis and treatment.

4) The nurse is providing care to a client with multiple organ dysfunction syndrome (MODS). What does the nurse understand is occurring in the body's cells as a result? A) A shift to aerobic metabolism B) Disruption of the cell cycle, leading to apoptosis C) Serum level of potassium increases D) Lactic acid production increases Answer: D Explanation: A) During multiple organ dysfunction syndrome (MODS), the body's cells shift from aerobic to anaerobic metabolism. B) Apoptosis is not a cellular response characteristic of MODS. C) An increased serum potassium level is not associated with multiple organ dysfunction syndrome (MODS). D) During multiple organ dysfunction syndrome (MODS), the body's cells shift from aerobic to anaerobic metabolism. There is also an increase in the level of serum lactate, and increased lactic acid production. Page Ref: 683 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Pathophysiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 28.2 Outline the pathophysiology, categories, and stages of shock. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of shock and multiple organ dysfunction syndrome to diagnosis and treatment.

5) The nurse is caring for a client with early shock. The nurse understands that which mechanism in the body is maintaining the client's blood flow? A) The kidneys respond to poor perfusion by activating the renin-angiotensin-aldosterone system. B) Baroreceptors respond to the increase in heart rate by increasing sympathetic outflow to the heart and blood vessels. C) The body's blood vessels are constricted as a result of parasympathetic stimulation. D) The cardiovascular center in the brain responds by slowing the pulse and increasing cardiac contractility. Answer: A Explanation: A) In early shock, the kidneys respond to poor perfusion by activating the reninangiotensin-aldosterone system (RAAS). B) In early shock, baroreceptors respond to decreased blood pressure by increasing sympathetic outflow to the heart and blood vessels. The body's blood vessels are constricted as a result of sympathetic stimulation. C) In early shock, baroreceptors respond to decreased blood pressure by increasing sympathetic outflow to the heart and blood vessels. The body's blood vessels are constricted as a result of sympathetic stimulation. D) The cardiovascular center in the brain responds by increasing the pulse and cardiac contractility. Page Ref: 683- 684 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Pathophysiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 28.2 Outline the pathophysiology, categories, and stages of shock. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of shock and multiple organ dysfunction syndrome to diagnosis and treatment.

6) The nurse is caring for a client presenting with confusion, angina, and muscular pain. The nurse understands that these findings are consistent with which stage of shock? A) Refractory shock B) Progressive shock C) Reversible shock D) Compensated shock Answer: B Explanation: A) Confusion, angina, and muscular pain are not characteristic of refractory or compensated shock. B) Stage II shock is also referred to as intermediate or progressive shock. A client with stage II shock may exhibit neurologic changes such as confusion and disorientation, angina due to decreased oxygen delivery to the myocardium, and muscular pain C) Reversible shock is not a term associated with a stage of shock. D) Confusion, angina, and muscular pain are not characteristic of refractory or compensated shock. Page Ref: 684 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pathophysiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 28.2 Outline the pathophysiology, categories, and stages of shock. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of shock and multiple organ dysfunction syndrome to diagnosis and treatment.

7) The emergency department nurse receives a call about an incoming client with hypovolemic shock. The nurse understands that which conditions can result in hypovolemic shock? Select all that apply. A) Diuresis B) Severe burns C) Congestive heart failure D) Blood loss E) Constipation Answer: A, B, D Explanation: A) Hypovolemic shock occurs when there is rapid or excessive loss of significant amount of whole blood as in trauma, internal bleeding from a ruptured ectopic pregnancy or gastrointestinal lesions, or loss of other body fluids (from diarrhea, vomiting, diaphoresis, severe burns, or diuresis as occurs in diabetes mellitus and diabetes insipidus), edema, or severe dehydration. B) Hypovolemic shock occurs when there is rapid or excessive loss of significant amount of whole blood as in trauma, internal bleeding from a ruptured ectopic pregnancy or gastrointestinal lesions, or loss of other body fluids (from diarrhea, vomiting, diaphoresis, severe burns, or diuresis as occurs in diabetes mellitus and diabetes insipidus), edema, or severe dehydration. C) Congestive heart failure and constipation do not typically result in a rapid or excessive loss of body fluids, and therefore are not directly related to hypovolemic shock. D) Hypovolemic shock occurs when there is rapid or excessive loss of significant amount of whole blood as in trauma, internal bleeding from a ruptured ectopic pregnancy or gastrointestinal lesions, or loss of other body fluids (from diarrhea, vomiting, diaphoresis, severe burns, or diuresis as occurs in diabetes mellitus and diabetes insipidus), edema, or severe dehydration. E) Congestive heart failure and constipation do not typically result in a rapid or excessive loss of body fluids, and therefore are not directly related to hypovolemic shock. Page Ref: 684 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Pathophysiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 28.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypovolemic shock and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of shock and multiple organ dysfunction syndrome to diagnosis and treatment.

8) The critical care nurse is preparing to admit a client with suspected hypovolemic shock to the intensive care unit. Which laboratory tests does the nurse anticipate to be included in the client's plan of care? Select all that apply. A) Urinalysis B) Blood glucose level C) Thyroid stimulating hormone (TSH) D) Complete blood count (CBC) E) Serum lactate concentration Answer: B, D, E Explanation: A) Thyroid stimulating hormone (TSH) and urinalysis are not tests that are typically included in the plan of care for a client with hypovolemic shock. B) Standard laboratory tests for clients with possible hypovolemic shock include the following: Complete blood count, determination of serum electrolyte concentrations, determination of blood glucose level, arterial blood gas determinations, prothrombin time and partial thromboplastin time to detect a clotting disorder, hemoglobin and hematocrit to determine the severity of blood loss or hemoconcentration due to dehydration, serum lactate concentration, and arterial pH to detect metabolic acidosis. C) Thyroid stimulating hormone (TSH) and urinalysis are not tests that are typically included in the plan of care for a client with hypovolemic shock. D) Standard laboratory tests for clients with possible hypovolemic shock include the following: Complete blood count, determination of serum electrolyte concentrations, determination of blood glucose level, arterial blood gas determinations, prothrombin time and partial thromboplastin time to detect a clotting disorder, hemoglobin and hematocrit to determine the severity of blood loss or hemoconcentration due to dehydration, serum lactate concentration, and arterial pH to detect metabolic acidosis. Thyroid stimulating hormone (TSH) and urinalysis are not tests that are typically included in the plan of care for a client with hypovolemic shock. E) Standard laboratory tests for clients with possible hypovolemic shock include the following: Complete blood count, determination of serum electrolyte concentrations, determination of blood glucose level, arterial blood gas determinations, prothrombin time and partial thromboplastin time to detect a clotting disorder, hemoglobin and hematocrit to determine the severity of blood loss or hemoconcentration due to dehydration, serum lactate concentration, and arterial pH to detect metabolic acidosis. Page Ref: 687 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pathophysiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 28.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypovolemic shock and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of shock and multiple organ dysfunction syndrome to diagnosis and treatment. 8

9) The nurse is reviewing the plan of care for a client with hypovolemic shock. Which objectives does the nurse recognize are relevant for this client? Select all that apply. A) Reducing body temperature B) Reducing blood pressure C) Prevent further fluid loss D) Replace lost fluids E) Maximize oxygen delivery Answer: C, D, E Explanation: A) There are three primary objectives for managing the client with hypovolemic shock: maximize oxygen delivery by ensuring adequate ventilation and oxygen saturation of the blood and by restoring blood flow, prevent further fluid loss, and replace lost fluids. Regulation of both body temperature and blood pressure are important factors in the management of a client with hypovolemic shock; however, the client with hypovolemic shock generally does not have an elevated body temperature nor does the client have high blood pressure. B) There are three primary objectives for managing the client with hypovolemic shock: maximize oxygen delivery by ensuring adequate ventilation and oxygen saturation of the blood and by restoring blood flow, prevent further fluid loss, and replace lost fluids. Regulation of both body temperature and blood pressure are important factors in the management of a client with hypovolemic shock; however, the client with hypovolemic shock generally does not have an elevated body temperature nor does the client have high blood pressure. C) There are three primary objectives for managing the client with hypovolemic shock: maximize oxygen delivery by ensuring adequate ventilation and oxygen saturation of the blood and by restoring blood flow, prevent further fluid loss, and replace lost fluids. Regulation of both body temperature and blood pressure are important factors in the management of a client with hypovolemic shock; however, the client with hypovolemic shock generally does not have an elevated body temperature nor does the client have high blood pressure. D) There are three primary objectives for managing the client with hypovolemic shock: maximize oxygen delivery by ensuring adequate ventilation and oxygen saturation of the blood and by restoring blood flow, prevent further fluid loss, and replace lost fluids. Regulation of both body temperature and blood pressure are important factors in the management of a client with hypovolemic shock; however, the client with hypovolemic shock generally does not have an elevated body temperature nor does the client have high blood pressure. E) There are three primary objectives for managing the client with hypovolemic shock: maximize oxygen delivery by ensuring adequate ventilation and oxygen saturation of the blood and by restoring blood flow, prevent further fluid loss, and replace lost fluids. Regulation of both body temperature and blood pressure are important factors in the management of a client with hypovolemic shock; however, the client with hypovolemic shock generally does not have an elevated body temperature nor does the client have high blood pressure. Page Ref: 687 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pathophysiological Adaptation

Standards: Nursing Process: Planning | Learning Outcome: 28.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypovolemic shock and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of shock and multiple organ dysfunction syndrome to diagnosis and treatment. 10) The nurse is caring for a client with an acute myocardial infarction. The nurse understands that this condition results in cardiogenic shock by which mechanism? A) Increased coronary perfusion pressure B) Increased left ventricular pressure C) Increased myocardial contractility D) Increased cardiac output Answer: B Explanation: A) Increased coronary perfusion pressure, myocardial contractility, and cardiac output are not part of the mechanisms leading to cardiogenic shock due to myocardial infarction. B) Cardiogenic shock caused by acute myocardial infarction shows a progressive decrease in coronary perfusion pressure, increased myocardial oxygen demand, and hypoxia. This cycle contributes to a decrease in myocardial contractility and stroke volume and an increase in endsystolic volume. The weak heart pumps less blood, and the pressure increases in the left ventricle, causing an increase in pulmonary pressure and pulmonary edema. C) Increased coronary perfusion pressure, myocardial contractility, and cardiac output are not part of the mechanisms leading to cardiogenic shock due to myocardial infarction. D) Increased coronary perfusion pressure, myocardial contractility, and cardiac output are not part of the mechanisms leading to cardiogenic shock due to myocardial infarction. Page Ref: 688 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Pathophysiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 28.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of cardiogenic shock and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of shock and multiple organ dysfunction syndrome to diagnosis and treatment.

11) The nurse is providing education to a client's family about cardiogenic shock. Which statement should be included in the education? A) "The heart's imbalanced pH, causes further tissue damage." B) "Compensatory mechanisms work to preserve the function of the heart." C) "This condition results in decreased fluid retention in the body." D) "The body works to shunt blood to major organs." Answer: D Explanation: A) During cardiogenic shock, the body works to shunt blood to major organs due to a failure of the heart to effectively circulate the body's blood volume. The heart's acidotic status causes further damage to cardiac tissue. B) During cardiogenic shock, the body works to shunt blood to major organs due to a failure of the heart to effectively circulate the body's blood volume. Compensatory mechanisms fail to preserve the function of the heart and instead result in further tissue damage. C) During cardiogenic shock, the body works to shunt blood to major organs due to a failure of the heart to effectively circulate the body's blood volume. The sympathetic nervous system initiates mechanisms to increase fluid retention to correct hypotension. D) During cardiogenic shock, the body works to shunt blood to major organs due to a failure of the heart to effectively circulate the body's blood volume. Page Ref: 688 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pathophysiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 28.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of cardiogenic shock and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Effective Communication MNL Learning Outcome: LO 4: Consider the pathophysiology of shock and multiple organ dysfunction syndrome to diagnosis and treatment.

12) The nurse is preparing to administer a client's medications. Which medications does the nurse recognize are used to treat the client's diagnosis of cardiogenic shock? Select all that apply. A) Antibiotic therapy B) Proton pump inhibitor therapy C) Nitroglycerine therapy D) Diuretic therapy E) Thrombolytic therapy Answer: C, D, E Explanation: A) Antibiotic therapy are more likely to be used in the treatment of septic shock. B) Proton pump inhibitor therapy is typically given to treat gastroesophageal reflux disease (GERD), not cardiogenic shock. C) During cardiogenic shock, coronary vasodilators such as nitroglycerin are given to dilate the coronary arteries and improve blood supply to the myocardium. D) When fluid overload is present in cardiogenic shock, as manifested by pulmonary edema and the presence of crackles, diuretic therapy is instituted. E) In cardiogenic shock, thrombolytic therapy or coronary artery revascularization improves blood flow to the myocardium. Page Ref: 690 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Planning | Learning Outcome: 28.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of cardiogenic shock and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of shock and multiple organ dysfunction syndrome to diagnosis and treatment.

13) The nurse is preparing to admit a client diagnosed with anaphylactic shock. The nurse understands that anaphylactic shock can have which triggers? A) Drugs B) Foods C) Hyperthermia D) Proteins E) Inactivity Answer: A, B, D Explanation: A) Anaphylaxis is typically triggered by the following: drugs, foods, proteins, animal or insect venoms, latex, heavy metal poisoning, and occasionally exercise and exposure to cold temperature. B) Anaphylaxis is typically triggered by the following: drugs, foods, proteins, animal or insect venoms, latex, heavy metal poisoning, and occasionally exercise and exposure to cold temperature. C) Hyperthermia and inactivity are not triggers for anaphylaxis. D) Anaphylaxis is typically triggered by the following: drugs, foods, proteins, animal or insect venoms, latex, heavy metal poisoning, and occasionally exercise and exposure to cold temperature. E) Hyperthermia and inactivity are not triggers for anaphylaxis. Page Ref: 690 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Pathophysiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 28.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of distributive shock and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of shock and multiple organ dysfunction syndrome to diagnosis and treatment.

14) While assessing a client, the nurse notes stridor, tachycardia, edema, and hives. The nurse understands that these findings are consistent with which type of shock? A) Anaphylactic B) Hypovolemic C) Cardiogenic D) Obstructive Answer: A Explanation: A) Anaphylaxis should be suspected if any of the following suddenly occur without explanation: shock, respiratory symptoms (e.g., dyspnea, stridor, wheezing), and two or more other manifestations of possible anaphylaxis (e.g., angioedema, rhinorrhea, gastrointestinal symptoms). B) Hypovolemic, cardiogenic, and obstructive shock are not characterized by stridor, tachycardia, edema, and hives. C) Hypovolemic, cardiogenic, and obstructive shock are not characterized by stridor, tachycardia, edema, and hives. D) Hypovolemic, cardiogenic, and obstructive shock are not characterized by stridor, tachycardia, edema, and hives. Page Ref: 690 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pathophysiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 28.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of distributive shock and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of shock and multiple organ dysfunction syndrome to diagnosis and treatment.

15) The nurse is reviewing medications for a client with anaphylactic shock. Which medication would the nurse anticipate to be included in the client's plan of care? Select all that apply. A) Beta agonist treatment B) Diphenhydramine infusion treatment C) Epinephrine treatment D) Lorazepam treatment E) Heparin treatment Answer: A, B, C Explanation: A) Medications given for anaphylactic shock include epinephrine given immediately, sometimes vasopressors for persistent hypotension, antihistamines, and inhaled beta agonists for bronchoconstriction. B) Treatment for anaphylactic shock includes: epinephrine given immediately, intubation, intravenous fluids and sometimes vasopressors for persistent hypotension, antihistamines, and inhaled beta agonists for bronchoconstriction. C) Treatment for anaphylactic shock includes: epinephrine given immediately, intubation, intravenous fluids and sometimes vasopressors for persistent hypotension, antihistamines, and inhaled beta agonists for bronchoconstriction. D) Orders for lorazepam and heparin may be present in the client's plan of care, but they are not typically given for the treatment of anaphylactic shock. E) Orders for lorazepam and heparin may be present in the client's plan of care, but they are not typically given for the treatment of anaphylactic shock. Page Ref: 692 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Planning | Learning Outcome: 28.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of distributive shock and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of shock and multiple organ dysfunction syndrome to diagnosis and treatment.

16) The nurse is providing education about anaphylaxis to a parent at a well-child visit. Which agents does the nurse include when reviewing common causes of anaphylaxis in children? Select all that apply. A) Lead-based paint B) Low grade plastics C) Nuts D) Bee stings E) Pool chemicals Answer: C, D Explanation: A) Lead-based paint and low grade plastics are not considered common agents that cause anaphylactic reactions in children. B) The most common agents that cause anaphylactic reactions in children are food (e.g., legumes, nuts, fish, shellfish, cow's milk, eggs), hymenoptera (i.e., bee or wasp) stings, and medications (particularly penicillins). C) The most common agents that cause anaphylactic reactions in children are food (e.g., legumes, nuts, fish, shellfish, cow's milk, eggs), hymenoptera (i.e., bee or wasp) stings, and medications (particularly penicillins). D) The most common agents that cause anaphylactic reactions in children are food (e.g., legumes, nuts, fish, shellfish, cow's milk, eggs), hymenoptera (i.e., bee or wasp) stings, and medications (particularly penicillins). Lead-based paint and low grade plastics are not considered common agents that cause anaphylactic reactions in children. E) Pool chemicals are not considered common agents that cause anaphylactic reactions in children. Page Ref: 692 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 28.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of distributive shock and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Effective Communication MNL Learning Outcome: LO 4: Consider the pathophysiology of shock and multiple organ dysfunction syndrome to diagnosis and treatment.

17) The nurse is assisting with a client undergoing a sequential organ failure assessment (SOFA). Which systems will the nurse anticipate being included in the assessment? Select all that apply. A) Respiratory B) Gastrointestinal C) Integumentary D) Neurological E) Cardiovascular Answer: A, D, E Explanation: A) The SOFA evaluates the following systems: respiratory status through evaluation of arterial oxygenation, coagulation status through evaluation of platelet count, hepatic status through evaluation of bilirubin level, cardiovascular status through evaluation of blood pressure, neurologic status through calculation of Glasgow Coma Scale ratings, and renal status through evaluation of urinary output and creatinine. B) Assessments of the gastrointestinal and integumentary systems are not part of the SOFA. C) Assessments of the gastrointestinal and integumentary systems are not part of the SOFA. D) The SOFA evaluates the following systems: respiratory status through evaluation of arterial oxygenation, coagulation status through evaluation of platelet count, hepatic status through evaluation of bilirubin level, cardiovascular status through evaluation of blood pressure, neurologic status through calculation of Glasgow Coma Scale ratings, and renal status through evaluation of urinary output and creatinine. E) The SOFA evaluates the following systems: respiratory status through evaluation of arterial oxygenation, coagulation status through evaluation of platelet count, hepatic status through evaluation of bilirubin level, cardiovascular status through evaluation of blood pressure, neurologic status through calculation of Glasgow Coma Scale ratings, and renal status through evaluation of urinary output and creatinine. Page Ref: 692 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Pathophysiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 28.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of distributive shock and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of shock and multiple organ dysfunction syndrome to diagnosis and treatment.

18) The nurse is reviewing orders for a client with a diagnosis of septic shock. Which order will the nurse verify with the health care provider before proceeding? A) 2 Liters per minute of oxygen by nasal cannula B) Sliding scale subcutaneous insulin C) Intravenous furosemide D) Intravenous amoxicillin Answer: C Explanation: A) Treatment for clients with septic shock includes the following: perfusion restored with intravenous fluids and sometimes vasopressors, O2 support, broad-spectrum antibiotics to treat infection, infection source control, and sometimes other supportive measures (e.g., corticosteroids, insulin). B) Treatment for clients with septic shock includes the following: perfusion restored with intravenous fluids and sometimes vasopressors, O2 support, broad-spectrum antibiotics to treat infection, infection source control, and sometimes other supportive measures (e.g., corticosteroids, insulin). C) The nurse will verify the order for IV furosemide, a loop diuretic, as this is likely to exacerbate hypotension associated with septic shock. D) Treatment for clients with septic shock includes the following: perfusion restored with intravenous fluids and sometimes vasopressors, O2 support, broad-spectrum antibiotics to treat infection, infection source control, and sometimes other supportive measures (e.g., corticosteroids, insulin). Page Ref: 694 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Planning | Learning Outcome: 28.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of distributive shock and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of shock and multiple organ dysfunction syndrome to diagnosis and treatment.

19) The nurse is providing education to a client about how the body responds to pulmonary emboli. Which statement will the nurse include in the teaching? A) "Initially, the body will be able to compensate for this condition." B) "Hypovolemic shock can occur as a result of this condition." C) "This condition raises the risk for obstructive shock." D) "This may result in a form of shock related to brain injury." Answer: C Explanation: A) A pulmonary embolism can result in right ventricular failure, which leads to obstructive shock. Stage I of shock is when the body's initial mechanisms for compensating for low blood flow are activated, which is not specifically related to the development of a pulmonary embolus. Neurogenic shock is a form of shock that can be caused by brain injury. B) A pulmonary embolism can result in right ventricular failure, which leads to obstructive shock. Stage I of shock is when the body's initial mechanisms for compensating for low blood flow are activated, which is not specifically related to the development of a pulmonary embolus. Neurogenic shock is a form of shock that can be caused by brain injury. C) A pulmonary embolism can result in right ventricular failure, which leads to obstructive shock. Stage I of shock is when the body's initial mechanisms for compensating for low blood flow are activated, which is not specifically related to the development of a pulmonary embolus. Neurogenic shock is a form of shock that can be caused by brain injury. D) A pulmonary embolism can result in right ventricular failure, which leads to obstructive shock. Stage I of shock is when the body's initial mechanisms for compensating for low blood flow are activated, which is not specifically related to the development of a pulmonary embolus. Neurogenic shock is a form of shock that can be caused by brain injury. Page Ref: 695 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 28.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of obstructive shock and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Effective Communication MNL Learning Outcome: LO 4: Consider the pathophysiology of shock and multiple organ dysfunction syndrome to diagnosis and treatment.

20) The nurse is caring for a client with multiple organ dysfunction syndrome (MODS). Which statement about this condition does the nurse know to be true? A) Three or more organ systems are affected B) Renal and hepatic function are monitored by urine and stool output C) Variable clinical presentations occur D) It is characterized by specific manifestations Answer: C Explanation: A) In multiple organ dysfunction syndrome (MODS), two or more organ systems are affected. B) Renal and hepatic function is monitored by serum creatinine and bilirubin levels. C) MODS is characterized by a wide variety of clinical presentations and may differ from one individual to the next. D) Protein-rich nutritional support is highly important for supporting the hypermetabolic needs of clients with MODS. Page Ref: 696 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Pathophysiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 28.7 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of multiple organ system dysfunction and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of shock and multiple organ dysfunction syndrome to diagnosis and treatment.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 29 Emotional Regulation and Mood 1) The nurse is caring for a client with major depression. Which statement about this condition does the nurse know to be true? A) Depression primarily affects older adults due to age-related changes in mood. B) Depression is rarely a debilitating condition. C) Depression can be a fatal illness. D) Depression is part of normal emotional regulation. Answer: C Explanation: A) Depression is a pervasive, debilitating condition that is not considered a normal part of the aging process. B) Depression, which can be pervasive and debilitating, is a mood disorder in which the individual has persistent feelings of sadness and lack of interest in life. C) Depression, if not treated successfully, can result in suicide. D) Emotional regulation is the ability to manage emotional responses to environmental stimuli that are perceived as aversive or negative. When these responses disrupt daily functioning, the individual could experience mood disorders such as depression. Page Ref: 703 Cognitive Level: Understanding Client Need & Sub: Psychosocial Integrity Standards: Nursing Process: Assessment | Learning Outcome: 29.1 Define emotional regulation, and discuss concepts related to anxiety and depression. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Examine the pathophysiology of emotional regulation and mood.

2) The nurse is providing education to a client about anxiety disorders. Which statement by the client requires further follow up by the nurse? A) "I can expect to experience anxiety throughout my life." B) "Sometimes anxiety can get out of hand." C) "Usually anxiety lasts for weeks after a stressor is gone." D) "Anxiety disorders sometimes lead people to feel panicked in social settings." Answer: C Explanation: A) Anxiety is an emotion that helps individuals adapt to a perceived challenge, and thus be expected from time to time in a person's life. B) Generally, after a stressor is gone, feelings of anxiety soon resolve. Anxiety is an emotion that helps individuals adapt to a perceived challenge, and thus be expected from time to time in a person's life. It can, however, also create sustained apprehension such that the individual develops avoidance patterns as a means of coping with distress C) Generally, after a stressor is gone, feelings of anxiety soon resolve. D) Anxiety is an emotion that helps individuals adapt to a perceived challenge, and thus be expected from time to time in a person's life. It can, however, also create sustained apprehension such that the individual develops avoidance patterns as a means of coping with distress. Page Ref: 703 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity Standards: Nursing Process: Evaluation | Learning Outcome: 29.1 Define emotional regulation, and discuss concepts related to anxiety and depression. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and wellbeing, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Examine the pathophysiology of emotional regulation and mood.

3) The nurse is caring for a client with generalized anxiety disorder. Which neurotransmitters does the nurse understand are tied to the pathogenesis of this condition? Select all that apply. A) Acetylcholine B) Oxytocin C) Dopamine D) Serotonin E) Neurokinin A Answer: C, D Explanation: A) Acetylcholine and Neurokinin A are not considered to be related to generalized anxiety disorder. B) Neurotransmitters associated with autonomic responses such as norepinephrine (NE), dopamine (DA), and serotonin are tied into the pathogenesis of anxiety disorders with the regulation of gamma-aminobutyric acid (GABA) playing a role in the treatment process. Acetylcholine, Oxytocin, and Neurokinin A are not considered to be related to generalized anxiety disorder. C) Neurotransmitters associated with autonomic responses such as norepinephrine (NE), dopamine (DA), and serotonin are tied into the pathogenesis of anxiety disorders with the regulation of gamma-aminobutyric acid (GABA) playing a role in the treatment process. D) Neurotransmitters associated with autonomic responses such as norepinephrine (NE), dopamine (DA), and serotonin are tied into the pathogenesis of anxiety disorders with the regulation of gamma-aminobutyric acid (GABA) playing a role in the treatment process. E) Acetylcholine and Neurokinin A are not considered to be related to generalized anxiety disorder. Page Ref: 703 Cognitive Level: Understanding Client Need & Sub: Psychosocial Integrity Standards: Nursing Process: Assessment | Learning Outcome: 29.1 Define emotional regulation, and discuss concepts related to anxiety and depression. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: I. 7. Integrate the knowledge and methods of a variety of disciplines to inform decision making NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Examine the pathophysiology of emotional regulation and mood.

4) The nurse is caring for a client with major depression who is hospitalized for failure to thrive. The nurse understands that which body system is directly tied to emotional regulation? A) The immune system B) The digestive system C) The integumentary system D) The musculoskeletal system Answer: A Explanation: A) The neurotransmitters associated with anxiety and depressive states are also tied into immunologic responses and inflammation. Immunologic disruptions or genetic dysregulation could then predispose an individual to the development of depression or anxiety. In turn, emotional states influence immunologic responses, placing the individual at the risk for disease. B) The digestive, integumentary, and musculoskeletal systems are not directly tied to emotional regulation. C) The digestive, integumentary, and musculoskeletal systems are not directly tied to emotional regulation. D) The digestive, integumentary, and musculoskeletal systems are not directly tied to emotional regulation. Page Ref: 703 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 29.1 Define emotional regulation, and discuss concepts related to anxiety and depression. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: I. 7. Integrate the knowledge and methods of a variety of disciplines to inform decision making NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Examine the pathophysiology of emotional regulation and mood.

5) The nurse is assessing a client exhibiting a sudden sense of fear and dread, heart palpitations, and shortness of breath. The nurse understands these findings to be consistent with which condition? A) Hypomania B) Depression C) Bipolar disorder D) Panic attack Answer: D Explanation: A) Hypomania is a less extreme form of mania characterized by an abnormally and persistently elevated, expansive, or irritable mood and increased energy. B) Depression is a mood disorder in which the individual has persistent feelings of sadness and lack of interest in life. C) Bipolar disorders are a group of mood disorders characterized by manic, hypomanic, and depressive episodes. D) A sudden sense of fear and dread, heart palpitations, and shortness of breath are consistent with a panic attack. These symptoms are due to an increase in sympathetic function. Page Ref: 713 Cognitive Level: Understanding Client Need & Sub: Psychosocial Integrity Standards: Nursing Process: Assessment | Learning Outcome: 29.1 Define emotional regulation, and discuss concepts related to anxiety and depression. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: I. 7. Integrate the knowledge and methods of a variety of disciplines to inform decision making NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Examine the pathophysiology of emotional regulation and mood.

6) The nurse cares for clients with a variety of depression disorders. Which client statements suggest the diagnosis of dysthymia? Select all that apply. A) "Every day for over 2 years I've been sad, tired, and can't seem to get my act together." B) "Ever since my husband died 2 weeks ago, I can't concentrate and have no reason to live." C) "I've been feeling down in the dumps for about 2 weeks now." D) "For the last 4 years, I can't make a decision and am so worthless at work every day." E) "For the last year, I have periods of time that I am sad and cry a lot." Answer: A, D Explanation: A) Dysthymia is also referred to as persistent depressive disorder and is characterized by a depressed mood (feeling sad or down) that occur more days than not for at least 2 years. B) Major depressive disorder is characterized by one or more depressive episodes lasting 2 weeks or longer. C) Major depressive disorder is characterized by one or more depressive episodes lasting 2 weeks or longer. D) Dysthymia is also referred to as persistent depressive disorder and is characterized by a depressed mood (feeling sad or down) that occur more days than not for at least 2 years. E) Major depressive disorder is characterized by one or more depressive episodes lasting 2 weeks or longer. Page Ref: 713 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 29.2 Describe the etiology, pathogenesis, and clinical manifestations of anxiety and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: I.B.1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Examine the pathophysiology of emotional regulation and mood.

7) The nurse is caring for a client with social anxiety disorder. Which distinguishing features does the nurse understand to be associated with this condition? Select all that apply. A) Increased distress in inescapable situations B) Avoidance of known stressors C) Excessive worry about events that are difficult to control D) Fear of being exposed to scrutiny E) Accompanying heart palpitations and chest pain Answer: B, D Explanation: A) Social anxiety disorder is characterized by avoidance of known stressors. More specifically, this condition involves fear of being exposed to scrutiny. This is distinct from agoraphobia, which is characterized by avoidance of inescapable situations, and generalized anxiety disorder, which involves excessive worry about events that are difficult to control. B) Social anxiety disorder is characterized by avoidance of known stressors. More specifically, this condition involves fear of being exposed to scrutiny. This is distinct from agoraphobia, which is characterized by avoidance of inescapable situations, and generalized anxiety disorder, which involves excessive worry about events that are difficult to control. C) Social anxiety disorder is characterized by avoidance of known stressors. More specifically, this condition involves fear of being exposed to scrutiny. This is distinct from agoraphobia, which is characterized by avoidance of inescapable situations, and generalized anxiety disorder, which involves excessive worry about events that are difficult to control. D) Social anxiety disorder is characterized by avoidance of known stressors. More specifically, this condition involves fear of being exposed to scrutiny. This is distinct from agoraphobia, which is characterized by avoidance of inescapable situations, and generalized anxiety disorder, which involves excessive worry about events that are difficult to control. E) Heart palpitations and chest pain are both assessment findings that may be present during a panic attack. Page Ref: 711 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity Standards: Nursing Process: Assessment | Learning Outcome: 29.2 Describe the etiology, pathogenesis, and clinical manifestations of anxiety and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: I. 7. Integrate the knowledge and methods of a variety of disciplines to inform decision making NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Examine the pathophysiology of emotional regulation and mood.

8) The nurse is preparing to administer paroxetine to a client with an anxiety disorder. The nurse understands which statement about this medication to be true? A) This is a selective norepinephrine reuptake inhibitor (SNRI). B) This is often a drug of choice for anxiety treatment. C) It well-established how paroxetine reduces anxiety. D) Although fast acting, This medication may cause physiologic dependency. Answer: B Explanation: A) Paroxetine (Paxil) is a selective serotonin reuptake inhibitor (SSRI), and is often one of the first drugs of choice for anxiety treatment due to its efficacy and safety profile. B) Paroxetine (Paxil) is a selective serotonin reuptake inhibitor (SSRI), and is often one of the first drugs of choice for anxiety treatment due to its efficacy and safety profile. C) The mechanism by which SSRIs reduce anxiety is not entirely clear. D) This medication is not known to cause physiologic dependency. Page Ref: 711 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Planning | Learning Outcome: 29.2 Describe the etiology, pathogenesis, and clinical manifestations of anxiety and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Examine the pathophysiology of emotional regulation and mood.

9) The nurse is performing a psychosocial assessment on an adolescent client. Which special considerations should the nurse take while performing the assessment? Select all that apply. A) Not all adolescents are aware of their emotional state. B) It is important to differentiate between normal fears and those that interfere with normal function. C) Adolescents may over-report anxiety due to normal developmental fears. D) Feelings of embarrassment may interfere with the assessment of adolescents. E) Physiological changes like puberty may result in inaccurate findings in adolescents. Answer: B, D Explanation: A) Feelings of embarrassment may cause adolescents to under report anxiety, but does not invalidate or make these clients less aware of their symptoms. B) When assessing children and adolescents, it is important to differentiate between normal fears and those that interfere with normal function. C) Feelings of embarrassment may cause children and adolescents to under report anxiety, but does not invalidate or make these clients less aware of their symptoms. D) Feelings of embarrassment may cause adolescents to under report anxiety, but does not invalidate or make these clients less aware of their symptoms. E) While physiological changes like puberty may increase mood swings in adolescents, these changes do not invalidate assessment findings related to emotional regulation and mood. Page Ref: 711 Cognitive Level: Applying Client Need & Sub: Psychological Integrity Standards: Nursing Process: Understanding | Learning Outcome: 29.2 Describe the etiology, pathogenesis, and clinical manifestations of anxiety and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: I.B.5. Assess levels of physical and emotional comfort | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith MNL Learning Outcome: LO 4: Examine the pathophysiology of emotional regulation and mood.

10) The nurse is reviewing a client's experience with cognitive behavioral therapy. Which statement by the client indicates the therapy has been effective? A) "I shared at group therapy, and the anxiety is not a problem now." B) "I no longer worry about leaving my house." C) "I just can't stand being in large crowds." D) "I wanted to run out of the grocery store, but I had no reason to." Answer: D Explanation: A) The client's statement is an example of cognitive restructuring, which is an indication that cognitive therapy has been effective. Cognitive therapy assists the client with identifying feelings of anxiety and faulty assumptions in stress-inducing situations. When the client states, "I had no reason to [run out of the grocery store]," the client identified the impulse as a response based on a faulty assumption, which is an indication that cognitive behavioral therapy has been effective. The statement of "I shared at group therapy, and the anxiety is not a problem now," indicates that the client is not experiencing anxiety at the moment, which is not reflective of the purpose of group therapy. B) The client's statement is an example of cognitive restructuring, which is an indication that cognitive therapy has been effective. Cognitive therapy assists the client with identifying feelings of anxiety and faulty assumptions in stress-inducing situations. When the client states, "I had no reason to [run out of the grocery store]," the client identified the impulse as a response based on a faulty assumption, which is an indication that cognitive behavioral therapy has been effective. The statement of "I no longer worry about leaving my house," indicates that the client is not experiencing anxiety at the moment, which is not reflective of the purpose of group therapy. C) The client's statement is an example of cognitive restructuring, which is an indication that cognitive therapy has been effective. Cognitive therapy assists the client with identifying feelings of anxiety and faulty assumptions in stress-inducing situations. When the client states, "I had no reason to [run out of the grocery store]," the client identified the impulse as a response based on a faulty assumption, which is an indication that cognitive behavioral therapy has been effective. The statement of "I just can't stand being in large crowds," is a statement which may or may not indicate the source of the client's distress, but is not reflective of the purpose of group therapy. D) The client's statement of, "I had no reason to [run out of the grocery store]," is an example of cognitive restructuring, which is an indication that cognitive therapy has been effective. Cognitive therapy assists the client with identifying feelings of anxiety and faulty assumptions in stress-inducing situations. The client identified the impulse as a response based on a faulty assumption, which is an indication that cognitive behavioral therapy has been effective. Page Ref: 712 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity Standards: Nursing Process: Evaluation | Learning Outcome: 29.2 Describe the etiology, pathogenesis, and clinical manifestations of anxiety and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.21. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship NLN Competencies: Relationship Centered Care: Effective Communication MNL Learning Outcome: LO 4: Examine the pathophysiology of emotional regulation and mood. 10

11) The nurse is assessing a client diagnosed with major depressive disorder (MDD). Which assessment findings will the nurse anticipate? Select all that apply. A) Mood swings B) Significant weight loss C) Diminished ability to think or concentrate D) Difficulty making decisions E) Increased or decreased appetite Answer: B, C Explanation: A) Mood swings are a characteristic of premenstrual dysphoric disorder. B) Major depressive disorder is characterized by having at least five symptoms present from this list every day during the same 2-week period: depressed mood, markedly diminished interest or pleasure in usual activities, significant weight loss, insomnia or hypersomnia, psychomotor changes (increased or decreased), fatigue, feelings of worthlessness or guilt, diminished ability to think or concentrate, and recurrent thoughts of death or suicide. C) Major depressive disorder is characterized by having at least five symptoms present from this list every day during the same 2-week period: depressed mood, markedly diminished interest or pleasure in usual activities, significant weight loss, insomnia or hypersomnia, psychomotor changes (increased or decreased), fatigue, feelings of worthlessness or guilt, diminished ability to think or concentrate, and recurrent thoughts of death or suicide. D) Difficulty making decisions and increased or decreased appetite are characteristic of persistent depressive disorder or dysthymia. E) Increased or decreased appetite are characteristic of persistent depressive disorder or dysthymia. Page Ref: 713 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity Standards: Nursing Process: Assessment | Learning Outcome: 29.3 Describe the etiology, pathogenesis, and clinical manifestations of depression and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: I.B.5. Assess levels of physical and emotional comfort | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith MNL Learning Outcome: LO 4: Examine the pathophysiology of emotional regulation and mood.

12) The nurse is providing education to a client about the role of neurotransmitters in depression. Which areas of cognition does the nurse review as being mediated by serotonin? Select all that apply. A) Interest B) Positive mood C) Drive D) Optimism E) Impulsivity Answer: B, D, E Explanation: A) Interest is mediated by norepinephrine, and drive is mediated by dopamine. B) Serotonin (5-HT) is the neurotransmitter that mediates positive mood, optimism, and impulsivity. C) Interest is mediated by norepinephrine, and drive is mediated by dopamine. D) Serotonin (5-HT) is the neurotransmitter that mediates positive mood, optimism, and impulsivity. E) Serotonin (5-HT) is the neurotransmitter that mediates positive mood, optimism, and impulsivity. Page Ref: 716 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 29.3 Describe the etiology, pathogenesis, and clinical manifestations of depression and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Examine the pathophysiology of emotional regulation and mood.

13) The nurse is caring for an older adult client with a diagnosis of major depressive disorder (MDD). What is the nurse's understanding of the presentation of depression in this client? A) It often presents by itself without other accompanying medical and neurological disorders. B) It may present in the context of cardiovascular disease, dementia, or stroke. C) It is associated with overall brain volume loss. D) It is characterized by frontostriatal changes that result in psychomotor agitation. Answer: B Explanation: A) Late-life depression often presents in the context of medical and neurologic disorders, such as cardiovascular disorders, dementia, and stroke. B) Late-life depression often presents in the context of medical and neurologic disorders, such as cardiovascular disorders, dementia, and stroke. C) The pathophysiology of late-onset depression is particularly marked by changes in the frontostriatal pathway. Anatomic studies suggest some volume loss there and in caudate structures. D) Older adults with such frontostriatal changes present with executive dysfunction, increased feelings of apathy, and psychomotor retardation. Page Ref: 719 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 29.3 Describe the etiology, pathogenesis, and clinical manifestations of depression and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: I.7. Integrate the knowledge and methods of a variety of disciplines to inform decision making NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Examine the pathophysiology of emotional regulation and mood.

14) The nurse is providing education to a client about recent brain imaging, which shows hippocampal volume loss. What is the nurse's understanding of this finding? A) Hippocampal volume loss may be linked with brief, intense bouts of stress. B) Hippocampal volume loss may be linked with depression, impaired learning, and memory. C) Underactivation of the hypothalamic-pituitary-adrenal (HPA) axis plays a role in damage to hippocampal neurons. D) Cortisol deficiency is thought to play a role in hippocampal damage. Answer: B Explanation: A) Hippocampal volume loss may be linked with depression, as well as impaired learning and memory. B) Hippocampal volume loss may be linked with depression, as well as impaired learning and memory. C) Overactivation of the hypothalamic-pituitary-adrenal (HPA) axis plays a role in damage to hippocampal neurons. D) Excess cortisol is also thought to play a role in hippocampal volume loss. Page Ref: 720 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 29.3 Describe the etiology, pathogenesis, and clinical manifestations of depression and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: I.7. Integrate the knowledge and methods of a variety of disciplines to inform decision making NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Examine the pathophysiology of emotional regulation and mood.

15) While the nurse is reviewing the client's medication list, the client notes the use of an MAO inhibitor. Which medications does the nurse understand are MAO inhibitors? A) Imipramine B) Duloxetine C) Isocarboxazid D) Bupropion E) Tranylcypromine Answer: C, E Explanation: A) Imipramine is an example of a tricyclic antidepressant. B) Isocarboxazid and tranylcypromine are both examples of MAO inhibitors. Imipramine is an Duloxetine is an examine of a serotonin and norepinephrine reuptake inhibitor (SNRI). C) Isocarboxazid and tranylcypromine are both examples of MAO inhibitors. D) Bupropion is an examine of a norepinephrine and dopamine reuptake inhibitor. E) Isocarboxazid and tranylcypromine are both examples of MAO inhibitors. Imipramine is an example of a tricyclic antidepressant. Page Ref: 721 Cognitive Level: Remembering Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Assessment | Learning Outcome: 29.3 Describe the etiology, pathogenesis, and clinical manifestations of depression and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Examine the pathophysiology of emotional regulation and mood.

16) The nurse is caring for a client with a bipolar disorder. The nurse understands that the client's condition is characterized by which types of episodes? Select all that apply. A) Hypomanic B) Seizure C) Manic D) Depressive E) Cyclothymic Answer: A, C, D Explanation: A) The bipolar disorders are a group of mood disorders characterized by manic, hypomanic, and depressive episodes. B) Seizures are not characteristic of bipolar disorders. C) The bipolar disorders are a group of mood disorders characterized by manic, hypomanic, and depressive episodes. D) The bipolar disorders are a group of mood disorders characterized by manic, hypomanic, and depressive episodes. E) Cyclothymic disorder is characterized by alternating periods of hypomanic and depressive symptoms that are not significant enough to meet the criteria for hypomania or depression, and is not considered an episode that characterizes bipolar disorders. Page Ref: 722 Cognitive Level: Understanding Client Need & Sub: Psychosocial Integrity Standards: Nursing Process: Assessment | Learning Outcome: 29.4 Describe the etiology, pathogenesis, and clinical manifestations of bipolar disorders and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Examine the pathophysiology of emotional regulation and mood.

17) The nurse is providing discharge instructions to a client recently diagnosed with a bipolar disorder. Which statement by the client indicates an understanding of the condition? A) "I have this only because it runs in my family." B) "I suffered a brain injury, and that's when it all started." C) "There's no way to know for sure how I developed this." D) "I blame the stress of my work for this condition." Answer: C Explanation: A) No definitive cause or specific pathophysiology has been identified for bipolar spectrum disorders. Rather, they are thought to arise from a complex combination of genetic, physiologic, environmental, and psychosocial factors. B) No definitive cause or specific pathophysiology has been identified for bipolar spectrum disorders. Rather, they are thought to arise from a complex combination of genetic, physiologic, environmental, and psychosocial factors. C) No definitive cause or specific pathophysiology has been identified for bipolar spectrum disorders. Rather, they are thought to arise from a complex combination of genetic, physiologic, environmental, and psychosocial factors. D) No definitive cause or specific pathophysiology has been identified for bipolar spectrum disorders. Rather, they are thought to arise from a complex combination of genetic, physiologic, environmental, and psychosocial factors. Page Ref: 723 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 29.4 Describe the etiology, pathogenesis, and clinical manifestations of bipolar disorders and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Examine the pathophysiology of emotional regulation and mood.

18) The nurse is about to administer lithium to a client with a bipolar disorder. Which statement by the client requires immediate follow up by the nurse? A) "My mouth feels dry." B) "I feel like I can't stop moving my hands." C) "I have been taking this for over two months." D) "I feel productive today." Answer: B Explanation: A) Dry mouth is an expected side effect of pharmacologic treatment of bipolar disorders, and may be due to other causes. B) The client's statement indicates the possibility of extrapyramidal effects such as Parkinsonlike symptoms (e.g. rigidity, tremor, or "pill rolling" movements of the fingers) and requires further follow up by the nurse. These symptoms may be due to an acute dystonic reaction, which may be severe and require immediate medical intervention. C) While it is important for the nurse to know how long the client has been taking lithium, this statement does not require immediate follow up by the nurse. D) Feelings of productivity on their own may or may not be related to the client's mood disorder, and thus is not the priority statement requiring follow up at this time. Page Ref: 724 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Evaluation | Learning Outcome: 29.4 Describe the etiology, pathogenesis, and clinical manifestations of bipolar disorders and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Examine the pathophysiology of emotional regulation and mood.

19) The nurse is assessing a client for hypomania. Which findings does the nurse associate with this condition? Select all that apply. A) Impaired functioning B) Euphoria C) Psychosis D) Increased energy E) Hallucinations Answer: B, D Explanation: A) Hypomania is less extreme in presentation than mania. Typically, the individual experiencing hypomania does not experience impairment in function or need hospitalization. Psychosis does not occur. Despite feelings of euphoria and increased energy during episodes of hypomania, the individual might not be aware that a change has occurred. Family members and coworkers, however, are aware of both mood and behavior changes. B) Hypomania is less extreme in presentation than mania. Typically, the individual experiencing hypomania does not experience impairment in function or need hospitalization. Psychosis does not occur. Despite feelings of euphoria and increased energy during episodes of hypomania, the individual might not be aware that a change has occurred. Family members and coworkers, however, are aware of both mood and behavior changes. C) Hypomania is less extreme in presentation than mania. Typically, the individual experiencing hypomania does not experience impairment in function or need hospitalization. Psychosis does not occur. Despite feelings of euphoria and increased energy during episodes of hypomania, the individual might not be aware that a change has occurred. Family members and coworkers, however, are aware of both mood and behavior changes. D) Hypomania is less extreme in presentation than mania. Typically, the individual experiencing hypomania does not experience impairment in function or need hospitalization. Psychosis does not occur. Despite feelings of euphoria and increased energy during episodes of hypomania, the individual might not be aware that a change has occurred. Family members and coworkers, however, are aware of both mood and behavior changes. E) Hypomania is less extreme in presentation than mania. Typically, the individual experiencing hypomania does not experience impairment in function or need hospitalization. Psychosis, including hallucinations, does not occur. Despite feelings of euphoria and increased energy during episodes of hypomania, the individual might not be aware that a change has occurred. Family members and coworkers, however, are aware of both mood and behavior changes. Page Ref: 722 Cognitive Level: Understanding Client Need & Sub: Psychosocial Integrity Standards: Nursing Process: Assessment | Learning Outcome: 29.4 Describe the etiology, pathogenesis, and clinical manifestations of bipolar disorders and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Examine the pathophysiology of emotional regulation and mood. 19

20) The nurse is teaching a community health class about the early detection and diagnosis of bipolar disorders. Which statement will the nurse include in the teaching? A) "If a child is being overly silly or joyful in a way that's unusual for the child, it is no cause for concern." B) "Pregnant women are 5-10 times more likely to be diagnosed with bipolar disorder." C) "The onset of bipolar disorders may occur at any time in life." D) "It should not be assumed that mood swings are common for teens, as this could be a sign of bipolar disorder." Answer: C Explanation: A) When a child behaves in a way that is unusual for that child, it is important to seek additional follow up to determine the underlying cause. B) Although pregnant women with an existing diagnosis of a bipolar disorder may be 5-10 times more likely to experience a bipolar episode, the incidence of diagnosis does not change with pregnancy. C) It is important for the nurse to reinforce the concept that the onset of bipolar disorder may occur at any time in life. D) Mood swings are common for adolescents, and it is important to differentiate normal changes in mood from mood disorders that may impair functioning. Page Ref: 723 Cognitive Level: Understanding Client Need & Sub: Psychosocial Integrity Standards: Nursing Process: Planning | Learning Outcome: 29.4 Describe the etiology, pathogenesis, and clinical manifestations of bipolar disorders and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Examine the pathophysiology of emotional regulation and mood.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 30 Neurocognitive and Neurodevelopmental Disorders 1) The nurse is educating a postpartum client about infant growth and development. Which statement will the nurse include in the material? A) "It is rare for infants who are carried to term to develop in predictable intervals." B) "As time passes, infants begin with simple tasks such as grasping, and later move toward more complex tasks." C) "Development refers primarily to the ability of children to communicate." D) "Cognition refers to behavioral aspects of a child's growth such as talking, walking, and running." Answer: B Explanation: A) Development involves the ability to adapt to the environment and refers to behavioral aspects of growth such as talking, walking, and running. It is common for babies who are carried to term to develop in predictable intervals. B) Growth and development begins with simple tasks such as grasping, and later moves toward more complex tasks. C) Development involves the ability to adapt to the environment and refers to behavioral aspects of growth such as talking, walking, and running. It is common for babies who are carried to term to develop in predictable intervals. D) Cognition is the way in which people acquire, store, learn, use and communication information. Page Ref: 731 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 30.1 Describe normal development and cognition, the range of disorders that affect development, and concepts related to those disorders. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders affecting mood and cognition to diagnosis and treatment.

2) The nurse is caring for a client with a permanent brain injury. What does the nurse understand about the link between this condition and cognitive pathophysiology? Select all that apply. A) Inflammation has an immediate effect on numerous neurotransmitters, leading to brain injury and cognitive dysfunction. B) Trauma is a common cause of schizophrenia and learning disabilities. C) Alzheimer disease is often a result of a traumatic brain injury leading to volume loss in key memory structures. D) Oxygen deprivation can lead to brain injury resulting in cognitive dysfunction. E) Brain function depends on a simple metabolic process which, when interrupted, results in permanent brain injury. Answer: B, D Explanation: A) Inflammation in the body does not have an immediate or permanent effect on neurotransmitters unless it is chronic in nature, in which case it can lead to brain injury and cognitive dysfunction. B) Trauma leading to permanent brain injury is a common cause of schizophrenia and learning disabilities. C) Although traumatic brain injury has been correlated with Alzheimer disease, it is not known to be a direct cause. D) Oxygen deprivation can also lead to cognitive dysfunction resulting from permanent brain injury. E) Brain function depends on a complex metabolic process that, when interrupted, results in permanent brain injury. Page Ref: 732 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 30.1 Describe normal development and cognition, the range of disorders that affect development, and concepts related to those disorders. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders affecting mood and cognition to diagnosis and treatment.

3) The nurse is caring for a client with increased intracranial pressure. Which mechanisms related to oxygenation and circulation does the nurse understand can lead to this condition? Select all that apply. A) Deficient neurochemical signaling pathways B) Impaired gas exchange C) Respiratory acidosis D) Increased vasodilation E) Decreased cerebral perfusion. Answer: B, C, D, E Explanation: A) Deficiencies in the neurochemical signaling pathway are an effect of impaired gas exchange and do not directly cause increased intracranial pressure. Increased vasodilation can lead to increased perfusion and gas exchange without other complicating factors, and is not necessarily related to an increase in intracranial pressure. B) An impairment in normal gas exchange leading to respiratory acidosis and increased CO2 levels in the body cause an increase in intracranial pressure. C) An impairment in normal gas exchange leading to respiratory acidosis and increased CO2 levels in the body cause an increase in intracranial pressure. D) An impairment in normal gas exchange leading to respiratory acidosis and increased CO2 levels in the body cause an increase in intracranial pressure. Cerebral perfusion and cognitive integrity depend on normal gas exchange and can result in brain injury when this mechanism is disrupted. Deficiencies in the neurochemical signaling pathway are an effect of impaired gas exchange and are not caused directly by increased intracranial pressure. Increased vasodilation increased blood flow, increasing intracranial pressure. E) Decreased cerebral perfusion results in brain injury and resulting increase in intracranial pressure. Page Ref: 731 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 30.1 Describe normal development and cognition, the range of disorders that affect development, and concepts related to those disorders. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders affecting mood and cognition to diagnosis and treatment.

4) The nurse is caring for a client with chronic peripheral inflammation. Which neurotransmitters considered central in cognition are affected by this condition? Select all that apply. A) Acetylcholine B) Oxytocin C) Dopamine D) Serotonin E) Glutamate Answer: A, C, D, E Explanation: A) Peripheral inflammation (outside of the central nervous system) causes a cascade of physiologic events that alter glutamate, serotonin, dopamine, and acetylcholine systems considered central in cognition, with implications for an array of affective, cognitive, and behavioral responses. B) Oxytocin is not a neurotransmitter considered central in cognition that is affected by peripheral inflammation. C) Peripheral inflammation (outside of the central nervous system) causes a cascade of physiologic events that alter glutamate, serotonin, dopamine, and acetylcholine systems considered central in cognition, with implications for an array of affective, cognitive, and behavioral responses. D) Peripheral inflammation (outside of the central nervous system) causes a cascade of physiologic events that alter glutamate, serotonin, dopamine, and acetylcholine systems considered central in cognition, with implications for an array of affective, cognitive, and behavioral responses. E) Peripheral inflammation (outside of the central nervous system) causes a cascade of physiologic events that alter glutamate, serotonin, dopamine, and acetylcholine systems considered central in cognition, with implications for an array of affective, cognitive, and behavioral responses. Page Ref: 731 Cognitive Level: Remembering Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 30.1 Describe normal development and cognition, the range of disorders that affect development, and concepts related to those disorders. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders affecting mood and cognition to diagnosis and treatment.

5) The nurse is providing education about fetal neurodevelopment and neurocognition to a client who is three months pregnant. Which factors will the nurse include in the education? Select all that apply. A) Smoking B) Maternal IQ C) Alcohol D) Nutrition Answer: A, C, D Explanation: A) Smoking, alcohol, and poor nutrition can increase fetal stress and permanently change fetal brain development. B) Maternal IQ does not influence neurodevelopment and neurocognition at this stage of development. C) Smoking, alcohol, and poor nutrition can increase fetal stress and permanently change fetal brain development. D) Smoking, alcohol, and poor nutrition can increase fetal stress and permanently change fetal brain development. Page Ref: 733-734 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 30.2 Differentiate the causes, classification, underlying pathogenesis, and mechanisms related to development of neurocognitive and neurodevelopmental disorders across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders affecting mood and cognition to diagnosis and treatment.

6) The nurse is providing education to a client with a neurocognitive development disorder. Which statement by the client requires further follow up by the nurse? A) "The specific gene has been identified that caused my disorder." B) "Maternal health can play a role in the development of disorders like mine." C) "Sometimes copy error mutations occur and result in a disorder in cognition." D) "The advanced age of my parents might have played a role in my condition." Answer: A Explanation: A) A large body of evidence supports the role of genetics in the development of neurocognitive and neurodevelopmental disorders, but the genes that are implicated and their degree of involvement vary widely among disorders, as well as among individuals. B) A large body of evidence supports the role of genetics in the development of neurocognitive and neurodevelopmental disorders, but the genes that are implicated and their degree of involvement vary widely among disorders, as well as among individuals. Advanced paternal age plays a role in the development of disorders such as autism, schizophrenia, and bipolar disorders. However, this is not yet a link between maternal health and neurocognitive development disorder. This may be a result of copy error mutations that occur as spermatogonial cells replicate across years in the life of the adult male, resulting in de novo mutations that may increase the risk for gene mutations in children. C) Advanced paternal age plays a role in the development of disorders such as autism, schizophrenia, and bipolar disorders. This may be a result of copy error mutations that occur as spermatogonial cells replicate across years in the life of the adult male, resulting in de novo mutations that may increase the risk for gene mutations in children. D) Advanced paternal age plays a role in the development of disorders such as autism, schizophrenia, and bipolar disorders. This may be a result of copy error mutations that occur as spermatogonial cells replicate across years in the life of the adult male, resulting in de novo mutations that may increase the risk for gene mutations in children. Advanced maternal age has not yet been linked to neurocognitive development disorder. Page Ref: 734 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 30.2 Differentiate the causes, classification, underlying pathogenesis, and mechanisms related to development of neurocognitive and neurodevelopmental disorders across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX. 2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders affecting mood and cognition to diagnosis and treatment.

7) The nurse is educating a postpartum client about breastfeeding. Which statement will the nurse include about the link between breastfeeding and mental health? A) "Breast milk has shown to have a positive effect on neurocognitive development." B) "Breast feeding is an nonmodifiable health behavior that has the potential to enhance development." C) "Numerous studies have shown that breastfeeding has a positive effect on children's development." D) "Breastfeeding has been linked to a lower socioeconomic status." Answer: C Explanation: A) Numerous studies have shown that breastfeeding has a positive effect on children's development. There is still debate regarding the nature of the link between breastfeeding and cognition, as it remains unclear whether it is breast milk augmenting neurological development. Regardless, breastfeeding is a modifiable health behavior that has the potential to enhance development, and is strongly related to socioeconomic status. B) Numerous studies have shown that breastfeeding has a positive effect on children's development. There is still debate regarding the nature of the link between breastfeeding and cognition, as it remains unclear whether it is breast milk augmenting neurological development. Regardless, breastfeeding is a modifiable health behavior that has the potential to enhance development, and is strongly related to socioeconomic status. C) Numerous studies have shown that breastfeeding has a positive effect on children's development. There is still debate regarding the nature of the link between breastfeeding and cognition, as it remains unclear whether it is breast milk augmenting neurological development. Regardless, breastfeeding is a modifiable health behavior that has the potential to enhance development, and is strongly related to socioeconomic status. D) Numerous studies have shown that breastfeeding has a positive effect on children's development. There is still debate regarding the nature of the link between breastfeeding and cognition, as it remains unclear whether it is breast milk augmenting neurological development. Regardless, breastfeeding is a modifiable health behavior that has the potential to enhance development, and is strongly related to socioeconomic status. Page Ref: 734 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 30.2 Differentiate the causes, classification, underlying pathogenesis, and mechanisms related to development of neurocognitive and neurodevelopmental disorders across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders affecting mood and cognition to diagnosis and treatment.

8) The nurse is reviewing the importance of maternal health with a woman who is three months pregnant. Which neurotransmitter will the nurse discuss with the client? A) Acetylcholine B) Gamma-aminobutyric acid (GABA) C) Dopamine D) Oxytocin Answer: D Explanation: A) While acetylcholine, gamma-aminobutyric acid (GABA), and dopamine may be important to discuss depending on the subjective needs of the client, oxytocin is the most relevant neurotransmitter to the client who is three months pregnant. B) While acetylcholine, gamma-aminobutyric acid (GABA), and dopamine may be important to discuss depending on the subjective needs of the client, oxytocin is the most relevant neurotransmitter to the client who is three months pregnant. C) While acetylcholine, gamma-aminobutyric acid (GABA), and dopamine may be important to discuss depending on the subjective needs of the client, oxytocin is the most relevant neurotransmitter to the client who is three months pregnant. D) Oxytocin is a neuropeptide synthesized in the hypothalamus. Linked to social engagement, plasma oxytocin levels are lower in individuals with severe depression, and this can negatively affect a mother's ability to engage with her baby. While acetylcholine, gamma-aminobutyric acid (GABA), and dopamine may be important to discuss depending on the subjective needs of the client, oxytocin is the most relevant neurotransmitter to the client who is three months pregnant. Page Ref: 734 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 30.2 Differentiate the causes, classification, underlying pathogenesis, and mechanisms related to development of neurocognitive and neurodevelopmental disorders across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders affecting mood and cognition to diagnosis and treatment.

9) The nurse is caring for a client with schizophrenia. What does the nurse understand about the prevalence of this condition? A) Schizophrenia affects approximately 3% of the population. B) Prevalence rates increase when the client is admitted for depression. C) Prevalence rates are similar across all cultures and ethnicities. D) Schizophrenia is more likely to develop in individuals residing in rural areas. Answer: C Explanation: A) Schizophrenia affects approximately 1% of the population. B) Individuals who have been hospitalized more than twice for the treatment of infections have an 80% increased risk of developing schizophrenia. Depression is not directly linked to the prevalence of schizophrenia. C) Prevalence rates for schizophrenia are similar across all cultures and ethnicities. D) Schizophrenia is more likely to develop in individuals living in urban areas. Page Ref: 735 Cognitive Level: Remembering Client Need & Sub: Psychosocial Integrity Standards: Nursing Process: Assessment | Learning Outcome: 30.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of schizophrenia and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders affecting mood and cognition to diagnosis and treatment.

10) The nurse is assessing a client with suspected formal thought disorder (FTD). Which findings does the nurse understand are consistent with this condition? Select all that apply. A) Abnormally slow speech B) Pressured or distracted speech C) Perseveration D) Poverty of speech E) Word salad Answer: B, D, E Explanation: A) Symptoms of formal thought disorder (FTD) include pressured or distracted speech that exhibits as rapid, often tangential speech with an extreme sense of urgency, not abnormally slow speech. B) Symptoms of formal thought disorder (FTD) include pressured or distracted speech that exhibits as rapid, often tangential speech with an extreme sense of urgency; poverty of speech, which is an absence of spontaneous speech; loose associations, in which the individual's ideas seem unrelated to the topic at hand or take another direction altogether; and word salad, speech that consists of meaningless phrases and words that are made up (neologisms), random, or not connected to each other or the current topic. C) Perseveration refers to the repetition of a particular response regardless of the absence or cessation of a stimulus, and is not a finding consistent with FTD. D) Symptoms of formal thought disorder (FTD) include pressured or distracted speech that exhibits as rapid, often tangential speech with an extreme sense of urgency; poverty of speech, which is an absence of spontaneous speech; loose associations, in which the individual's ideas seem unrelated to the topic at hand or take another direction altogether; and word salad, speech that consists of meaningless phrases and words that are made up (neologisms), random, or not connected to each other or the current topic. E) Symptoms of formal thought disorder (FTD) include pressured or distracted speech that exhibits as rapid, often tangential speech with an extreme sense of urgency; poverty of speech, which is an absence of spontaneous speech; loose associations, in which the individual's ideas seem unrelated to the topic at hand or take another direction altogether; and word salad, speech that consists of meaningless phrases and words that are made up (neologisms), random, or not connected to each other or the current topic. Page Ref: 736 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 30.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of schizophrenia and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders affecting mood and cognition to diagnosis and treatment.

11) The nurse is educating the family of a client about the negative symptoms of schizophrenia spectrum disorder. Which symptoms will the nurse review in the material? Select all that apply. A) Memory deficits B) Delusions C) Hallucinations D) Social withdrawal E) Avolition Answer: D, E Explanation: A) Memory deficits are considered a cognitive symptom of schizophrenia spectrum disorder. B) Delusions and hallucinations are considered positive symptoms of schizophrenia spectrum disorder. C) Delusions and hallucinations are considered positive symptoms of schizophrenia spectrum disorder. D) Negative symptoms of schizophrenia spectrum disorder include diminished affects and behaviors: flat or blunted affect, thought blocking, avolition, poverty of speech, and social withdrawal. E) Negative symptoms of schizophrenia spectrum disorder include diminished affects and behaviors: flat or blunted affect, thought blocking, avolition, poverty of speech, and social withdrawal. Page Ref: 736 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity Standards: Nursing Process: Planning | Learning Outcome: 30.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of schizophrenia and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders affecting mood and cognition to diagnosis and treatment.

12) A client with schizophrenia asks the nurse, "What are my chances for recovery?" What response should the nurse give? A) "The right medications have proven to be extremely effective in assisting with recovery." B) "Substantial recovery can occur with appropriate treatment and support." C) "Although treatment may help with symptoms, there is no cure for schizophrenia." D) "Lack of clinical insight is one of the most important features of recovery." Answer: B Explanation: A) Pharmacological interventions have so far had limited effectiveness for improving negative symptoms o cognitive deficits of schizophrenia. B) Substantial recovery can occur with the appropriate treatment and support with a diagnosis of schizophrenia. Schizophrenia is now seen as a disorder that affects the individual episodically and from which many, if not most, patients will recover substantially with appropriate treatment and supports. C) Schizophrenia is now seen as a disorder that affects the individual episodically and from which many, if not most, patients will recover substantially with appropriate treatment and supports; however, there is no cure for schizophrenia. D) Lack of clinical insight has been accepted as one of the most important features of schizophrenia. Insight can be defined as the awareness of having a mental disorder, of specific symptoms and their attribution to the disorder, of social consequences, and of need for treatment. Page Ref: 736 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity Standards: Nursing Process: Implementation | Learning Outcome: 30.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of schizophrenia and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders affecting mood and cognition to diagnosis and treatment.

13) The nurse is caring for a client with delirium. What does the nurse understand about the onset of this condition? A) It is rapid in onset and may last between hours and days. B) It is chronic and insidious in nature and is progressive in onset. C) It is typically episodic in nature and variable in onset. D) It is characterized by developing late in life and is caused by brain disease or injury. Answer: A Explanation: A) Delirium is rapid in onset and may last between hours and days. B) Dementia, as opposed to delirum, is chronic and insidious in nature and is progressive in onset, characterized by developing late in life and being cause by brain disease or injury. C) Depression is typically episodic in nature and variable in onset. D) Dementia, not delirium, is chronic and insidious in nature and is progressive in onset, characterized by developing late in life and being cause by brain disease or injury. Page Ref: 737 Cognitive Level: Understanding Client Need & Sub: Psychosocial Integrity Standards: Nursing Process: Assessment | Learning Outcome: 30.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of neurocognitive disorders and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders affecting mood and cognition to diagnosis and treatment.

14) The nurse is caring for a patient diagnosed with Alzheimer disease. What does the nurse understand to be objectives identified for Alzheimer disease as defined by Healthy People 2020? Select all that apply. A) Reduce the proportion of preventable hospitalizations in adults aged 65 and older with diagnosed Alzheimer disease or other dementias. B) Reduce the proportion of preventable cases of Alzheimer disease and other dementias in adults aged 65 and older. C) Increase the number of adults aged 65 and older on active pharmacological treatment for Alzheimer disease and other dementias. D) Increase the proportion of adults aged 65 and older with diagnosed Alzheimer disease and other dementias, or their caregivers, who are aware of the diagnosis. E) Reduce the proportion of adults aged 65 and older who require long term care as a result of Alzheimer disease or other dementias. Answer: A, D Explanation: A) The objectives identified by Healthy People 2020 are: increase the proportion of adults aged 65 years and older with diagnosed Alzheimer disease and other dementias, or their caregivers, who are aware of the diagnosis; and reduce the proportion of preventable hospitalizations in adults aged 65 years and older with diagnosed Alzheimer disease and other dementias. B) The objectives identified by Healthy People 2020 are: increase the proportion of adults aged 65 years and older with diagnosed Alzheimer disease and other dementias, or their caregivers, who are aware of the diagnosis; and reduce the proportion of preventable hospitalizations in adults aged 65 years and older with diagnosed Alzheimer disease and other dementias. C) The objectives identified by Healthy People 2020 are: increase the proportion of adults aged 65 years and older with diagnosed Alzheimer disease and other dementias, or their caregivers, who are aware of the diagnosis; and reduce the proportion of preventable hospitalizations in adults aged 65 years and older with diagnosed Alzheimer disease and other dementias. D) The objectives identified by Healthy People 2020 are: increase the proportion of adults aged 65 years and older with diagnosed Alzheimer disease and other dementias, or their caregivers, who are aware of the diagnosis; and reduce the proportion of preventable hospitalizations in adults aged 65 years and older with diagnosed Alzheimer disease and other dementias. E) The objectives identified by Healthy People 2020 are: increase the proportion of adults aged 65 years and older with diagnosed Alzheimer disease and other dementias, or their caregivers, who are aware of the diagnosis; and reduce the proportion of preventable hospitalizations in adults aged 65 years and older with diagnosed Alzheimer disease and other dementias. Page Ref: 737 Cognitive Level: Understanding Client Need & Sub: Psychosocial Integrity Standards: Nursing Process: Assessment | Learning Outcome: 30.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of neurocognitive disorders and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care 14

MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders affecting mood and cognition to diagnosis and treatment. 15) The nurse is educating the family of a client diagnosed with Alzheimer disease about the cause of this condition. Which statements will the nurse include in the teaching? Select all that apply. A) "Enlargement of the hippocampus occurs." B) "The death of brain cells occurs." C) "This is an inherited genetic condition." D) "A buildup of proteins occurs in the brain." E) "A series of small strokes leads to changes in thinking." Answer: B, D Explanation: A) An effect of Alzheimer disease is enlargement of the ventricles, not enlargement of the hippocampus. B) Ultimately, Alzheimer disease results in the death of brain cells due to a buildup in proteins that causes interference of neuronal transport and a thinning of the cortex. C) Although there is thought to be a genetic component to the development of Alzheimer disease, the cause of Alzheimer disease is not yet fully understood. D) Ultimately, Alzheimer disease results in the death of brain cells due to a buildup in proteins that causes interference of neuronal transport and a thinning of the cortex. E) Vascular dementia is associated with changes in thinking following a series of small strokes, not Alzheimer disease. Page Ref: 738 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 30.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of neurocognitive disorders and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders affecting mood and cognition to diagnosis and treatment.

16) The nurse is reviewing the plan of care for a client with delirium. Which interventions will the nurse include in the care for this client? Select all that apply. A) Apply arm restraints to prevent self harm B) Allow client to eat alone during mealtimes C) Provide a calm, well-lit environment D) Reduce sound in the client's room at night E) Avoid constant observation to increase autonomy and security Answer: C, D Explanation: A) Physical restraints should be avoided and other measures should be taken to reduce the risk of harm. B) Nutrition should be given carefully because the client may be unwilling or unable to maintain a balanced intake. Additionally, a client who is experiencing delirium should not be left alone toeat do to a risk of aspiration and injury. C) The client's room should be stable, quiet, and well lit to reduce symptoms. D) Reduction in sound during the night may reduce symptoms. E) Severely delirious clients benefit from constant observation, which may be cost effective for these patients and help to avoid the use of physical restraints, which can exacerbate or extend the delirium. These clients should never be left alone or unattended. Page Ref: 739 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 30.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of neurocognitive disorders and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders affecting mood and cognition to diagnosis and treatment.

17) The nurse is educating the parent of a 7-year-old child during a well-child visit about the symptoms of attention-deficit/hyperactivity disorder (ADHD). Which symptoms will the nurse review in the teaching? Select all that apply. A) Continual fidgeting B) Excessive daydreaming C) Unnecessary risk taking D) Trouble taking turns E) Excessive anxiety Answer: A, B, C, D Explanation: A) The symptoms of attention-deficit/hyperactivity disorder (ADHD) can include: daydreaming a lot, forgetting or losing things a lot, squirming or fidgeting, talking too much, making careless mistakes or taking unnecessary risks, having a hard time resisting temptation, having trouble taking turns, and having difficulty getting along with others. B) The symptoms of attention-deficit/hyperactivity disorder (ADHD) can include: daydreaming a lot, forgetting or losing things a lot, squirming or fidgeting, talking too much, making careless mistakes or taking unnecessary risks, having a hard time resisting temptation, having trouble taking turns, and having difficulty getting along with others. C) The symptoms of attention-deficit/hyperactivity disorder (ADHD) can include: daydreaming a lot, forgetting or losing things a lot, squirming or fidgeting, talking too much, making careless mistakes or taking unnecessary risks, having a hard time resisting temptation, having trouble taking turns, and having difficulty getting along with others. D) The symptoms of attention-deficit/hyperactivity disorder (ADHD) can include: daydreaming a lot, forgetting or losing things a lot, squirming or fidgeting, talking too much, making careless mistakes or taking unnecessary risks, having a hard time resisting temptation, having trouble taking turns, and having difficulty getting along with others. E) Excessive anxiety is not considered to be a characteristic of ADHD. Page Ref: 740 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 30.5 Differentiate the genetics and genomics, classification, underlying pathogenesis, and clinical manifestations of neurodevelopmental disorders and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders affecting mood and cognition to diagnosis and treatment.

18) The nurse is assessing an older adult client with suspected attention-deficit/hyperactivity disorder (ADHD). What does the nurse understand about the diagnosis and treatment of ADHD in this age group? Select all that apply. A) The number of older adults diagnosed with ADHD is increasing due to increased media attention. B) ADHD continues to impair function into adulthood. C) Patterns in functional impairment are similar between adults and children with ADHD. D) Individualized therapy is important in older adults with ADHD. E) ADHD diagnosis and treatment in older adults is a well-researched area of psychiatric health. Answer: B, D Explanation: A) The number of older adults diagnosed with attention-deficit/hyperactivity disorder (ADHD) is increasing due to an increased number of adults seeking diagnosis and treatment for ADHD, not due to increased media attention. B) ADHD continues to impair function into adulthood, resulting in different patterns of impairment between children and adults. C) ADHD continues to impair function into adulthood, resulting in different patterns of impairment between children and adults. D) ADHD diagnosis and treatment in older adults is a virtually unexplored area of psychiatric health, which makes individualized therapy important in older adult clients with ADHD. E) ADHD diagnosis and treatment in older adults is a virtually unexplored area of psychiatric health. Page Ref: 741 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 30.5 Differentiate the genetics and genomics, classification, underlying pathogenesis, and clinical manifestations of neurodevelopmental disorders and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders affecting mood and cognition to diagnosis and treatment.

19) The nurse is teaching a community health class about autism spectrum disorder (ASD). What statement will the nurse include in the teaching? A) "Individuals with ASD have similarly impaired capacities for learning, thinking, and problem solving." B) "Individuals with ASD have a distinct appearance that sets them apart from their peers." C) "Individuals with ASD may have one of several conditions." D) "Individuals with ASD undergo a specific test to determine the underlying cause of the disorder." Answer: C Explanation: A) The learning, thinking, and problem solving abilities of people with autism spectrum disorder (ASD) occur across a spectrum or continuum. Some individuals with ASD need a lot of help in their daily lives; others need less. B) Individuals with ASD appear no different than their peers. C) A diagnosis of ASD now includes several conditions that used to be diagnosed separately: autistic disorder, pervasive developmental disorder not otherwise specified, and Asperger syndrome. D) There is no specific medical test to diagnose or determine the underlying cause of ASD. ASD is typically diagnosed with a series of diagnostic tests, as well as a complete history of symptoms. Page Ref: 741 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 30.5 Differentiate the genetics and genomics, classification, underlying pathogenesis, and clinical manifestations of neurodevelopmental disorders and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders affecting mood and cognition to diagnosis and treatment.

20) The nurse is assessing a four-year old child with suspected fetal alcohol syndrome. What assessment findings will the nurse anticipate? Select all that apply. A) Deficiency in height and weight B) Excessive forgetfulness C) Thin upper lip D) Hearing problems E) Stereotyped behavioral patterns Answer: A, C Explanation: A) The typical clinical presentation of FAS includes a deficiency in the weight and height growth before and after birth, abnormalities in the neurodevelopment of the nervous central system, and a series of typical facial abnormalities, including small palpebral fissures, a thin upper lip, and a smooth philtrum. B) Excessive forgetfulness is characteristic of attention-deficit hyperactivity disorder (ADHD), not FAS. C) The typical clinical presentation of FAS includes a deficiency in the weight and height growth before and after birth, abnormalities in the neurodevelopment of the nervous central system, and a series of typical facial abnormalities, including small palpebral fissures, a thin upper lip, and a smooth philtrum. D) Hearing problems are associated with Down syndrome, not FAS. E) Restricted, repetitive and/or stereotyped behavioral patterns are characteristic of autism spectrum disorder (ASD), not FAS. Page Ref: 743 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 30.5 Differentiate the genetics and genomics, classification, underlying pathogenesis, and clinical manifestations of neurodevelopmental disorders and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders affecting mood and cognition to diagnosis and treatment.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 31 Disorders of Hearing, Balance, and Vision 1) Following Healthy People 2020 guidelines for hearing, when should the pediatric nurse recommend to new parents that their baby be screened for hearing loss? A) By 1 month of age B) By 3 months of age C) By 6 months of age D) By 1 year of age Answer: A Explanation: A) Healthy People 2020 guidelines recommend that newborns be screened for hearing loss no later than age 1 month, have audiologic evaluation by age 3 months, and are enrolled in appropriate intervention services no later than age 6 months. B) Healthy People 2020 guidelines recommend that newborns be screened for hearing loss no later than age 1 month, have audiologic evaluation by age 3 months, and are enrolled in appropriate intervention services no later than age 6 months. C) Healthy People 2020 guidelines recommend that newborns be screened for hearing loss no later than age 1 month, have audiologic evaluation by age 3 months, and are enrolled in appropriate intervention services no later than age 6 months. D) Healthy People 2020 guidelines recommend that newborns be screened for hearing loss no later than age 1 month, have audiologic evaluation by age 3 months, and are enrolled in appropriate intervention services no later than age 6 months. Page Ref: 752 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 31.1 Describe disorders of sensation and concepts related to disorders of hearing, vision, and balance. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of hearing, balance, and vision disorders.

2) When performing an assessment on a patient reporting hearing loss, which cranial nerve would the nurse include in the assessment? A) Cranial nerve I B) Cranial nerve III C) Cranial nerve V D) Cranial nerve VIII Answer: D Explanation: A) Cranial nerve VIII is the vestibulocochlear nerve and is responsible for hearing and balance. B) Cranial nerve VIII is the vestibulocochlear nerve and is responsible for hearing and balance. C) Cranial nerve VIII is the vestibulocochlear nerve and is responsible for hearing and balance. D) Cranial nerve VIII is the vestibulocochlear nerve and is responsible for hearing and balance. Page Ref: 755 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 31.2 Describe the auditory and vestibular pathways, and identify critical peripheral and central structures involved in processing hearing and balance information. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of hearing, balance, and vision disorders.

3) Which concept should the nurse keep in mind when developing a care plan for a patient with conductive hearing loss? A) Conductive hearing loss is due to problems in the inner ear. B) The volume of sound that reaches the inner ear is increased. C) Sound is processed normally by the inner ear. D) Hearing loss of this type is due to problems in the cerebral cortex. Answer: C Explanation: A) Problems that affect the outer and middle ear system structures prevent sound from traveling normally to the inner ear. The result is a conductive hearing loss. A conductive hearing loss reflects an audibility problem. Loss of the natural acoustic benefits of the outer ear and/or the impedance matching of the middle ear structures reduces the intensity (volume) of the sound that reaches the inner ear. So although sounds can be processed normally in the inner ear, they are no longer as loud as they should be when they reach that part of the auditory system. B) Problems that affect the outer and middle ear system structures prevent sound from traveling normally to the inner ear. The result is a conductive hearing loss. A conductive hearing loss reflects an audibility problem. Loss of the natural acoustic benefits of the outer ear and/or the impedance matching of the middle ear structures reduces the intensity (volume) of the sound that reaches the inner ear. So although sounds can be processed normally in the inner ear, they are no longer as loud as they should be when they reach that part of the auditory system. C) Problems that affect the outer and middle ear system structures prevent sound from traveling normally to the inner ear. The result is a conductive hearing loss. A conductive hearing loss reflects an audibility problem. Loss of the natural acoustic benefits of the outer ear and/or the impedance matching of the middle ear structures reduces the intensity (volume) of the sound that reaches the inner ear. So although sounds can be processed normally in the inner ear, they are no longer as loud as they should be when they reach that part of the auditory system. D) Problems that affect the outer and middle ear system structures prevent sound from traveling normally to the inner ear. The result is a conductive hearing loss. A conductive hearing loss reflects an audibility problem. Loss of the natural acoustic benefits of the outer ear and/or the impedance matching of the middle ear structures reduces the intensity (volume) of the sound that reaches the inner ear. So although sounds can be processed normally in the inner ear, they are no longer as loud as they should be when they reach that part of the auditory system. Page Ref: 755 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 31.2 Describe the auditory and vestibular pathways, and identify critical peripheral and central structures involved in processing hearing and balance information. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of hearing, balance, and vision disorders.

4) Which response should the nurse give the parent who is concerned about permanent hearing loss in her child with one episode of acute otitis media (AOM)? A) "Hearing loss is temporary and should pose no problem." B) "This one episode of AOM can develop into permanent hearing loss." C) "Make an appointment to have your child's hearing tested after the infection is resolved." D) "Don't worry, hearing aids are very effective." Answer: A Explanation: A) Although conductive hearing loss can be associated with AOM, given its relatively short duration, the hearing loss is typically temporary. Therefore, the parent should be reassured that the child's hearing well improve once the infection is resolved. In recurrent AOM, hearing loss is a consideration, and hearing testing is done after resolution of the infections. B) Although conductive hearing loss can be associated with AOM, given its relatively short duration, the hearing loss is typically temporary. Therefore, the parent should be reassured that the child's hearing well improve once the infection is resolved. In recurrent AOM, hearing loss is a consideration, and hearing testing is done after resolution of the infections. C) Because hearing loss with AOM is typically temporary, there is no need to have the child's hearing tested after the infection is resolved. In recurrent AOM, hearing loss is a consideration, and hearing testing is done after resolution of the infections. D) Because hearing loss is temporary, talking about hearing aids is not an appropriate response. In recurrent AOM, hearing loss is a consideration, and hearing testing is done after resolution of the infections. Page Ref: 757-758 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 31.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of conductive hearing loss and approaches to treatment of those conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of hearing, balance, and vision disorders to diagnosis and treatment.

5) An nursing assessment of a patient with otosclerosis is likely to reveal: A) unilateral hearing loss. B) conductive hearing loss. C) an acute loss of hearing. D) sensorineural hearing loss. Answer: B Explanation: A) Hearing loss from otosclerosis is typically bilateral, slowly progressive, and conductive in nature. B) Hearing loss from otosclerosis is typically bilateral, slowly progressive, and conductive in nature. C) Hearing loss from otosclerosis is typically bilateral, slowly progressive, and conductive in nature. D) Hearing loss from otosclerosis is typically bilateral, slowly progressive, and conductive in nature. Page Ref: 758 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 31.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of conductive hearing loss and approaches to treatment of those conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Effective Communication MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of hearing, balance, and vision disorders.

6) A patient with otosclerosis tells the nurse she can hear better in a noisy room. The nurse explains that this is called: A) tinnitus. B) paracusis Willisii. C) presbycusis. D) vertigo. Answer: B Explanation: A) Tinnitus, the subjective experience of hearing a noise such as ringing, buzzing, or hissing in the head or ears in the absence of any external noise, is a common symptom among individuals with otosclerosis. B) The ability of a person with otosclerosis to hear better in a noisy environment is known as paracusis Willisii. C) Hearing loss due to aging is commonly referred to as presbycusis. D) Vertigo is a false sensation of rotation of oneself or one's environment that may be accompanied by intense nausea and vomiting. Page Ref: 759, 755 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 31.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of conductive hearing loss and approaches to treatment of those conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of hearing, balance, and vision disorders.

7) Which statement by a patient receiving an osseointegrated hearing implant indicates to the nurse that teaching about the implant has been effective? A) "The implant works by improving middle ear conduction of sound." B) "The device helps with sensorineural hearing loss." C) "The device amplifies sound traveling to the eardrum." D) "The implant uses bone conduction to stimulate the inner ear." Answer: D Explanation: A) Osseointegrated hearing implants are a relatively new option for individuals with otosclerosis. These devices are surgically implanted and use bone conduction of sound to stimulate the inner ear, thus bypassing the conductive component of the hearing loss caused by otosclerosis. Middle ear conduction of sound is not improved; rather, it is bypassed by the implant. B) This implant does not help with sensorineural hearing loss. Instead, it bypasses conductive hearing loss. C) Middle ear conduction of sound is not improved; rather, it is bypassed by the implant. D) Osseointegrated hearing implants are a relatively new option for individuals with otosclerosis. These devices are surgically implanted and use bone conduction of sound to stimulate the inner ear, thus bypassing the conductive component of the hearing loss caused by otosclerosis. Page Ref: 759 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 31.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of conductive hearing loss and approaches to treatment of those conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of hearing, balance, and vision disorders to diagnosis and treatment.

8) The nurse plans care for a patient with presbycusis by taking which of the following into account? A) Lower frequency hearing is lost more than high frequency hearing. B) Higher frequency hearing is lost more than low frequency hearing. C) It is a form of conductive hearing loss. D) Understanding speech in a quiet room is difficult. Answer: B Explanation: A) Mean audiometric thresholds as a function of age show decreased highfrequency hearing loss as compared to lower frequencies. B) Mean audiometric thresholds as a function of age show decreased high-frequency hearing loss as compared to lower frequencies. C) The inner ear and auditory pathway are vulnerable to structural aging changes that can result in sensorineural hearing loss, such as presbycusis. D) Although speech understanding in quiet remains stable with age, older listeners experience greater difficulty understanding comfortably loud speech in the presence of background noise. Page Ref: 759-760 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 31.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of sensorineural hearing loss and approaches to treatment of those conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of hearing, balance, and vision disorders to diagnosis and treatment.

9) When providing discharge instructions to a patient with Ménière disease, which instruction should the nurse include? A) Increase sodium in the diet. B) Avoid vestibular suppressant medications. C) Identify and avoid triggering allergens. D) Avoid antinausea medications. Answer: C Explanation: A) Adherence to a strict low-salt diet has been found to effectively reduce the intensity of symptoms in some patients by reducing fluid and pressure in the ear. B) Antinausea, antiemetic, and vestibular suppressant medications are generally prescribed to help Ménière sufferers manage their severe vertiginous symptoms. C) Avoidance of any possible triggering allergens should be included in any medical management plan for Ménière disease. D) Antinausea, antiemetic, and vestibular suppressant medications are generally prescribed to help Ménière sufferers manage their severe vertiginous symptoms. Page Ref: 761 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 31.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of sensorineural hearing loss and approaches to treatment of those conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of hearing, balance, and vision disorders to diagnosis and treatment.

10) The occupational safety nurse in a manufacturing plant is developing an employee program to prevent hearing loss. Which statement by a participant indicates that more teaching is needed? A) "I should limit exposure to 85 dB to not more than 8 hours per day." B) "The louder the noise, the less time I should be exposed to it." C) "I should cut exposure in half for every 3-dB increase in noise intensity." D) "Noise outside of work will not affect my hearing." Answer: D Explanation: A) The National Institute for Occupational Safety and Health (NIOSH) promotes an allowable exposure limit of 8 hours per day for an 85-dB sound and applies a reduction in that time exposure limit as the intensity of the sound increases above 85 dB. B) Following NIOSH calculations, time exposure is cut in half for each 3-dB increase in the noise intensity (a doubling of the energy). C) Following NIOSH calculations, time exposure is cut in half for each 3-dB increase in the noise intensity (a doubling of the energy). D) Noise-induced hearing loss can result either from prolonged exposure to a high-intensity noise, at work or at home, such as a jackhammer or leafblower, or from a single exposure to a brief but intense impulse sound, such as a gunshot close to the ear or a fireworks explosion. Page Ref: 762 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 31.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of sensorineural hearing loss and approaches to treatment of those conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of hearing, balance, and vision disorders.

11) Which information would the nurse give to a family with a newborn with a hearing loss? A) Genetic testing is not recommended because it will not restore newborn hearing. B) Genetic testing can help families determine risk recurrence. C) Genetic testing cannot help determine if hearing aids will help improve hearing. D) Genetic testing will not affect treatment. Answer: B Explanation: A) While genetic testing cannot restore hearing loss, it can help to direct further diagnostic testing, treatment, and rehabilitative intervention; and genetic counseling can inform families not only about the nature and progression of a disorder but also about recurrence risk related to a specific inheritance pattern. B) While genetic testing cannot restore hearing loss, it can help to direct further diagnostic testing, treatment, and rehabilitative intervention; and genetic counseling can inform families not only about the nature and progression of a disorder but also about recurrence risk related to a specific inheritance pattern. C) While genetic testing cannot restore determine if hearing aids are indicated, it can help to direct further diagnostic testing, treatment, and rehabilitative intervention; and genetic counseling can inform families not only about the nature and progression of a disorder but also about recurrence risk related to a specific inheritance pattern. D) Genetic testing can help to direct further diagnostic testing, treatment, and rehabilitative intervention. Page Ref: 765 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 31.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of sensorineural hearing loss and approaches to treatment of those conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX. 2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of hearing, balance, and vision disorders.

12) Which instruction should the nurse give to the parent of a 4-year-old child with bacterial conjunctivitis? A) The child may attend daycare as long as he does not touch his eyes. B) There is no need to notify daycare because the bacteria does not survive on dry surfaces. C) The parent and child should wash hands frequently. D) There is no need to wash bedding and towels. Answer: C Explanation: A) Children with bacterial conjunctivitis should be removed from school and/or daycare settings until their healthcare provider indicates that they are no longer contagious, regardless of whether or not they touch their eyes. B) Caregivers and teachers should be notified so that appropriate steps can be taken to thoroughly clean shared surfaces, thereby reducing the risk of spreading bacterial conjunctivitis to other children. C) Patients with infectious conjunctivitis should be counseled to avoid touching their eyes and to wash their hands frequently. D) Bedding and towels should be washed frequently to avoid spreading and reinfection. Page Ref: 767-768 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Implementation | Learning Outcome: 31.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of external eye pathologies and approaches to treatment of those conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of hearing, balance, and vision disorders to diagnosis and treatment.

13) Which statement indicates to the nurse that the patient understands his blurred vision caused by astigmatism? A) "Light focuses in front of my retina making far objects blurry." B) "My eye has an elliptical shape making objects blurry." C) "Light focus behind my retina, making near objects blurry." D) "I need reading glasses to read." Answer: B Explanation: A) Myopia, or nearsightedness, is caused by an eye that has a long axial length. Light entering a "long eye" focuses short of the retina, making distant objects blurry while leaving vision for near objects unaffected. B) In astigmatism, the eye has an elliptical shape rather than a spherical shape; as a result, light focuses on two different points in the eye. Astigmatic refractive errors can make objects both far away and up close appear blurry. C) Hyperopia, or farsightedness, results when an eye has a short axial length, causing light to focus "behind" the retina. Individuals with hyperopia have difficulty seeing near objects clearly but can see objects at distance relatively well. D) Presbyopia develops when the ciliary muscle that controls the shape of the lens is no longer able to function properly, resulting in a decline in the accommodative (focusing) ability. Presbyopia results in difficulty viewing objects, such as reading materials, at close range. Page Ref: 769 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 31.7 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of vision pathologies and approaches to treatment of those conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of hearing, balance, and vision disorders.

14) Which finding would the nurse expect during a history and physical exam of a child with refractive amblyopia? A) One eye has normal vision. B) Both eyes have high refractive errors. C) With corrective lenses, the affected eye can see clearly. D) The affected eye has an abnormal appearance. Answer: A Explanation: A) Amblyopia is a condition in which one or both eyes cannot see clearly despite corrective lenses and a normal, healthy ocular appearance. In refractive amblyopia, one eye has normal vision, and the other eye has a high refractive error that goes untreated. B) Amblyopia is a condition in which one or both eyes cannot see clearly despite corrective lenses and a normal, healthy ocular appearance. In refractive amblyopia, one eye has normal vision, and the other eye has a high refractive error that goes untreated. C) Amblyopia is a condition in which one or both eyes cannot see clearly despite corrective lenses and a normal, healthy ocular appearance. D) Amblyopic eyes appear normal and healthy despite the fact that the "wiring" to the brain was interrupted during the person's formative years. Page Ref: 769 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 31.7 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of vision pathologies and approaches to treatment of those conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of hearing, balance, and vision disorders.

15) During a community health fair, which information on risk factors for glaucoma should the nurse present? A) Diabetes increases the risk for glaucoma. B) The risk for glaucoma is not hereditary. C) The risk for glaucoma increases beginning after age 30. D) The risk is higher in Caucasian people. Answer: A Explanation: A) Risk factors for glaucoma include age greater than 40 years, family history, African or Hispanic heritage, need for corrective lenses, previous history of eye injury, thinning of the optic nerve, and systemic health issues such as diabetes. B) Risk factors for glaucoma include age greater than 40 years, family history, African or Hispanic heritage, need for corrective lenses, previous history of eye injury, thinning of the optic nerve, and systemic health issues such as diabetes. C) Risk factors for glaucoma include age greater than 40 years, family history, African or Hispanic heritage, need for corrective lenses, previous history of eye injury, thinning of the optic nerve, and systemic health issues such as diabetes. D) Risk factors for glaucoma include age greater than 40 years, family history, African or Hispanic heritage, need for corrective lenses, previous history of eye injury, thinning of the optic nerve, and systemic health issues such as diabetes. Page Ref: 770 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 31.7 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of vision pathologies and approaches to treatment of those conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of hearing, balance, and vision disorders.

16) In caring for a patient with open-angle glaucoma, which medication class of eye drops can the nurse anticipate administering to reduce the production of aqueous humor? A) Beta blockers B) Alpha agonists C) Carbonic anhydrase inhibitors D) Cholinergics Answer: D Explanation: A) Medical management is directed toward reducing the intraocular pressure with the use of eyedrops that either lower the production of aqueous humor (prostaglandins, cholinergics) or increase the outflow of aqueous humor (beta blockers, alpha agonists, and carbonic anhydrase inhibitors). B) Medical management is directed toward reducing the intraocular pressure with the use of eyedrops that either lower the production of aqueous humor (prostaglandins, cholinergics) or increase the outflow of aqueous humor (beta blockers, alpha agonists, and carbonic anhydrase inhibitors). C) Medical management is directed toward reducing the intraocular pressure with the use of eyedrops that either lower the production of aqueous humor (prostaglandins, cholinergics) or increase the outflow of aqueous humor (beta blockers, alpha agonists, and carbonic anhydrase inhibitors). D) Medical management is directed toward reducing the intraocular pressure with the use of eyedrops that either lower the production of aqueous humor (prostaglandins, cholinergics) or increase the outflow of aqueous humor (beta blockers, alpha agonists, and carbonic anhydrase inhibitors). Page Ref: 770 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Implementation | Learning Outcome: 31.7 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of vision pathologies and approaches to treatment of those conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of hearing, balance, and vision disorders to diagnosis and treatment.

17) Following an ophthalmologic exam with dilating drops, a patient calls the clinic to report eye pain and seeing halos around lights. The nurse realizes that this may be narrow-angle glaucoma due to the angle between the iris and cornea being blocked. Which advice should the nurse give to the patient? A) "This is normal and will go away as the dilating drops wear off." B) "Have someone drive you to the clinic to be evaluated immediately." C) "Call the clinic in the morning if these symptoms continue." D) "Take acetaminophen to relieve the pain." Answer: B Explanation: A) Usually treated as an emergency, closed-angle glaucoma, also called narrowangle glaucoma, occurs when the angle between the iris and cornea is blocked. The patient should be seen immediately in the clinic to lower the intraocular pressure through the use of miotic eyedrops, carbonic anhydrase inhibitors, and acetazolamide. B) Usually treated as an emergency, closed-angle glaucoma, also called narrow-angle glaucoma, occurs when the angle between the iris and cornea is blocked. Symptoms of closed-angle glaucoma include a dilated pupil that does not react to light, a "steamy" looking cornea, redness, and pain. Vomiting and blurred vision in the form of halos and glare around lights may also occur. The patient should be seen immediately in the clinic to lower the intraocular pressure through the use of miotic eyedrops, carbonic anhydrase inhibitors, and acetazolamide. C) Usually treated as an emergency, closed-angle glaucoma, also called narrow-angle glaucoma, occurs when the angle between the iris and cornea is blocked. The patient should be seen immediately in the clinic to lower the intraocular pressure through the use of miotic eyedrops, carbonic anhydrase inhibitors, and acetazolamide. D) Usually treated as an emergency, closed-angle glaucoma, also called narrow-angle glaucoma, occurs when the angle between the iris and cornea is blocked. The patient should be seen immediately in the clinic to lower the intraocular pressure through the use of miotic eyedrops, carbonic anhydrase inhibitors, and acetazolamide. Page Ref: 770 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 31.7 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of vision pathologies and approaches to treatment of those conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of hearing, balance, and vision disorders to diagnosis and treatment.

18) Which statement is typical of a patient with recently diagnosed open-angle glaucoma? A) "I have difficulty seeing objects to the sides." B) "My central vision is getting blurry." C) "I have pain in my eyes." D) "I am seeing floaters." Answer: A Explanation: A) In open-angle glaucoma there are no symptoms or warning signs during the early stages of the disease. Peripheral vision is affected first, but these changes often go unnoticed because central vision is not involved. If glaucoma goes undiagnosed or untreated, the vision loss gradually affects the central portion of the patient's vision. B) In open-angle glaucoma there are no symptoms or warning signs during the early stages of the disease. Peripheral vision is affected first, but these changes often go unnoticed because central vision is not involved. If glaucoma goes undiagnosed or untreated, the vision loss gradually affects the central portion of the patient's vision. C) Open-angle glaucoma is not associated with pain. Pain occurs with closed- or narrow-angle glaucoma. D) Floaters occur with a detached retina, not with open angle glaucoma. Page Ref: 770-771 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 31.7 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of vision pathologies and approaches to treatment of those conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of hearing, balance, and vision disorders.

19) When assessing an adolescent with latent nystagmus, which finding should the nurse expect? A) Nystagmus occurs when both eyes are open. B) Nystagmus occurs in a vertical direction. C) Nystagmus is directed away from the covered eye. D) Nystagmus is present when both eyes are closed. Answer: C Explanation: A) Latent nystagmus develops in some individuals with amblyopia and strabismus and is present from infancy. This nystagmus is not present when both eyes are open but becomes visible when one eye is covered. Latent nystagmus is horizontal in nature, but the direction of the nystagmus can change and is always directed away from the eye that is covered. B) Latent nystagmus develops in some individuals with amblyopia and strabismus and is present from infancy. This nystagmus is not present when both eyes are open but becomes visible when one eye is covered. Latent nystagmus is horizontal in nature, but the direction of the nystagmus can change and is always directed away from the eye that is covered. C) Latent nystagmus develops in some individuals with amblyopia and strabismus and is present from infancy. This nystagmus is not present when both eyes are open but becomes visible when one eye is covered. Latent nystagmus is horizontal in nature, but the direction of the nystagmus can change and is always directed away from the eye that is covered. D) Latent nystagmus develops in some individuals with amblyopia and strabismus and is present from infancy. This nystagmus is not present when both eyes are open but becomes visible when one eye is covered. Latent nystagmus is horizontal in nature, but the direction of the nystagmus can change and is always directed away from the eye that is covered. Page Ref: 772 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 31.8 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of nystagmus and related approaches to treatment across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of hearing, balance, and vision disorders.

20) Which statement by a parent of an adolescent recently diagnosed with amblyopia requires more teaching? A) "Patching the nonaffected eye will help restore vision." B) "Patching at this age will not help restore vision." C) "Eye exercise at this age cannot help restore vision." D) "There is no surgical cure." Answer: A Explanation: A) It is important to treat amblyopia as early as possible. Very often, amblyopia is first diagnosed in adolescence or adulthood, at which point therapy has no effect. B) It is important to treat amblyopia as early as possible. Very often, amblyopia is first diagnosed in adolescence or adulthood, at which point therapy has no effect. C) It is important to treat amblyopia as early as possible. Very often, amblyopia is first diagnosed in adolescence or adulthood, at which point therapy has no effect. D) It is important to treat amblyopia as early as possible. Very often, amblyopia is first diagnosed in adolescence or adulthood, at which point therapy has no effect. Page Ref: 769 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 31.7 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of vision pathologies and approaches to treatment of those conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of hearing, balance, and vision disorders to diagnosis and treatment.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 32 Pain, Neuropathy, and Headache 1) Which concept should the nurse use when assessing a patient's level of pain? A) Pain is defined by the nurse based on the type of injury. B) Consider the source of the pain when assessing for pain. C) A family member can determine the patient's level of pain if the patient is nonverbal. D) Pain is subjective experience of the patient. Answer: D Explanation: A) Clinically, pain is subjectively defined as whatever the patient reports experiencing whenever it occurs. B) Clinically, pain is subjectively defined as whatever the patient reports experiencing whenever it occurs. C) Clinically, pain is subjectively defined as whatever the patient reports experiencing whenever it occurs. D) Clinically, pain is subjectively defined as whatever the patient reports experiencing whenever it occurs. Page Ref: 779 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 32.1 Define pain, and discuss concepts related to pain. | QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of pain, neuropathy, and headache.

2) When a patient complains of intense throbbing hip pain with ambulation, the nurse categorizes this as which type of pain? A) Nociceptive pain B) Central pain C) Visceral pain D) Somatic pain Answer: D Explanation: A) Nociceptive pain is a physiologic response to heat, cold, vibration, stretch, or chemicals released from damaged cells that may cause actual or have the potential to cause tissue damage. B) Central pain is caused by a primary lesion or dysfunction of the central nervous system and persists after resolution of the initial inflammation or trauma. C) Visceral pain is a squeezing, cramping, dull, and deep pain originating in a bodily organ that is often poorly localized to the affected organ and commonly associated with referred patterns of pain. D) Somatic pain is an aching, throbbing, or dull pain arising from the skin, muscles, and joints that is usually discrete and intense. Page Ref: 781 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 32.2 Outline the four parts of the pain pathway, and explain the significance of pain threshold and tolerance. | QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of pain, neuropathy, and headache.

3) To assess a patient's quality of pain, which question would the nurse ask the patient? A) When did the pain start? B) How would you describe the pain? C) Can you point the site of your pain? D) On a scale of 0 to 10, how bad is your pain? Answer: B Explanation: A) This question assesses the onset of pain. B) This question assesses the quality of pain. C) This question assesses the region of the pain. D) This question assesses the severity of the pain. Page Ref: 788 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 32.3 Discuss the components of a thorough assessment of pain. | QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of pain, neuropathy, and headache.

4) Which scale would be most appropriate for the nurse to use when assessing pain in a 5-yearold? A) Visual Analog Scale B) Verbal Numeric Scale C) McGill Pain Questionnaire D) Wong-Baker FACES Scale Answer: D Explanation: A) The most commonly used is the visual analog scale (VAS); in using the VAS, patients rate their pain by indicating a position along a continuous line between two end points of no pain to very severe pain. B) In using the verbal numeric scale (VNS), patients verbally rate their pain on a scale of 0 (no pain) to 10 (most intense pain imaginable). C) The McGill Pain Questionnaire (MPQ), which lists 78 pain descriptor items categorized into 20 subclasses, is a multidimensional pain questionnaire that measures the sensory, affective, and evaluative aspects of chronic pain. D) A visual analog scale, such as the Wong-Baker FACES scale, is useful in determining pain in young children. Page Ref: 790 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 32.3 Discuss the components of a thorough assessment of pain. | QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of pain, neuropathy, and headache.

5) Which patient statement indicates to the nurse that more teaching is needed about multimodal pain management? A) "This method will provide better pain control." B) "I will need a lower dose of each drug." C) "It reduces the need for opioid drugs." D) "It may increase the severity of the side effects I experience." Answer: D Explanation: A) Multimodal pain management uses two or more agents with different mechanisms of action. This method of pain management reduces the use of opioids and avoids their adverse side effects. Advantages include improved analgesia due to synergistic or additive effects between the agents, reduced doses of each analgesic, and decreased incidence and severity of side effects. B) Multimodal pain management uses two or more agents with different mechanisms of action. This method of pain management reduces the use of opioids and avoids their adverse side effects. Advantages include improved analgesia due to synergistic or additive effects between the agents, reduced doses of each analgesic, and decreased incidence and severity of side effects. C) Multimodal pain management uses two or more agents with different mechanisms of action. This method of pain management reduces the use of opioids and avoids their adverse side effects. Advantages include improved analgesia due to synergistic or additive effects between the agents, reduced doses of each analgesic, and decreased incidence and severity of side effects. D) Multimodal pain management uses two or more agents with different mechanisms of action. This method of pain management reduces the use of opioids and avoids their adverse side effects. Advantages include improved analgesia due to synergistic or additive effects between the agents, reduced doses of each analgesic, and decreased incidence and severity of side effects. Page Ref: 791 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 32.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of acute pain and approaches to treatment of acute pain across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and selfcare management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of pain, neuropathy, and headache to diagnosis and treatment.

6) Which medication should the nurse anticipate administering to a patient in severe acute pain who is being treated using the WHO analgesic ladder? A) Ibuprofen B) Tramadol C) Codeine D) Morphine Answer: D Explanation: A) Because acute pain can be intense, its initial management usually starts at the third step of the WHO ladder with gradual movement down the ladder during the recovery phase. In the first step of the ladder, the pain is initially managed with nonopioids such as nonsteroidal anti-inflammatory drugs (NSAIDs; e.g., ibuprofen, naproxen, ketorolac), COX-2 selective inhibitor (celecoxib), acetaminophen, and aspirin. Severe pain places the patient on the third step of the WHO analgesic ladder. B) Because acute pain can be intense, its initial management usually starts at the third step of the WHO ladder with gradual movement down the ladder during the recovery phase. In the second step, a weak opioid such as codeine, dihydrocodeine, or tramadol is added to the nonopioid with or without adjuvant medications. Severe pain places the patient on the third step of the WHO analgesic ladder. C) Because acute pain can be intense, its initial management usually starts at the third step of the WHO ladder with gradual movement down the ladder during the recovery phase. In the second step, a weak opioid such as codeine, dihydrocodeine, or tramadol is added to the nonopioid with or without adjuvant medications. Severe pain places the patient on the third step of the WHO analgesic ladder. D) Because acute pain can be intense, its initial management usually starts at the third step of the WHO ladder with gradual movement down the ladder during the recovery phase. Medications at this step include a strong opioid such as morphine as well as fentanyl, buprenorphine oxymorphone, oxycodone, hydromorphone, and methadone. Severe pain places the patient on the third step of the WHO analgesic ladder. Page Ref: 792 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Planning | Learning Outcome: 32.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of acute pain and approaches to treatment of acute pain across the lifespan. | QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of pain, neuropathy, and headache to diagnosis and treatment.

7) The nursing plan of care for a patient in pain should include which strategy? A) Administer pain medication when the patient reports pain of at least a level of 4 out of 10. B) Administer pain medications around the clock. C) Administer pain medication when the nurse perceives the patient to be in pain. D) Administer pain medication only when patient states a need for pain relief. Answer: B Explanation: A) To maintain a pain-free state, the WHO recommends that medications be administered around the clock, usually every 3-6 hours rather than on demand. B) To maintain a pain-free state, the WHO recommends that medications be administered around the clock, usually every 3-6 hours rather than on demand. C) To maintain a pain-free state, the WHO recommends that medications be administered around the clock, usually every 3-6 hours rather than on demand. Pain is subjectively defined as whatever the patient reports experiencing whenever it occurs. D) To maintain a pain-free state, the WHO recommends that medications be administered around the clock, usually every 3-6 hours rather than on demand. Page Ref: 792 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Planning | Learning Outcome: 32.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of acute pain and approaches to treatment of acute pain across the lifespan. | QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of pain, neuropathy, and headache to diagnosis and treatment.

8) Using the WHO pain ladder, the nursing plan of care for a patient with chronic lower back pain should include which strategy? A) Start with the first step and advance slowly up the ladder. B) Treat breakthrough pain with a long-acting analgesic. C) Administer an opioid and then slowly move back down the ladder. D) Aim for complete pain control as the goal of therapy. Answer: A Explanation: A) The WHO pain ladder is appropriate for the management of chronic pain. In contrast to acute pain, management of chronic pain starts at the first step and advances slowly up the ladder. B) Breakthrough pain can occur randomly and suddenly; it needs to be treated with shorteracting opioids while longer-acting medications continue to be used for the chronic pain. C) The WHO pain ladder is appropriate for the management of chronic pain. In contrast to acute pain, management of chronic pain starts at the first step and advances slowly up the ladder. D) The goal of chronic pain management is pain reduction, not pain elimination, and improved quality of life. Page Ref: 793 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Planning | Learning Outcome: 32.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of chronic pain and approaches to treatment of chronic pain across the lifespan. | QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX.8 Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of pain, neuropathy, and headache to diagnosis and treatment.

9) The nurse would expect to assess which finding in a patient with allodynia? A) A diminished response to pain B) A hypersensitive response to an innocuous stimulus such as light touch C) An increased sensitivity to thermal stimulation D) A decreased sensitivity to tactile stimulation Answer: B Explanation: A) Hypoalgesia is a diminished pain response to a normally painful tactile and/or thermal stimulus. B) Allodynia occurs when an area of the body becomes abnormally sensitive, and pain results from an innocuous stimulus such as light touch. Allodynia is associated with sensitization of peripheral nociceptors in the skin resulting in hyperalgesia. C) Hyperesthesia is the increased sensitivity to tactile or thermal stimulation. D) Hypoesthesia is the decreased sensitivity to tactile or thermal stimulation. Page Ref: 793 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 32.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of neuropathic pain and approaches to treatment of neuropathic pain. | QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of pain, neuropathy, and headache.

10) Which manifestation would the nurse expect to find in a patient with diabetic neuropathy? A) Pain and paresthesia starting in both feet and progressing up the leg B) Pain and paresthesia in one foot that eventually progresses up the leg C) A dull cramping pain in both calves D) Leg pain that is more severe in the morning Answer: A Explanation: A) Pain and paresthesia are usually symmetric and start in the feet with gradual progression up the legs, followed by involvement of the fingers, hands, and arms. It is characterized by sharp, burning, aching, and tingling pain; cold sensations; numbness; and allodynia. The pain of diabetic neuropathy is more severe at night. B) Pain and paresthesia are usually symmetric and start in the feet with gradual progression up the legs, followed by involvement of the fingers, hands, and arms. It is characterized by sharp, burning, aching, and tingling pain; cold sensations; numbness; and allodynia. The pain of diabetic neuropathy is more severe at night. C) Pain and paresthesia are usually symmetric and start in the feet with gradual progression up the legs, followed by involvement of the fingers, hands, and arms. It is characterized by sharp, burning, aching, and tingling pain; cold sensations; numbness; and allodynia. The pain of diabetic neuropathy is more severe at night. D) Pain and paresthesia are usually symmetric and start in the feet with gradual progression up the legs, followed by involvement of the fingers, hands, and arms. It is characterized by sharp, burning, aching, and tingling pain; cold sensations; numbness; and allodynia. The pain of diabetic neuropathy is more severe at night. Page Ref: 794 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 32.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of neuropathic pain and approaches to treatment of neuropathic pain. | QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of pain, neuropathy, and headache.

11) What sign(s) should alert the nurse to a potential problem in a patient taking a non-steroidal anti-inflammatory drug (NSAID) for diabetic polyneuropathy? A) Elevated liver function tests B) Elevated white blood cell count C) Elevated blood urea nitrogen (BUN) and serum creatinine levels D) Elevated prothrombin time Answer: C Explanation: A) Because of their negative effect on the kidney, NSAIDs should be used with caution in diabetic patients who have impaired renal function. Elevated blood urea nitrogen (BUN) and serum creatinine levels indicate renal impairment and an increased risk in using NSAID drugs. B) Because of their negative effect on the kidney, NSAIDs should be used with caution in diabetic patients who have impaired renal function. Elevated blood urea nitrogen (BUN) and serum creatinine levels indicate renal impairment and an increased risk in using NSAID drugs. C) Because of their negative effect on the kidney, NSAIDs should be used with caution in diabetic patients who have impaired renal function. Elevated blood urea nitrogen (BUN) and serum creatinine levels indicate renal impairment and an increased risk in using NSAID drugs. D) Because of their negative effect on the kidney, NSAIDs should be used with caution in diabetic patients who have impaired renal function. Elevated blood urea nitrogen (BUN) and serum creatinine levels indicate renal impairment and an increased risk in using NSAID drugs. Page Ref: 795 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Assessment | Learning Outcome: 32.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of neuropathic pain and approaches to treatment of neuropathic pain. | QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of pain, neuropathy, and headache to diagnosis and treatment.

12) A patient who has had a right leg amputation below the knee describes a feeling that his toes are getting closer to his knee. The nurse explains to the patient that this sensation is known as: A) stump pain. B) phantom sensations. C) phantom limb pain. D) telescoping. Answer: D Explanation: A) Stump pain is acute nociceptive pain at the site of amputation that generally resolves as the stump heals. B) Phantom sensations, feelings other than pain in the missing body part, include sensations of movement, numbness, or twitching. C) Phantom limb pain is pain that is perceived to be coming from a limb or body part that has been removed or amputated. D) Telescoping is the sensation that the distal part of the missing limb is gradually approaching the limb stump. Page Ref: 795 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 32.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of neuropathic pain and approaches to treatment of neuropathic pain. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and selfcare management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of pain, neuropathy, and headache.

13) Which drug of choice should the nurse anticipate administering to a patient with severe new onset pain due to trigeminal neuralgia? A) Gabapentin B) Carbamazepine C) Baclofen D) Phenytoin Answer: B Explanation: A) Carbamazepine, the drug of choice, blocks sodium channels, inhibits spontaneous generation of ectopic nerve impulses, and reduces the transmissions of ephaptic impulses. Other anticonvulsants may be used if the side effects of carbamazepine cannot be tolerated; these include oxcarbazepine, topiramate, gabapentin, pregabalin, clonazepam, phenytoin, lamotrigine, and valproic acid. B) Carbamazepine, the drug of choice, blocks sodium channels, inhibits spontaneous generation of ectopic nerve impulses, and reduces the transmissions of ephaptic impulses. C) Carbamazepine, the drug of choice, blocks sodium channels, inhibits spontaneous generation of ectopic nerve impulses, and reduces the transmissions of ephaptic impulses. Baclofen, a GABA agonist that blocks the excitation of second-order neurons, may also be effective. D) Carbamazepine, the drug of choice, blocks sodium channels, inhibits spontaneous generation of ectopic nerve impulses, and reduces the transmissions of ephaptic impulses. Other anticonvulsants may be used if the side effects of carbamazepine cannot be tolerated; these include oxcarbazepine, topiramate, gabapentin, pregabalin, clonazepam, phenytoin, lamotrigine, and valproic acid. Page Ref: 797 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Planning | Learning Outcome: 32.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of neuropathic pain and approaches to treatment of neuropathic pain. | QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of pain, neuropathy, and headache to diagnosis and treatment.

14) Which finding would the nurse expect when assessing a patient with a tension type headache (TTH)? A) A throbbing unilateral headache B) A constant, bilateral, dull bandlike pain around the head with vomiting C) A sudden onset of severe unilateral piercing or burning pain, located behind or around the eye D) Premonitory or prodromic symptoms Answer: B Explanation: A) Patients with a migraine headache may present with a throbbing or pulsatile unilateral headache (frontal or ocular) that lasts anywhere from 4 to 72 hours, nausea and vomiting, and sensitivity to light (photophobia) and sound (phonophobia). B) Tension type headaches are characterized by a constant, bilateral, dull, nonthrobbing bandlike pain around the head, especially at the temples or the back of the head and neck. C) Symptoms of cluster headache include a sudden onset of a severe unilateral pain that is piercing or burning in nature and located behind or around the eye. The pain is strongest in the first 10-15 minutes and spreads to the forehead, jaw, upper teeth, temples, nostrils, shoulder, or neck. D) In many patients, migraine headache is preceded by premonitory or prodromic symptoms that last less than 24 hours. These include fatigue, excessive yawning, fluid retention, sensory hypersensitivity, mood changes, and increased appetite and thirst. Over 30% of migraines are accompanied by an aura, a reversible focal neurologic symptom that generally precedes the headache. Page Ref: 800 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 32.7 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of headaches and approaches to treatment of headaches across the lifespan. | QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of pain, neuropathy, and headache.

15) To reduce the incidence of migraine headaches, the nurse is teaching the patient to avoid foods high in tyramine. Which foods should the nurse tell the patient to avoid? A) Cheddar cheese B) White wine C) Cottage cheese D) Smoked fish Answer: A Explanation: A) Food triggers of migraine headache include processed, fermented, pickled, and marinated foods. These are often high in MSG, histamine (seafood), tyramine (aged cheese, red wine, smoked fish), and nitrates (salami, bacon). B) Food triggers of migraine headache include processed, fermented, pickled, and marinated foods. These are often high in MSG, histamine (seafood), tyramine (aged cheese, red wine, smoked fish), and nitrates (salami, bacon). C) Food triggers of migraine headache include processed, fermented, pickled, and marinated foods. These are often high in MSG, histamine (seafood), tyramine (aged cheese, red wine, smoked fish), and nitrates (salami, bacon). D) Food triggers of migraine headache include processed, fermented, pickled, and marinated foods. These are often high in MSG, histamine (seafood), tyramine (aged cheese, red wine, smoked fish), and nitrates (salami, bacon). Page Ref: 802 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 32.7 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of headaches and approaches to treatment of headaches across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and selfcare management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of pain, neuropathy, and headache to diagnosis and treatment.

16) A nursing assessment on a patient experiencing myofascial pain is most likely to reveal: A) a feeling of pins and needles. B) constant pain. C) pain aggravated by cold. D) taut muscle band. Answer: D Explanation: A) Myofascial pain syndrome is a regional pain syndrome characterized by discrete trigger point, localized areas of deep muscle tenderness or hyperirritability, and a pattern of referred pain that may be localized or remote from the trigger point. Symptoms of myofascial pain include a taut or hard muscle band, a twitch or local contraction of muscle band on stimulation, restricted range of motion, and referred pain. B) Myofascial pain syndrome is a regional pain syndrome characterized by discrete trigger point, localized areas of deep muscle tenderness or hyperirritability, and a pattern of referred pain that may be localized or remote from the trigger point. Symptoms of myofascial pain include a taut or hard muscle band, a twitch or local contraction of muscle band on stimulation, restricted range of motion, and referred pain. C) Myofascial pain syndrome is a regional pain syndrome characterized by discrete trigger point, localized areas of deep muscle tenderness or hyperirritability, and a pattern of referred pain that may be localized or remote from the trigger point. Symptoms of myofascial pain include a taut or hard muscle band, a twitch or local contraction of muscle band on stimulation, restricted range of motion, and referred pain. D) Myofascial pain syndrome is a regional pain syndrome characterized by discrete trigger point, localized areas of deep muscle tenderness or hyperirritability, and a pattern of referred pain that may be localized or remote from the trigger point. Symptoms of myofascial pain include a taut or hard muscle band, a twitch or local contraction of muscle band on stimulation, restricted range of motion, and referred pain. Page Ref: 803 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 32.8 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of selected other pain syndromes and approaches to treatment of these syndromes across the lifespan. | QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of pain, neuropathy, and headache.

17) Which patient statement indicates to the nurse that more teaching about the diagnostic process of fibromyalgia is needed? A) "Pain needs to be present in 7 of 18 trigger points." B) "Diagnosis is made if I have widespread pain for 6 months or more." C) "There is no definitive test for fibromyalgia." D) "We need to rule out other causes for my pain." Answer: B Explanation: A) Diagnostic criteria includes a 3-month duration of widespread pain, presence and severity of pain in 7 of the 18 trigger points, fatigue, and absence of other disorders that could explain the pain. B) Diagnostic criteria includes a 3-month duration of widespread pain, presence and severity of pain in 7 of the 18 trigger points, fatigue, and absence of other disorders that could explain the pain. C) Diagnostic criteria includes a 3-month duration of widespread pain, presence and severity of pain in 7 of the 18 trigger points, fatigue, and absence of other disorders that could explain the pain. D) Diagnostic criteria includes a 3-month duration of widespread pain, presence and severity of pain in 7 of the 18 trigger points, fatigue, and absence of other disorders that could explain the pain. Page Ref: 804 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 32.8 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of selected other pain syndromes and approaches to treatment of these syndromes across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of pain, neuropathy, and headache to diagnosis and treatment.

18) Which is the most appropriate pain scale for the nurse to use when assessing pain in a 7-yearold developmentally disabled child? A) Neonatal Infants Pain Scale (NIPS) B) Faces, Legs, Activity, Crying, Consolability Scale (FLACC) C) CRIES observational assessment tool D) Wong-Baker FACES scale Answer: C Explanation: A) Assessment scales for pain in children younger than 1 year of age include the Neonatal Infants Pain Scale (NIPS), which assesses facial expression, cry, breathing pattern, muscle state of arms and legs, and state of arousal, and the Face, Legs, Activity, Crying, Consolability (FLACC) scale. The CRIES observational assessment tool for children younger than 3 years old can also be utilized for pain assessment of older developmentally disabled children. It assesses crying, oxygen requirement, increased vital signs, facial expression, and sleep. For children over the age of 3 years, the Wong-Baker FACES scale is used for pain assessment. B) Assessment scales for pain in children younger than 1 year of age include the Neonatal Infants Pain Scale (NIPS), which assesses facial expression, cry, breathing pattern, muscle state of arms and legs, and state of arousal, and the Face, Legs, Activity, Crying, Consolability (FLACC) scale. The CRIES observational assessment tool for children younger than 3 years old can also be utilized for pain assessment of older developmentally disabled children. It assesses crying, oxygen requirement, increased vital signs, facial expression, and sleep. For children over the age of 3 years, the Wong-Baker FACES scale is used for pain assessment. C) Assessment scales for pain in children younger than 1 year of age include the Neonatal Infants Pain Scale (NIPS), which assesses facial expression, cry, breathing pattern, muscle state of arms and legs, and state of arousal, and the Face, Legs, Activity, Crying, Consolability (FLACC) scale. The CRIES observational assessment tool for children younger than 3 years old can also be utilized for pain assessment of older developmentally disabled children. It assesses crying, oxygen requirement, increased vital signs, facial expression, and sleep. For children over the age of 3 years, the Wong-Baker FACES scale is used for pain assessment. D) Assessment scales for pain in children younger than 1 year of age include the Neonatal Infants Pain Scale (NIPS), which assesses facial expression, cry, breathing pattern, muscle state of arms and legs, and state of arousal, and the Face, Legs, Activity, Crying, Consolability (FLACC) scale. The CRIES observational assessment tool for children younger than 3 years old can also be utilized for pain assessment of older developmentally disabled children. It assesses crying, oxygen requirement, increased vital signs, facial expression, and sleep. For children over the age of 3 years, the Wong-Baker FACES scale is used for pain assessment. Page Ref: 805 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 32.9 Compare and contrast the assessment and treatment of pain in nonverbal or cognitively impaired patients across the lifespan. | QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches 18

NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of pain, neuropathy, and headache to diagnosis and treatment. 19) Using the Pain Assessment in Advanced Dementia (PAINAD) tool, the nurse assesses a patient with Alzheimer disease to have a score of 5. The nurse prepares to treat this patient for which level of pain? A) No pain B) Mild pain C) Moderate pain D) Severe pain Answer: C Explanation: A) The Pain Assessment in Advanced Dementia (PAINAD) is used to assess pain in older patients with dementia or other cognitive impairments for five behaviors: respiratory status, negative vocalization, facial expression, body language, and consolability. The total score ranges from 0 to 10 points; scores of 1-3 indicate mild pain, scores of 4-6 indicate moderate pain, and scores of 7-10 are associated with severe pain. B) The Pain Assessment in Advanced Dementia (PAINAD) is used to assess pain in older patients with dementia or other cognitive impairments for five behaviors: respiratory status, negative vocalization, facial expression, body language, and consolability. The total score ranges from 0 to 10 points; scores of 1-3 indicate mild pain, scores of 4-6 indicate moderate pain, and scores of 7-10 are associated with severe pain. C) The Pain Assessment in Advanced Dementia (PAINAD) is used to assess pain in older patients with dementia or other cognitive impairments for five behaviors: respiratory status, negative vocalization, facial expression, body language, and consolability. The total score ranges from 0 to 10 points; scores of 1-3 indicate mild pain, scores of 4-6 indicate moderate pain, and scores of 7-10 are associated with severe pain. D) The Pain Assessment in Advanced Dementia (PAINAD) is used to assess pain in older patients with dementia or other cognitive impairments for five behaviors: respiratory status, negative vocalization, facial expression, body language, and consolability. The total score ranges from 0 to 10 points; scores of 1-3 indicate mild pain, scores of 4-6 indicate moderate pain, and scores of 7-10 are associated with severe pain. Page Ref: 807 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 32.9 Compare and contrast the assessment and treatment of pain in nonverbal or cognitively impaired patients across the lifespan. | QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of pain, neuropathy, and headache to diagnosis and treatment. 19

20) The nursing plan of care for a 4-year-old following a tonsillectomy should include which of the following concepts? A) Analgesic dosing is based on year in school and weight. B) Administer analgesics by the least painful route. C) Administer analgesics only when the Wong-Baker FACES scale indicates a pain rating of 6 or higher. D) Administer analgesics rectally. Answer: B Explanation: A) Analgesic dosing must be based on the age and weight of the patient. B) Analgesics should be administered to children by the simplest, most effective, and least painful route; oral formulations are the most convenient and usually the least expensive route of administration. C) The WHO recommends that analgesics in pediatrics be administered at regular intervals, not as needed, with the addition of rescue doses for intermittent and breakthrough pain. D) Rectal administration has an unreliable bioavailability. Page Ref: 806 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Planning | Learning Outcome: 32.9 Compare and contrast the assessment and treatment of pain in nonverbal or cognitively impaired patients across the lifespan. | QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of pain, neuropathy, and headache to diagnosis and treatment.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 33 Disorders of Thermoregulation 1) A patient in the emergency department fell through the ice on a pond and was rescued by friends and driven to the hospital, still in wet clothes. By removing the wet clothes, the nurse is preventing: A) radiant heat loss. B) evaporative heat loss. C) convective heat loss. D) conductive heat loss. Answer: B Explanation: A) Radiant heat loss is the transfer of heat that involves an electromagnetic energy exchange between two objects of different temperatures, again from warmer to cooler areas. Because body temperatures are warmer than ambient conditions, heat is radiated to the air. B) Evaporative heat loss occurs when a liquid on the skin such as sweat or a person's wet clothes, vaporizes. Evaporative heat loss is effective only when the environmental humidity is relatively low and convective flow keeps the air moisture concentration low. C) Convective heat loss is the transfer of heat that is promoted by currents from fans, air conditioning, or drafty conditions that rapidly remove heat from the skin. D) Conductive heat loss is the transfer of heat from warmer skin to colder surfaces such as examining tables, bed linens, or examining instruments. Page Ref: 818 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 33.2 Describe how changes in body temperature involve both physics and physiologic factors. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of disorders of thermoregulation.

2) After removing the wet clothing from a patient who fell through the ice into cold water, the nurse wraps the patient in warm blankets to prevent heat loss by which means? A) Radiant heat loss B) Evaporative heat loss C) Convective heat loss D) Conductive heat loss Answer: C Explanation: A) Radiant heat loss is the transfer of heat that involves an electromagnetic energy exchange between two objects of different temperatures, again from warmer to cooler areas. Because body temperatures are warmer than ambient conditions, heat is radiated to the air. B) Evaporative heat loss occurs when a liquid on the skin such as sweat, vaporizes. Evaporative heat loss is effective only when the environmental humidity is relatively low and convective flow keeps the air moisture concentration low. C) Convective heat loss is the transfer of heat that is promoted by currents from fans, air conditioning, or drafty conditions that rapidly remove heat from the skin. D) Conductive heat loss is the transfer of heat from warmer skin to colder surfaces such as examining tables, bed linens, or examining instruments. Page Ref: 818 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 33.2 Describe how changes in body temperature involve both physics and physiologic factors. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of disorders of thermoregulation.

3) A patient who is unconscious, not shivering, and has a core body temperature of 25oC is classified as which stage of the Swiss Hypothermia Staging System? A) Stage I B) Stage II C) Stage III D) Stage IV Answer: C Explanation: A) The patient at stage I of the Swiss Hypothermia Staging System exhibits shivering, is conscious, and has a body temperature of 32-35°C. B) Stage II of the Swiss Hypothermia Staging System is characterized by no shivering, impaired consciousness, and a body temperature of 28-32°C. C) Stage III of the Swiss Hypothermia Staging System is characterized by no shivering, unconsciousness, and a body temperature of 24-28°C. D) Stage IV of the Swiss Hypothermia Staging System is characterized by no shivering, no vital signs, and a body temperature of <24°C. Page Ref: 824 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 33.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypothermia and frostbite and approaches to treatment of those conditions, and explain the rationale for therapeutic hypothermia. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of thermoregulations.

4) A patient who was found in the snow with impaired consciousness, no shivering, and a body temperature of 33°C is being transported by life flight helicopter to a hospital with rewarming resources. Which interventions should the life flight nurse anticipate? A) Giving warm beverages B) Encouraging active movement C) Applying heat packs to the trunk D) Taking the time to stabilize at the scene before transporting to hospital Answer: C Explanation: A) This patient is at stage II of the Swiss Hypothermia Staging System and has impaired consciousness. Therefore, he should not be given oral fluids. B) This patient is at stage II of the Swiss Hypothermia Staging System and has impaired consciousness. He should not be encouraged to actively move, but should be gently moved and immobilized. C) This patient is at stage II of the Swiss Hypothermia Staging System and has impaired consciousness. With a body temperature of 33°C, heat packs should be placed against the trunk to rewarm the patient. D) This patient is at stage II of the Swiss Hypothermia Staging System, has impaired consciousness, and has a body temperature of 33°C. He should be transported without delay to a hospital with an active rewarming resource. Page Ref: 824 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 33.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypothermia and frostbite and approaches to treatment of those conditions, and explain the rationale for therapeutic hypothermia. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.8. Implement evidencebased nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of thermoregulation to diagnosis and treatment.

5) In a community program, the community health nurse warns that alcohol increases the risk of hypothermia due to: A) impaired judgement. B) vasoconstriction. C) hyperglycemia. D) impaired shivering. Answer: A Explanation: A) Alcohol intoxication not only alters judgment about cold exposure, but is also accompanied by vasodilation and hypoglycemia. B) Alcohol intoxication not only alters judgment about cold exposure, but is also accompanied by vasodilation and hypoglycemia. C) Alcohol intoxication not only alters judgment about cold exposure, but is also accompanied by vasodilation and hypoglycemia. D) Alcohol intoxication not only alters judgment about cold exposure, but is also accompanied by vasodilation and hypoglycemia. Page Ref: 824 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 33.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypothermia and frostbite and approaches to treatment of those conditions, and explain the rationale for therapeutic hypothermia. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of disorders of thermoregulation.

6) When a patient with a febrile illness begins to shiver, the nurse understands that which of the following has occurred? A) A rise in body temperature has been sensed by the central thermoreceptors. B) A drop in body temperature has been sensed by the central thermoreceptors. C) The core temperature has risen above the set point range. D) The core temperature has fallen below the set point range. Answer: D Explanation: A) Peripheral thermoreceptors that detect a drop in core temperature below the set point range transmit signals to the primary shivering center in the posterior hypothalamus. Subsequently, efferent impulses from the primary shivering center descend through pathways in the brainstem and spinal cord, resulting in skeletal muscle contractions. B) Central thermoreceptors are heat sensitive and contain few cold sensitive receptors. In contrast to central thermosensitive receptors, most peripheral thermoreceptors are cold-sensitive, making them more responsive in stimulating cold-defense mechanisms. C) Peripheral thermoreceptors that detect a drop in core temperature below the set point range transmit signals to the primary shivering center in the posterior hypothalamus. Subsequently, efferent impulses from the primary shivering center descend through pathways in the brainstem and spinal cord, resulting in skeletal muscle contractions. D) Peripheral thermoreceptors that detect a drop in core temperature below the set point range transmit signals to the primary shivering center in the posterior hypothalamus. Subsequently, efferent impulses from the primary shivering center descend through pathways in the brainstem and spinal cord, resulting in skeletal muscle contractions. Page Ref: 819-820 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 33.3 Explain the sensory inputs and effectors of thermoregulatory responses as complex, separate, but interacting responses with both autonomic and behavioral components. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of disorders of thermoregulation.

7) Through which mechanism is the newborn able to generate heat in a cool delivery room? A) Shivering B) Nonshivering thermogenesis C) Voluntary skeletal muscle activity D) Vasoconstriction Answer: B Explanation: A) Because of musculoskeletal and neurologic immaturity, the newborn is not yet equipped to generate heat by movement or shivering. B) Generation of heat from brown adipose tissue occurs from effects of uncoupling protein 1 in the mitochondria, resulting in the release of energy in the form of heat. Infants have large deposits of brown adipose tissue and depend on nonshivering thermogenesis by increased fat oxidation from brown adipose tissue, which at room temperature has a metabolic cost of about 150 kcal/min. C) Because of musculoskeletal and neurologic immaturity, the newborn is not yet equipped to generate heat by movement or shivering. D) The newborn has an immature thermoregulation system. Therefore, for neonates, the responsibilities for survival and thermal balance rest with caregivers to provide warmth, ensure oxygenation for infant breathing, and support heat conservation. Page Ref: 821 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 33.3 Explain the sensory inputs and effectors of thermoregulatory responses as complex, separate, but interacting responses with both autonomic and behavioral components. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of disorders of thermoregulation.

8) Which concept should the nurse use to develop a community program teaching older adults about the hazards of cold winter temperatures? A) Older adults have a higher metabolic rate. B) Older adults have a lower mean body mass. C) Older adults have a higher vasoconstrictor response. D) Older adults have a higher ability to generate heat when cold. Answer: B Explanation: A) Research findings show that adults over age 65 have a lower resting metabolic rate and metabolic response to generate heat under cold stress. B) Older adults also had lower mean body mass and lower metabolic rate throughout the study, resulting in lower core temperatures, which makes the older adult particularly vulnerable to severely cold temperatures. C) When tested in mildly colder conditions in a comparative study with younger adults, older adults had a lower vasoconstrictor response. D) Research findings show that adults over age 65 have a lower resting metabolic rate and metabolic response to generate heat under cold stress. Page Ref: 821 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 33.3 Explain the sensory inputs and effectors of thermoregulatory responses as complex, separate, but interacting responses with both autonomic and behavioral components. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and selfcare management | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of disorders of thermoregulation.

9) The nurse in the intensive care unit is caring for a patient whose body temperature has been cooled to decrease the oxygen requirement of the brain and heart. The nurse explains to the family that this treatment is called: A) accidental hypothermia. B) inadvertent hypothermia. C) iatrogenic hypothermia. D) therapeutic hypothermia. Answer: D Explanation: A) Accidental hypothermia is used to designate situations in which an unintended fall in core temperature to hypothermic levels occurs. The term is used to describe a situation outside the hospital, typically in association with exposure to cold or traumatic conditions. B) Inadvertent hypothermia refers to unintended heat loss in homes or institutional settings and often included vulnerable infants, ill individuals, or those with impaired thermoregulation. C) The term iatrogenic hypothermia or nosocomial hypothermia designates the inadvertent heat loss associated with anesthesia, convective air flow, or evaporation of solutions from the skin during treatments. D) Therapeutic hypothermia is the deliberate lowering of the body temperature to decrease the oxygen requirements of vital tissue, particularly those of the brain and heart. It has been most widely studied in hypothermic cardiac bypass surgery and ischemic disorders of the brain. Page Ref: 823 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 33.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypothermia and frostbite and approaches to treatment of those conditions, and explain the rationale for therapeutic hypothermia. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of thermoregulation to diagnosis and treatment.

10) The nurse in the newborn intensive care unit is caring for a low birth-weight newborn, born at 36-weeks' gestation, who was delivered in a car en route to the hospital in a snowstorm. Which statement by a parent of the newborn indicates a lack of understanding of the risks of hypothermia? A) "My baby is burning calories at a higher rate." B) "My baby is under a radiant warmer because he doesn't have enough body fat to keep warm." C) "Now that my baby is warmed, I can give him a bath outside the warmer." D) "When my baby is out of the warmer, I need to keep him wrapped." Answer: C Explanation: A) The full-term neonate depends on nonshivering thermogenesis by increased fat oxidation from brown adipose tissue, which at room temperature has a metabolic cost of about 150 kcal/min. B) For neonates, the behavioral responsibilities for survival and thermal balance rest with caregivers to provide warmth, ensure oxygenation for infant breathing, and support heat conservation. Low-birth-weight neonates are particularly at risk for several reasons. Their thin skin and subcutaneous tissue provide poor insulation from heat loss, and their flaccid positions do little to conserve heat. They have lower amounts of brown adipose tissue deposits, which are therefore less able to support nonshivering thermogenesis. C) Preterm infants and newborns have a vulnerability and high potential for central heat loss from the infant's circulation through the skin to the cooler ambient air, cold surfaces, and bed linen. A bath will increase heat loss through evaporation and convection. The metabolic activity required to convert brown adipose tissue into heat requires extra oxygen, so the cold-stressed infant often experiences respiratory distress when exposed to unwarmed environmental air. D) For neonates, the behavioral responsibilities for survival and thermal balance rest with caregivers to provide warmth, ensure oxygenation for infant breathing, and support heat conservation. Page Ref: 822, 824 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Evaluation | Learning Outcome: 33.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypothermia and frostbite and approaches to treatment of those conditions, and explain the rationale for therapeutic hypothermia. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of thermoregulation to diagnosis and treatment.

11) When caring for a patient with mild hypothermia, which finding would the nurse expect? A) Diuresis B) Hypoventilation C) Vasodilation D) Bradycardia Answer: A Explanation: A) In mild hypothermia, the renal tubules become resistant to arginine vasopressin, and the resulting diuresis depletes both water and potassium, resulting in hypokalemia. B) In mild hypothermia, hyperventilation provides O2 to shivering muscles. C) Cardiovascular signs in mild hypothermia are usually caused by warming responses of vasoconstriction to conserve heat and hyperventilation to provide O2 to shivering muscles. Increased sympathetic nervous system stimulation raises heart rate, blood pressure, and cardiac output. D) Cardiovascular signs in mild hypothermia are usually caused by warming responses of vasoconstriction to conserve heat and hyperventilation to provide O2 to shivering muscles. Increased sympathetic nervous system stimulation raises heart rate, blood pressure, and cardiac output. Page Ref: 826-827 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 33.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypothermia and frostbite and approaches to treatment of those conditions, and explain the rationale for therapeutic hypothermia. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of thermoregulations.

12) When assessing the electrocardiogram of a hypothermic patient, which finding signals that the patient has become moderately hypothermic? A) Inverted T waves B) J waves C) Inverted P waves D) U waves Answer: B Explanation: A) Osborne waves, also called J waves because its deflection creates an inverted dome after the QRS complex in the electrocardiogram, occur in about 80% of hypothermic individuals. B) Osborne waves, also called J waves because its deflection creates an inverted dome after the QRS complex in the electrocardiogram, occur in about 80% of hypothermic individuals. C) Osborne waves, also called J waves because its deflection creates an inverted dome after the QRS complex in the electrocardiogram, occur in about 80% of hypothermic individuals. D) Osborne waves, also called J waves because its deflection creates an inverted dome after the QRS complex in the electrocardiogram, occur in about 80% of hypothermic individuals. Page Ref: 827 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 33.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypothermia and frostbite and approaches to treatment of those conditions, and explain the rationale for therapeutic hypothermia. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of thermoregulations.

13) A patient who was found in the snow with impaired consciousness, no shivering, and a body temperature of 28°C is being transported by life flight helicopter to a hospital with rewarming resources. The patient warms to 30°C en route to the hospital, and the nurse cautions the team to move the patient gently, explaining that at this body temperature: A) the bones are brittle and can fracture easily. B) the skin is fragile and tears easily. C) the heart is irritable and susceptible to ventricular fibrillation. D) the muscles become rigid and can cause fractures and joint injury. Answer: C Explanation: A) Cardiac irritability is one of the most serious hazards of treatment, and the risk for dysrhythmia increases in a specific range of core temperatures. As the patient rewarms to 30°C, accumulations of pooled lactic acid enter the circulation and produce acidosis. In addition, ventricular fibrillation related to cardiac hyperirritability during hypothermia is triggered by rough handling or vagal stimulation associated with cardiopulmonary resuscitation that involves chest compression. B) Cardiac irritability is one of the most serious hazards of treatment, and the risk for dysrhythmia increases in a specific range of core temperatures. As the patient rewarms to 30°C, accumulations of pooled lactic acid enter the circulation and produce acidosis. In addition, ventricular fibrillation related to cardiac hyperirritability during hypothermia is triggered by rough handling or vagal stimulation associated with cardiopulmonary resuscitation that involves chest compression. C) Cardiac irritability is one of the most serious hazards of treatment, and the risk for dysrhythmia increases in a specific range of core temperatures. As the patient rewarms to 30°C, accumulations of pooled lactic acid enter the circulation and produce acidosis. In addition, ventricular fibrillation related to cardiac hyperirritability during hypothermia is triggered by rough handling or vagal stimulation associated with cardiopulmonary resuscitation that involves chest compression. D) Cardiac irritability is one of the most serious hazards of treatment, and the risk for dysrhythmia increases in a specific range of core temperatures. As the patient rewarms to 30°C, accumulations of pooled lactic acid enter the circulation and produce acidosis. In addition, ventricular fibrillation related to cardiac hyperirritability during hypothermia is triggered by rough handling or vagal stimulation associated with cardiopulmonary resuscitation that involves chest compression. Page Ref: 827 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 33.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypothermia and frostbite and approaches to treatment of those conditions, and explain the rationale for therapeutic hypothermia. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of thermoregulation to diagnosis and treatment. 13

14) The nurse should expect which manifestations in a patient in the chill phase of fever? A) Shivering, vasoconstriction, report of feeling cold B) No chills, no report of feeling distressed C) Report of feeling uncomfortably hot, sweating D) Hot dry skin, confusion Answer: A Explanation: A) The chill phase is marked by mild to severe shivering, vasoconstriction, and an uncomfortable sense of cold. Thermoregulatory responses in the chill phase generate and conserve heat to adjust the body temperature to the new higher set point. B) The plateau phase occurs when body temperature reaches the new set point and thermoregulatory warming responses are no longer stimulated. In this phase, chills stop, and the warm body temperature is not particularly distressing to the patient. C) The defervescence phase occurs when the pyrogen level subsides, the set point stabilizes to lower levels, and febrile temperatures feel uncomfortably hot. Sweating becomes profuse, and the individual complains of feeling hot. D) Heat stroke is characterized by a decrease in sweating and hot, flushed, dry skin. Page Ref: 829-832 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 33.5 Differentiate the causes, underlying pathogenesis, clinical manifestations, benefits and adverse effects of fever and approaches to its treatment. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of thermoregulations.

15) When assessing a patient with a 40oC core body temperature, which manifestations cause the nurse to determine that the patient has heat stroke? A) Heavy sweating, excessive thirst, bradycardia B) Nausea, weakness, sweating C) Confusion, anxiety, sweating D) Hot, flushed dry skin; bradycardia; confusion Answer: D Explanation: A) In heat exhaustion, the patient may manifest heavy sweating, excessive thirst, nausea, bradycardia, weakness, and dizziness. Temperatures rise to 40°C or greater. B) In heat exhaustion, the patient may manifest heavy sweating, excessive thirst, nausea, bradycardia, weakness, and dizziness. Temperatures rise to 40°C or greater. C) Heat stroke has many of the same symptoms of nausea, bradycardia, and weakness as heat exhaustion. In heat stroke, confusion, anxiety, or loss of consciousness also occur as the body temperature rises. Unlike the clammy, drenched skin of the heat exhaustion victim, heat stroke is characterized by a decrease in sweating and hot, flushed, dry skin. D) Heat stroke has many of the same symptoms of nausea, bradycardia, and weakness as heat exhaustion. In heat stroke, confusion, anxiety, or loss of consciousness also occur as the body temperature rises. Unlike the clammy, drenched skin of the heat exhaustion victim, heat stroke is characterized by a decrease in sweating and hot, flushed, dry skin. Page Ref: 832 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 33.6 Differentiate the causes, underlying pathogenesis, and clinical manifestations of disorders causing hyperthermia and treatment approaches for those disorders. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of thermoregulations.

16) A patient asks the surgical nurse why the anesthesiologist asked if a member of his family ever had hyperthermia during surgery. The nurse responds that malignant hyperthermia is a lifethreatening crisis that: A) is transmitted in an autosomal recessive pattern. B) is transmitted in an autosomal dominant pattern. C) is an X-linked trait. D) is caused by an extra chromosome. Answer: B Explanation: A) Malignant hyperthermia is a rare, life-threatening hypermetabolic crisis that can occur when a genetically susceptible individual is exposed to an anesthetic agent that has adrenergic, anticholinergic, serotonergic, and antidopaminergic properties. The reaction is caused by a mutation in the type 1 ryanodine receptor (RYR1) gene. This mutation is transmitted in an autosomal dominant pattern. B) Malignant hyperthermia is a rare, life-threatening hypermetabolic crisis that can occur when a genetically susceptible individual is exposed to an anesthetic agent that has adrenergic, anticholinergic, serotonergic, and antidopaminergic properties. The reaction is caused by a mutation in the type 1 ryanodine receptor (RYR1) gene. This mutation is transmitted in an autosomal dominant pattern. C) Malignant hyperthermia is a rare, life-threatening hypermetabolic crisis that can occur when a genetically susceptible individual is exposed to an anesthetic agent that has adrenergic, anticholinergic, serotonergic, and antidopaminergic properties. The reaction is caused by a mutation in the type 1 ryanodine receptor (RYR1) gene. This mutation is transmitted in an autosomal dominant pattern. D) Malignant hyperthermia is a rare, life-threatening hypermetabolic crisis that can occur when a genetically susceptible individual is exposed to an anesthetic agent that has adrenergic, anticholinergic, serotonergic, and antidopaminergic properties. The reaction is caused by a mutation in the type 1 ryanodine receptor (RYR1) gene. This mutation is transmitted in an autosomal dominant pattern. Page Ref: 833 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 33.6 Differentiate the causes, underlying pathogenesis, and clinical manifestations of disorders causing hyperthermia and treatment approaches for those disorders. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and selfcare management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of disorders of thermoregulation.

17) Which findings should the nurse expect in patient with second-degree frostbite in the fingers? A) Hard white plaque on the fingertips B) Superficial clear fluid-filled blisters C) Deep purple fluid-filled blisters D) No skin changes. Answer: B Explanation: A) First-degree frostbite appears as hard white plaque; second-degree frostbite has clear fluid in superficial blisters; and third-degree frostbite presents with purple fluid in deep blisters with discolored skin. B) First-degree frostbite appears as hard white plaque; second-degree frostbite has clear fluid in superficial blisters; and third-degree frostbite presents with purple fluid in deep blisters with discolored skin. C) First-degree frostbite appears as hard white plaque; second-degree frostbite has clear fluid in superficial blisters; and third-degree frostbite presents with purple fluid in deep blisters with discolored skin. D) First-degree frostbite appears as hard white plaque; second-degree frostbite has clear fluid in superficial blisters; and third-degree frostbite presents with purple fluid in deep blisters with discolored skin. Page Ref: 828 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 33.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypothermia and frostbite and approaches to treatment of those conditions, and explain the rationale for therapeutic hypothermia. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of thermoregulations.

18) The nurse should expect to assess which manifestations in a patient with profound hypothermia? A) Absent neurological reflexes, asystole B) Absent muscle reflexes, undetectable pulse C) J-waves on ECG, exaggerated tendon reflexes D) Agitation, vigorous shivering Answer: A Explanation: A) In profound hypothermia, with a core temperature less than 17°C, the patient has absent neurological reflexes, absent muscular activity, and asystole. B) In deep hypothermia, with a core temperature less than 17-29°C, the patient has absent muscle reflexes, an undetectable pulse, and fixed and dilated pupils. C) In moderate hypothermia, with a core temperature less than 29-34°C, the patient has J waves on ECG, premature ventricular beats, stupor, delirium, and exaggerated tendon reflexes. D) In mild hypothermia, with a core temperature less than 34-35°C, the patient has agitation, confusion, vigorous shivering, and hyperventilation. Page Ref: 826 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 33.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of hypothermia and frostbite and approaches to treatment of those conditions, and explain the rationale for therapeutic hypothermia. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of thermoregulations.

19) The nurse is teaching a community health program on the danger of extremes of hot and cold temperatures. Which statement by a participant indicates to the nurse that more teaching is needed? A) "I need to check on my elderly neighbors during the winter." B) "I need to make sure my elderly parents are drinking enough and staying cool in the summer." C) "We should make sure the homeless have shelter in extremes of weather." D) "There are homeless shelters, so why do we need to check on those who chose to sleep in the park?" Answer: D Explanation: A) Nurses have both a direct care responsibility and an indirect opportunity to inform families and community members about the dangers of extreme thermal environments for vulnerable populations such as infants, older adults, and chronically ill people. B) Nurses have both a direct care responsibility and an indirect opportunity to inform families and community members about the dangers of extreme thermal environments for vulnerable populations such as infants, older adults, and chronically ill people. C) Nurses have both a direct care responsibility and an indirect opportunity to inform families and community members about the dangers of extreme thermal environments for vulnerable populations such as infants, older adults, and chronically ill people. D) Each year, incapacitated older adults, cognitively impaired individuals, and homeless people living on the streets die from hypothermia because they find themselves in locations with inadequate heating. Likewise, the heat takes a toll on individuals without air conditioning who are fearful of living with windows open and on victims of exposure. Page Ref: 822 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Evaluation | Learning Outcome: 33.3 Explain the sensory inputs and effectors of thermoregulatory responses as complex, separate, but interacting responses with both autonomic and behavioral components. | QSEN Competencies: I.A.1 Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences, values | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, costeffectiveness and equity NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of disorders of thermoregulation.

20) Which of the following problems would be a priority in the nursing care plan for a patient with hypohidrotic ectodermal dysplasia? A) Maintaining an open airway B) Ensuring adequate nutrition C) Maintaining a safe body temperature D) Reducing the risk for bleeding Answer: C Explanation: A) The importance of eccrine sweating as a cooling mechanism is apparent in individuals with hypohidrotic ectodermal dysplasia, a rare genetic condition characterized by a reduced ability to sweat. Patients with this disorder are at risk for overheating. B) The importance of eccrine sweating as a cooling mechanism is apparent in individuals with hypohidrotic ectodermal dysplasia, a rare genetic condition characterized by a reduced ability to sweat. Patients with this disorder are at risk for overheating. C) The importance of eccrine sweating as a cooling mechanism is apparent in individuals with hypohidrotic ectodermal dysplasia, a rare genetic condition characterized by a reduced ability to sweat. Patients with this disorder are at risk for overheating. D) The importance of eccrine sweating as a cooling mechanism is apparent in individuals with hypohidrotic ectodermal dysplasia, a rare genetic condition characterized by a reduced ability to sweat. Patients with this disorder are at risk for overheating. Page Ref: 820 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 33.3 Explain the sensory inputs and effectors of thermoregulatory responses as complex, separate, but interacting responses with both autonomic and behavioral components. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of thermoregulation to diagnosis and treatment.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 34 Disorders Affecting Motor Function 1) Which of the following would the nurse consider focal seizure disorders? A) Simple partial and complex partial seizures B) Absence seizures C) Tonic-clonic seizures D) Status epilepticus Answer: A Explanation: A) Partial seizures (also known as focal seizures) occur when abnormal electrical activity is contained within a limited area of the brain. These seizures are referred to as partial seizures because the electrical activity resulting in a seizure may occur only within one lobe or hemisphere of the brain, in comparison to generalized seizures. B) Generalized seizures are caused by abnormal electrical discharges that originate from both hemispheres of the brain. Types of generalized seizures include tonic-clonic, absence, and status epilepticus. C) Generalized seizures are caused by abnormal electrical discharges that originate from both hemispheres of the brain. Types of generalized seizures include tonic-clonic, absence, and status epilepticus. D) Generalized seizures are caused by abnormal electrical discharges that originate from both hemispheres of the brain. Types of generalized seizures include tonic-clonic, absence, and status epilepticus. Page Ref: 856 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 34.6 Seizure Disorders: Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of seizure disorders and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders affecting motor function.

2) Which findings would the nurse expect when assessing a patient with parkinsonism? A) Chorea, tics, seizures B) Hyperreflexia, hoarse voice, poor balance C) Tremors, bradykinesia, rigidity D) Bradypnea, poor balance, chorea Answer: C Explanation: A) Many neurodegenerative disorders display signs and symptoms that are collectively known as parkinsonism (tremors, bradykinesia, rigidity, and postural instability). B) Many neurodegenerative disorders display signs and symptoms that are collectively known as parkinsonism (tremors, bradykinesia, rigidity, and postural instability). C) Many neurodegenerative disorders display signs and symptoms that are collectively known as parkinsonism (tremors, bradykinesia, rigidity, and postural instability). D) Many neurodegenerative disorders display signs and symptoms that are collectively known as parkinsonism (tremors, bradykinesia, rigidity, and postural instability). Page Ref: 844 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 34.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of Parkinson disease and approaches to diagnosis and treatment of the condition. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders affecting motor function.

3) Which patient statement indicates an understanding about the risk factors associated with Parkinson disease? A) "Aluminum exposure does not increase the risk for Parkinson disease." B) "The risk for Parkinson disease declines with age." C) "Women are at greater risk for Parkinson disease than men." D) "My high caffeine intake has a protective effect against Parkinson disease." Answer: D Explanation: A) Risk factors for PD include increased age; male gender; environmental exposures to pesticides, metals, and compounds such as manganese, lead, copper, iron, zinc, and aluminum; family history of PD; and genetic factors if age of onset is younger than 50 years. Cigarette smoking, caffeine intake, and high levels of urate in the blood inversely related to the risk of PD. Age is the most significant risk factor. There is little difference in incidence between men and women before 60 years of age. After 60 years of age, however, males are affected approximately 1.5 times more often than females, and this difference becomes greater as the age of onset gets older. B) Risk factors for PD include increased age; male gender; environmental exposures to pesticides, metals, and compounds such as manganese, lead, copper, iron, zinc, and aluminum; family history of PD; and genetic factors if age of onset is younger than 50 years. Cigarette smoking, caffeine intake, and high levels of urate in the blood inversely related to the risk of PD. Age is the most significant risk factor. There is little difference in incidence between men and women before 60 years of age. After 60 years of age, however, males are affected approximately 1.5 times more often than females, and this difference becomes greater as the age of onset gets older. C) Risk factors for PD include increased age; male gender; environmental exposures to pesticides, metals, and compounds such as manganese, lead, copper, iron, zinc, and aluminum; family history of PD; and genetic factors if age of onset is younger than 50 years. Cigarette smoking, caffeine intake, and high levels of urate in the blood inversely related to the risk of PD. Age is the most significant risk factor. There is little difference in incidence between men and women before 60 years of age. After 60 years of age, however, males are affected approximately 1.5 times more often than females, and this difference becomes greater as the age of onset gets older. D) Risk factors for PD include increased age; male gender; environmental exposures to pesticides, metals, and compounds such as manganese, lead, copper, iron, zinc, and aluminum; family history of PD; and genetic factors if age of onset is younger than 50 years. Cigarette smoking, caffeine intake, and high levels of urate in the blood inversely related to the risk of PD. Age is the most significant risk factor. There is little difference in incidence between men and women before 60 years of age. After 60 years of age, however, males are affected approximately 1.5 times more often than females, and this difference becomes greater as the age of onset gets older. Page Ref: 845 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance

Standards: Nursing Process: Evaluation | Learning Outcome: 34.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of Parkinson disease and approaches to diagnosis and treatment of the condition. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and wellbeing, and self-care management | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of disorders affecting motor function. 4) When assessing a patient for Parkinson disease, which is the earliest sign the nurse may observe? A) Shuffling gait B) Pill rolling resting tremor C) Lack of affect D) Rigidity Answer: B Explanation: A) Approximately 85% of individuals with PD display a supination-pronation, or "pill rolling," resting tremor of the hand. In 75% of people with PD, it is the first presenting motor feature. B) Approximately 85% of individuals with PD display a supination-pronation, or "pill rolling," resting tremor of the hand. In 75% of people with PD, it is the first presenting motor feature. C) Approximately 85% of individuals with PD display a supination-pronation, or "pill rolling," resting tremor of the hand. In 75% of people with PD, it is the first presenting motor feature. D) Approximately 85% of individuals with PD display a supination-pronation, or "pill rolling," resting tremor of the hand. In 75% of people with PD, it is the first presenting motor feature. Page Ref: 846 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 34.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of Parkinson disease and approaches to diagnosis and treatment of the condition. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders affecting motor function.

5) Which information about tremors should the nurse give to a patient newly diagnosed with Parkinson disease? A) The tremor disappears with sleep. B) The tremor worsens with action C) The tremor gets milder with walking. D) The tremor goes away with excitement. Answer: A Explanation: A) The tremor disappears with action and during sleep but worsens with walking or excitement. B) The tremor disappears with action and during sleep but worsens with walking or excitement. C) The tremor disappears with action and during sleep but worsens with walking or excitement. D) The tremor disappears with action and during sleep but worsens with walking or excitement. Page Ref: 846 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 34.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of Parkinson disease and approaches to diagnosis and treatment of the condition. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and wellbeing, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders affecting motor function.

6) When observing a patient with Parkinson disease walk, which gait is the nurse likely to observe? A) A shuffling gait with short steps B) A wide-based staggering gait C) A stiff gait with thighs overlapping with each step D) A toe-dragging gait Answer: A Explanation: A) In Parkinson disease, walking is characterized by a shuffling gait, short steps and steppage height, and turning en bloc. B) In Parkinson disease, walking is characterized by a shuffling gait, short steps and steppage height, and turning en bloc. C) In Parkinson disease, walking is characterized by a shuffling gait, short steps and steppage height, and turning en bloc. D) In Parkinson disease, walking is characterized by a shuffling gait, short steps and steppage height, and turning en bloc. Page Ref: 846 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 34.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of Parkinson disease and approaches to diagnosis and treatment of the condition. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders affecting motor function.

7) When teaching about the process of diagnosing Parkinson disease, the nurse tells the patient that a diagnosis is based on: A) three specific symptoms of Parkinson disease that must all be present. B) a positive CT scan. C) findings on the medical history and neurologic examination. D) only the presence of bradykinesia. Answer: C Explanation: A) Bradykinesia plus one other of the cardinal symptoms (tremor or rigidity) must be present to make the diagnosis of PD. The diagnosis of PD is based on the patient's medical history and a thorough neurologic examination. There are no tests that confirm the diagnosis. B) Bradykinesia plus one other of the cardinal symptoms (tremor or rigidity) must be present to make the diagnosis of PD. The diagnosis of PD is based on the patient's medical history and a thorough neurologic examination. There are no tests that confirm the diagnosis. C) Bradykinesia plus one other of the cardinal symptoms (tremor or rigidity) must be present to make the diagnosis of PD. The diagnosis of PD is based on the patient's medical history and a thorough neurologic examination. There are no tests that confirm the diagnosis. D) Bradykinesia plus one other of the cardinal symptoms (tremor or rigidity) must be present to make the diagnosis of PD. The diagnosis of PD is based on the patient's medical history and a thorough neurologic examination. There are no tests that confirm the diagnosis. Page Ref: 847 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 34.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of Parkinson disease and approaches to diagnosis and treatment of the condition. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and wellbeing, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders affecting motor function to diagnosis and treatment.

8) A patient with Parkinson disease is exhibiting rigidity, bradykinesia, and a limited ability to walk. The nurse explains to the patient that he is now in which Hoehn and Yahr stage of Parkinson disease? A) Stage 1 B) Stage 2 C) Stage 3 D) Stage 4 Answer: D Explanation: A) Stage 1 on the Hoehn and Yahr Scale of Parkinson disease is marked by signs and symptoms on one side only, mild symptoms, symptoms that are inconvenient but not disabling, tremor of one limb, and changes in posture, locomotion, and facial expression noted by friends. B) Stage 2 on the Hoehn and Yahr Scale of Parkinson disease is marked by bilateral symptoms, minimal disability, and posture and gait are affected. C) Stage 3 on the Hoehn and Yahr Scale of Parkinson disease is marked by a significant slowing of body movements, early impairment of equilibrium on walking or standing, and generalized dysfunction that is moderately severe. D) Stage 4 on the Hoehn and Yahr Scale of Parkinson disease is marked by severe symptoms, the ability to still walk to a limited extent, rigidity and bradykinesia, an inability able to live alone, and tremor that may be less than in earlier stages. Page Ref: 848 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 34.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of Parkinson disease and approaches to diagnosis and treatment of the condition. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and wellbeing, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders affecting motor function.

9) When taking a healthy history from a patient newly diagnosed with multiple sclerosis, which of the following is the nurse most likely to find? A) The patient is 60 years of age. B) The patient lives in the southern United States. C) The patient is of northern European descent. D) The patient is male. Answer: C Explanation: A) The risk factors for MS are related to age, gender, ethnicity, geography related to latitude, and genetics. Most people with MS are diagnosed between the ages of 20 and 50. MS is at least 2-3 times more common in women than in men; suggesting that hormones may play a role in susceptibility to MS. MS occurs in most ethic groups but is more common in Caucasians of northern European descent. MS is more common in areas farther from the equator. Genetic factors are thought to play an important role in the development of MS, as the disease clusters within families. B) The risk factors for MS are related to age, gender, ethnicity, geography related to latitude, and genetics. Most people with MS are diagnosed between the ages of 20 and 50. MS is at least 2-3 times more common in women than in men; suggesting that hormones may play a role in susceptibility to MS. MS occurs in most ethic groups but is more common in Caucasians of northern European descent. MS is more common in areas farther from the equator. Genetic factors are thought to play an important role in the development of MS, as the disease clusters within families. C) The risk factors for MS are related to age, gender, ethnicity, geography related to latitude, and genetics. Most people with MS are diagnosed between the ages of 20 and 50. MS is at least 2-3 times more common in women than in men; suggesting that hormones may play a role in susceptibility to MS. MS occurs in most ethic groups but is more common in Caucasians of northern European descent. MS is more common in areas farther from the equator. Genetic factors are thought to play an important role in the development of MS, as the disease clusters within families. D) The risk factors for MS are related to age, gender, ethnicity, geography related to latitude, and genetics. Most people with MS are diagnosed between the ages of 20 and 50. MS is at least 2-3 times more common in women than in men; suggesting that hormones may play a role in susceptibility to MS. MS occurs in most ethic groups but is more common in Caucasians of northern European descent. MS is more common in areas farther from the equator. Genetic factors are thought to play an important role in the development of MS, as the disease clusters within families. Page Ref: 849 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 34.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of multiple sclerosis and approaches to diagnosis and treatment of the condition across the lifespan | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health 9

MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of disorders affecting motor function. 10) Which patient statement indicates that more teaching about multiple sclerosis is needed? A) "Tai chi can help my sense of balance." B) "I can expect remissions mixed with relapses since I have relapsing-remitting MS." C) "A warm bath will help relieve muscular aches." D) "I need to include fiber in my diet." Answer: C Explanation: A) Tai chi and other forms of therapy can help with balance problems. B) Relapsing-Remitting MS (RRMS), the most common form, is characterized by acute attacks with full recovery. Primary Progressive MS is characterized by progression of disability, with or without plateaus and temporary minor improvements. Secondary-Progressive MS starts with an initial RRMA disease course, followed by progression of disability with occasional relapses and minor remissions/plateaus. C) Individuals with MS may experience temporary worsening of symptoms when the weather is very hot and humid, when they have a fever, or when they get overheated from exercising, sunbathing, or taking a hot shower or using a hot tub. D) Increasing fiber in the diet can help alleviate the constipation that often occurs in MS. Page Ref: 849 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 34.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of multiple sclerosis and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders affecting motor function.

11) Which finding indicates to the nurse that a patient with multiple sclerosis is experiencing Uhthoff sign? A) A worsening of symptoms and blurred vision when the weather is hot and humid. B) An elevated body temperature with no change in symptom severity. C) A progressive worsening of symptoms over time. D) A temporary improvement in symptoms. Answer: A Explanation: A) Individuals with MS may experience temporary worsening of symptoms when the weather is very hot and humid, when they have a fever, or when they get overheated from exercising, sunbathing, or taking a hot shower or using a hot tub. They may experience blurred vision, called Uhthoff sign. The symptoms resolve as the body temperature returns to normal. B) Individuals with MS may experience temporary worsening of symptoms when the weather is very hot and humid, when they have a fever, or when they get overheated from exercising, sunbathing, or taking a hot shower or using a hot tub. They may experience blurred vision, called Uhthoff sign. The symptoms resolve as the body temperature returns to normal. C) Individuals with MS may experience temporary worsening of symptoms when the weather is very hot and humid, when they have a fever, or when they get overheated from exercising, sunbathing, or taking a hot shower or using a hot tub. They may experience blurred vision, called Uhthoff sign. The symptoms resolve as the body temperature returns to normal. D) Individuals with MS may experience temporary worsening of symptoms when the weather is very hot and humid, when they have a fever, or when they get overheated from exercising, sunbathing, or taking a hot shower or using a hot tub. They may experience blurred vision, called Uhthoff sign. The symptoms resolve as the body temperature returns to normal. Page Ref: 849 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 34.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of multiple sclerosis and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders affecting motor function.

12) Which statement by a patient with multiple sclerosis (MS) indicates that more teaching is needed about immunomodulatory therapy (IMT)? A) "IMT can reduce the severity of my symptoms." B) "IMT can completely cure MS." C) "IMT can slow the progression of MS." D) "IMT can slow the development of plaque." Answer: B Explanation: A) MS is treated with immunomodulatory therapy (IMT) for the underlying immune disorder and therapies to relieve or limit other symptoms. IMT is used to reduce the frequency and severity of MS attacks, to slow the progress of disability, and to decrease the accumulation of CNS plaque. B) MS is treated with immunomodulatory therapy (IMT) for the underlying immune disorder and therapies to relieve or limit other symptoms. IMT is used to reduce the frequency and severity of MS attacks, to slow the progress of disability, and to decrease the accumulation of CNS plaque. C) MS is treated with immunomodulatory therapy (IMT) for the underlying immune disorder and therapies to relieve or limit other symptoms. IMT is used to reduce the frequency and severity of MS attacks, to slow the progress of disability, and to decrease the accumulation of CNS plaque. D) MS is treated with immunomodulatory therapy (IMT) for the underlying immune disorder and therapies to relieve or limit other symptoms. IMT is used to reduce the frequency and severity of MS attacks, to slow the progress of disability, and to decrease the accumulation of CNS plaque. Page Ref: 850 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Evaluation | Learning Outcome: 34.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of multiple sclerosis and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders affecting motor function to diagnosis and treatment.

13) What recommendation should the nurse give to a patient with multiple sclerosis regarding vaccinations? A) Inactivated vaccines are never safe for people with MS. B) Live attenuated virus vaccines are safe for people with MS receiving IMT therapy. C) People with MS should avoid live attenuated virus vaccines. D) All vaccinations should be avoided. Answer: C Explanation: A) The use of live attenuated virus vaccines, such as herpes zoster vaccine for protection from shingles, is not recommended for individuals with MS, particularly those being treated with IMT. The live virus in the vaccine can trigger the onset of an MS attack. B) The use of live attenuated virus vaccines, such as herpes zoster vaccine for protection from shingles, is not recommended for individuals with MS, particularly those being treated with IMT. The live virus in the vaccine can trigger the onset of an MS attack. C) The use of live attenuated virus vaccines, such as herpes zoster vaccine for protection from shingles, is not recommended for individuals with MS, particularly those being treated with IMT. The live virus in the vaccine can trigger the onset of an MS attack. D) The use of live attenuated virus vaccines, such as herpes zoster vaccine for protection from shingles, is not recommended for individuals with MS, particularly those being treated with IMT. The live virus in the vaccine can trigger the onset of an MS attack. Other vaccinations can be safe if given according to national guidelines. Page Ref: 852 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 34.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of multiple sclerosis and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders affecting motor function to diagnosis and treatment.

14) What response should the nurse give when a patient diagnosed with amyotrophic lateral sclerosis (ALS) asks about the disease course? A) "The disease is progressive." B) "The disease is marked by periods of remission and exacerbation." C) "The disease worsens over time, but is marked by a series of plateaus." D) "The disease will gradually worsen with periodic relapses." Answer: A Explanation: A) Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease that causes weakness, disability, and death within 3-5 years. B) Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease that causes weakness, disability, and death within 3-5 years. C) Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease that causes weakness, disability, and death within 3-5 years. D) Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease that causes weakness, disability, and death within 3-5 years. Page Ref: 853 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 34.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of amyotrophic lateral sclerosis and approaches to diagnosis and treatment of the condition. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders affecting motor function to diagnosis and treatment.

15) The children of a man diagnosed with amyotrophic lateral sclerosis ask if they are at risk for developing this disorder. How should the nurse respond? A) "No, this is not an inherited disorder." B) "You may be at risk but genetic testing will help to answer this question." C) "You have the same risk as the rest of the population." D) "Yes, you will get this disorder." Answer: B Explanation: A) About 5-10% of cases are inherited, and most of these follow an autosomal dominant inheritance pattern in which a genetic mutation is inherited from one parent. The children of a parent with an autosomal dominant mutation have a 50% chance of inheriting the gene and developing ALS. B) About 5-10% of cases are inherited, and most of these follow an autosomal dominant inheritance pattern in which a genetic mutation is inherited from one parent. The children of a parent with an autosomal dominant mutation have a 50% chance of inheriting the gene and developing ALS. C) About 5-10% of cases are inherited, and most of these follow an autosomal dominant inheritance pattern in which a genetic mutation is inherited from one parent. The children of a parent with an autosomal dominant mutation have a 50% chance of inheriting the gene and developing ALS. D) About 5-10% of cases are inherited, and most of these follow an autosomal dominant inheritance pattern in which a genetic mutation is inherited from one parent. The children of a parent with an autosomal dominant mutation have a 50% chance of inheriting the gene and developing ALS. Page Ref: 853 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 34.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of amyotrophic lateral sclerosis and approaches to diagnosis and treatment of the condition. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of disorders affecting motor function.

16) The nurse should expect to assess which finding in a patient with ALS who is experiencing bulbar involvement? A) Choking B) Hyperreflexia C) Fasciculations D) Slow movements Answer: A Explanation: A) Progression of bulbar symptoms leads to poor nutrition and dehydration and to choking on food or on the person's own secretions and aspiration. B) Hyperreflexia occurs with upper motor neuron involvement. C) Fasciculations (muscle twitching) occur with lower motor neuron involvement. D) Upper motor neuron involvement produces a slowness of movement. Page Ref: 854 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 34.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of multiple sclerosis and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders affecting motor function.

17) Which response by the nurse is best when a patient with the Huntington gene asks at what age he can expect symptoms to start? A) "If you are lucky, symptoms won't appear until after age 70." B) "Some people with the Huntington gene never develop symptoms." C) "Typically, symptoms can be detected as early as 10 years old." D) "The age on onset of symptoms is variable, but generally between 35 to 44 years old." Answer: D Explanation: A) Onset of symptoms usually occurs at 35-44 years of age. Onset in people younger than 10 years or older than 70 years of age is rare. The nurse should also be objective and not imply that some patients are unlucky. B) Onset of symptoms usually occurs at 35-44 years of age. Onset in people younger than 10 years or older than 70 years of age is rare. It is an autosomal dominant inherited disease in which a child of a parent with HD has a 50% chance of inheriting the gene mutation that causes the disease. C) Onset of symptoms usually occurs at 35-44 years of age. Onset in people younger than 10 years or older than 70 years of age is rare. D) Onset of symptoms usually occurs at 35-44 years of age. Onset in people younger than 10 years or older than 70 years of age is rare. Page Ref: 855 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 34.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of Huntington disease and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders affecting motor function.

18) When assessing an older adult for seizures, the nurse should be alert for: A) a blank stare and brief unresponsiveness. B) muscular rigidity and loss of consciousness. C) muscular contraction and relaxation. D) extremities rigid and extended. Answer: A Explanation: A) The manifestations of seizures in older adults are often different from those in children and younger adults. Older adults more frequently have simple or complex partial seizures rather than the classic tonic-clonic seizures. Older adults often present with a blank stare, brief unresponsiveness, language difficulties, confusion, and automatisms such as lip smacking. The postictal phase is also longer in older adults, sometimes lasting up to 2 weeks, with symptoms such as sleepiness and confusion. B) Tonic-clonic seizures are the most common seizure type in children, characterized by alternating repetitive tonic-clonic activity. The initial tonic phase is characterized by muscular rigidity and a sudden loss of consciousness. The individual will fall and may display a pattern in which the head and feet bend backwards with the body arched forward. Muscles are rigid, with the arms and legs extended and the jaw clenched. Pupils are fixed and dilated. C) Tonic-clonic seizures are the most common seizure type in children, characterized by alternating repetitive tonic-clonic activity. During the clonic phase, the patient experiences alternating periods of muscular contraction and relaxation in all extremities. D) Tonic-clonic seizures are the most common seizure type in children, characterized by alternating repetitive tonic-clonic activity. The initial tonic phase is characterized by muscular rigidity and a sudden loss of consciousness. The individual will fall and may display a pattern in which the head and feet bend backwards with the body arched forward. Muscles are rigid, with the arms and legs extended and the jaw clenched. Pupils are fixed and dilated. Page Ref: 858 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 34.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of seizure disorders and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders affecting motor function.

19) What is the priority nursing intervention in a patient with status epilepticus? A) Pad the bed frame to protect from injury. B) Document characteristics of the seizure. C) Administer 50% glucose. D) Establish and maintain an open airway. Answer: D Explanation: A) Although all interventions are correct, the priority is establishing an open airway to maintain oxygenation. Once an open airway is established, the other interventions may be carried out. B) Although all interventions are correct, the priority is establishing an open airway to maintain oxygenation. Once an open airway is established, the other interventions may be carried out. C) Although all interventions are correct, the priority is establishing an open airway to maintain oxygenation. Once an open airway is established, the other interventions may be carried out. D) Although all interventions are correct, the priority is establishing an open airway to maintain oxygenation. Once an open airway is established, the other interventions may be carried out. Page Ref: 857 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 34.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of seizure disorders and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders affecting motor function to diagnosis and treatment.

20) The nurse is counseling a woman with the Huntington gene who wants to become pregnant. What teaching would be most appropriate? A) Advise the woman not to become pregnant. B) Recommend genetic testing of fertilized eggs with in vitro fertilization. C) Advise the woman to become pregnant and have amniocentesis at 14 to 18 weeks. D) Recommend use of a donor egg. Answer: B Explanation: A) Advising the woman not to become pregnant is not necessary as there are ways of testing the fertilized egg for the gene prior to in vitro fertilization. B) For individuals with HD who want to have a child who does not have the HD gene, there are some options. Genetic diagnostic testing can be used with in vitro fertilization to ensure that the fertilized egg does not have the abnormal gene. If the woman is already pregnant, a chorionic villus biopsy can be performed at 10-11 weeks or amniocentesis at 14-18 weeks to test the fetus for the HD gene. C) For individuals with HD who want to have a child who does not have the HD gene, there are some options. Genetic diagnostic testing can be used with in vitro fertilization to ensure that the fertilized egg does not have the abnormal gene. If the woman is already pregnant, a chorionic villus biopsy can be performed at 10-11 weeks or amniocentesis at 14-18 weeks to test the fetus for the HD gene. D) Although a donor egg can be used, there are ways of testing the fertilized egg for the gene prior to in vitro fertilization. Page Ref: 856 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 34.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of Huntington disease and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of disorders affecting motor function.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 35 Acute Musculoskeletal Disorders 1) Which manifestations is the nurse most likely to assess in a patient with a simple closed fracture of the radial bone? A) Broken skin at the site of the fracture B) Visible bone at the site of the fracture C) Pain and intact skin at the site of the fracture D) Crepitus and bone protrusion through skin Answer: C Explanation: A) With a simple or closed fracture the bone ends are aligned and the skin is intact. B) With a simple or closed fracture the bone ends are aligned and the skin is intact. C) Pain and swelling are commonly associated with fractures. With a simple closed fracture, the skin remains intact. D) With a simple or closed fracture, the bone ends should not be grating or protruding through the skin. Page Ref: 865-867 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 35.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of fractures and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of acute musculoskeletal disorders.

2) How should the nurse respond when a patient with a fracture asks if the bone will return to its original strength? A) "Yes, the bone should have its original strength within 6 to 8 weeks." B) "No, the bone will never be as strong as before the fracture." C) "Yes, the bone will become just as strong but it may take a few years." D) "Yes, once your cast is removed, the bone will be back to its original strength." Answer: C Explanation: A) In the remodeling phase of bone healing, woven bone produced in the reparative stage of bone healing, is replaced by highly organized lamellar bone. Lamellar bone is stronger and more compact with better blood circulation in comparison to woven bone. However, it may be several years before the bone returns to its original strength. B) In the remodeling phase of bone healing, woven bone produced in the reparative stage of bone healing, is replaced by highly organized lamellar bone. Lamellar bone is stronger and more compact with better blood circulation in comparison to woven bone. However, it may be several years before the bone returns to its original strength. C) In the remodeling phase of bone healing, woven bone produced in the reparative stage of bone healing, is replaced by highly organized lamellar bone. Lamellar bone is stronger and more compact with better blood circulation in comparison to woven bone. However, it may be several years before the bone returns to its original strength. D) In the remodeling phase of bone healing, woven bone produced in the reparative stage of bone healing, is replaced by highly organized lamellar bone. Lamellar bone is stronger and more compact with better blood circulation in comparison to woven bone. However, it may be several years before the bone returns to its original strength. Page Ref: 866 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 35.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of fractures and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of acute musculoskeletal disorders.

3) Which statement by a patient scheduled for surgery for malunion of a fractured femur indicates to the nurse that he understands the reason for surgery? A) "My fracture is healing normally." B) "The bone fragments did not heal in a good alignment." C) "My bones have not healed in 3 months." D) "My bone healing is taking longer than expected." Answer: B Explanation: A) A bone that fractures and undergoes normal healing is called a union. B) A malunion occurs when the bone fragments join in a position that is not anatomically correct. C) A nonunion is a fracture that shows no clinically significant progress toward complete healing for at least 3 months according to x-rays. This may occur at any point along the healing process. D) A delayed union occurs when the healing process takes significantly longer than expected. Page Ref: 866 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 35.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of fractures and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of acute musculoskeletal disorders to diagnosis and treatment.

4) A patient with a fractured femur has pins inserted through the skin with a rod holding the pins in place. The nurse documents that the patient has had which type of procedure? A) External fixation B) Internal fixation C) Closed reduction D) Open reduction Answer: A Explanation: A) A surgical procedure used for direct healing includes external fixation, or the application of a device placed over and attached to the bone through external pins. These pins are placed above and below the fracture line to stabilize the fracture. B) Internal fixation is the term used to describe another surgical procedure called an open reduction and internal fixation (ORIF). With this procedure the bone is realigned or reduced and held into place with nails, screws, plates, or pins. C) Closed reduction occurs when the bone is repositioned externally. After the bone and fragments are realigned, the bone is stabilized through the use of traction or a cast. D) Internal fixation is the term used to describe a procedure called an open reduction and internal fixation (ORIF). With this procedure the bone is realigned or reduced and held into place with nails, screws, plates, or pins. Page Ref: 866-868 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 35.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of fractures and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of acute musculoskeletal disorders to diagnosis and treatment.

5) A patient in a cast for a right tibial fracture complains of increasing pain, unrelieved by analgesics. Assessment by the nurse reveals paresthesias and paleness of the right foot. What action should the nurse take first? A) Administer analgesia for breakthrough pain, and reassess the patient in 30 minutes. B) Elevate the leg above the heart, and reassess the patient in 30 minutes. C) Notify the orthopedic physician immediately. D) Ask the patient to do dorsiflexion and plantar flexion exercises of the foot. Answer: C Explanation: A) Compartment syndrome is a medical emergency, and the nurse should not wait to call the physician. B) Compartment syndrome is a medical emergency, and elevating the leg above the heart will not reduce the pressure within the cast. C) Compartment syndrome, a medical emergency, occurs when edema and swelling cause increased pressure in a muscle compartment, leading to decreased blood flow and possibly muscle and nerve damage. Symptoms of compartment syndrome include severe pain and tenderness, swelling, paresthesia, pallor, numbness or paralysis, and decreased or absent pulse and poikilothermia (normalization to room temperature) in the distal portion of the affected limb. Compartment syndrome should be suspected when complaints of pain and swelling are disproportionate to negative x-ray findings. It can result from a fracture, a muscle bruise, a crush injury, or a bandage that is too tight, such as a cast. The first step in treatment is to remove a tight cast. If internal pressure is causing the symptoms, it is generally treated by surgery to relieve the pressure. D) Compartment syndrome is a medical emergency, and performing these exercises will not reduce the pressure in the compartment. Page Ref: 870 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 35.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of fractures and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of acute musculoskeletal disorders to diagnosis and treatment.

6) Which assessment finding in a patient with a fractured femur would lead the nurse to suspect a fat embolism? A) Dyspnea and tachypnea B) Unrelieved pain in the fractured leg C) Volkmann contracture D) Edema of the affected leg Answer: A Explanation: A) Fat embolism may occur in conjunction with closed long bone or pelvic fractures. Respiratory consequences are typically the first symptom of fat embolism syndrome to occur. Fat emboli released from the bone marrow enter the bloodstream and become trapped in the pulmonary and dermal capillaries. In severe cases, dyspnea may progress to respiratory failure with tachypnea and hypoxia. B) This is a finding in compartment syndrome. C) A Volkmann contracture is a deformity of the wrist, hand, and fingers caused by ischemia to the forearm, usually as a result of compartment syndrome. Ischemia in the forearm causes the nerves and muscles to become scarred and shortened, forcing the joint to be permanently bent. D) Fat embolism may occur in conjunction with closed long bone or pelvic fractures. Respiratory consequences are typically the first symptom of fat embolism syndrome to occur. Fat emboli released from the bone marrow enter the bloodstream and become trapped in the pulmonary and dermal capillaries. In severe cases, dyspnea may progress to respiratory failure with tachypnea and hypoxia. Page Ref: 870 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 35.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of fractures and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of acute musculoskeletal disorders.

7) What finding would the nurse expect when assessing a patient with a right shoulder subluxation? A) Right shoulder deformity, reduced joint mobility B) Decreased length of the right arm C) Deformity of the wrist, hand, and fingers D) Pain unrelieved by appropriate analgesics Answer: A Explanation: A) The most common manifestations of dislocations and subluxations include pain, limb or joint deformity, and altered mobility of the affected joint. B) The length of the arm is not shortened in a shoulder dislocation. C) These are manifestations of a Volkmann contracture secondary to compartment syndrome and not findings for a shoulder dislocation. D) While the patient with a shoulder subluxation may have pain, it should be relieved with analgesics. Page Ref: 870-871 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 35.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of dislocations and subluxations and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of acute musculoskeletal disorders.

8) Which finding should alert the nurse that a patient is experiencing carpal tunnel syndrome? A) Pain worsens by shaking the affected hand and wrist. B) Pain is alleviated by elevating the hand. C) Pain is alleviated by shaking the affected hand and wrist D) Pain is alleviated by rubbing the palm of the affected hand. Answer: C Explanation: A) At first, the patient may experience numbness and tingling of the thumb, index finger, and lateral ventral surface of the middle finger. Over time, the numbness and tingling become more acute during sleep and are alleviated by shaking or rubbing the hand and wrist. B) At first, the patient may experience numbness and tingling of the thumb, index finger, and lateral ventral surface of the middle finger. Over time, the numbness and tingling become more acute during sleep and are alleviated by shaking or rubbing the hand and wrist. C) At first, the patient may experience numbness and tingling of the thumb, index finger, and lateral ventral surface of the middle finger. Over time, the numbness and tingling become more acute during sleep and are alleviated by shaking or rubbing the hand and wrist. D) At first, the patient may experience numbness and tingling of the thumb, index finger, and lateral ventral surface of the middle finger. Over time, the numbness and tingling become more acute during sleep and are alleviated by shaking or rubbing the hand and wrist. Page Ref: 872 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 35.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of nerve entrapment and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of acute musculoskeletal disorders.

9) Which assessment data indicates a positive Phalen test? A) Tingling in the fingers when the median nerve is tapped B) Tingling in the fingers when the ulna nerve is tapped C) Tingling or numbness of the fingers when the wrist is flexed D) Tingling or numbness of the fingers when the wrist is extended Answer: C Explanation: A) With carpal tunnel syndrome, the Tinsel test is positive for the disorder if the patient experiences tingling in the fingers when the median nerve is tapped. B) With carpal tunnel syndrome, the Tinsel test is positive for the disorder if the patient experiences tingling in the fingers when the median nerve is tapped. C) In carpal tunnel syndrome, the Phalen maneuver is positive if the patient experiences tingling or numbness of the fingers when the wrists are flexed. D) In carpal tunnel syndrome, the Phalen maneuver is positive if the patient experiences tingling or numbness of the fingers when the wrists are flexed. Page Ref: 872 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 35.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of nerve entrapment and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of acute musculoskeletal disorders.

10) Which instruction should the nurse give to the patient for the initial management of acute bursitis of the knee? A) Apply heat to the affected joint. B) Gently exercise the affected joint. C) Take acetaminophen, as prescribed. D) Rest the joint. Answer: D Explanation: A) Reduction of pain and inflammation is the priority when treating bursitis. The patient may be prescribed rest, compression, elevation, and nonsteroidal anti-inflammatory drugs (NSAIDs). If the inflammation is acute, ice may be recommended. However, if the inflammation is chronic, ice will not be beneficial. Once the initial pain is reduced, gentle stretching and strengthening exercises are recommended. B) Reduction of pain and inflammation is the priority when treating bursitis. The patient may be prescribed rest, compression, elevation, and nonsteroidal anti-inflammatory drugs (NSAIDs). If the inflammation is acute, ice may be recommended. However, if the inflammation is chronic, ice will not be beneficial. Once the initial pain is reduced, gentle stretching and strengthening exercises are recommended. C) Reduction of pain and inflammation is the priority when treating bursitis. The patient may be prescribed rest, compression, elevation, and nonsteroidal anti-inflammatory drugs (NSAIDs). If the inflammation is acute, ice may be recommended. However, if the inflammation is chronic, ice will not be beneficial. Once the initial pain is reduced, gentle stretching and strengthening exercises are recommended. D) Reduction of pain and inflammation is the priority when treating bursitis. The patient may be prescribed rest, compression, elevation, and nonsteroidal anti-inflammatory drugs (NSAIDs). If the inflammation is acute, ice may be recommended. However, if the inflammation is chronic, ice will not be beneficial. Once the initial pain is reduced, gentle stretching and strengthening exercises are recommended. Page Ref: 872 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 35.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of bursitis and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of acute musculoskeletal disorders to diagnosis and treatment.

11) Which of the following statements indicates that more discharge teaching is needed for the patient receiving traditional treatment in the emergency department for a sprained ankle? A) "I should stay off my foot and rest my ankle." B) "Wrapping my ankle with a compression bandage will reduce swelling." C) "I will keep my ankle elevated." D) "I will apply heat to my ankle." Answer: D Explanation: A) Traditional treatment has been through the use of RICE: rest, ice, compression, and elevation. B) Traditional treatment has been through the use of RICE: rest, ice, compression, and elevation. C) Traditional treatment has been through the use of RICE: rest, ice, compression, and elevation. D) Traditional treatment has been through the use of RICE: rest, ice, compression, and elevation. Page Ref: 873 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 35.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of strains and sprains and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of acute musculoskeletal disorders to diagnosis and treatment.

12) Which statement is typical of data collected from a patient with an anterior cruciate ligament (ACL) tear? A) "I heard my knee pop, and then it gave out." B) "My knee has locked up." C) "My knee is weak and buckles." D) "My knee doesn't move smoothly." Answer: A Explanation: A) At the time of an ACL injury, the patient typically reports intense pain and a feeling that the knee "popped" and "gave out." B) With a meniscus tear, the patient reports feeling that knee is "locking up" or not moving smoothly, and a feeling that the knee is weak or "buckling." C) With a meniscus tear, the patient reports feeling that knee is "locking up" or not moving smoothly, and a feeling that the knee is weak or "buckling." D) With a meniscus tear, the patient reports feeling that knee is "locking up" or not moving smoothly, and a feeling that the knee is weak or "buckling." Page Ref: 873-874 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 35.7 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of knee injuries and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of acute musculoskeletal disorders.

13) Which statement by a patient indicates an understanding of postoperative instructions following rotator cuff repair? A) "My arm will be immobilized for 2 weeks after surgery." B) "Passive range of motion exercises may be performed for the first 6 weeks." C) "I can start active range of motion exercises after 2 weeks." D) "Active range of motion exercises will restore arm function in 2 weeks." Answer: B Explanation: A) Procedures to repair the tear include open or arthroscopic approaches. Arm and shoulder immobilization occurs for the first 4-6 weeks after surgery and may include passive exercising. Active exercising begins during the next 4-6 weeks and progresses until full or maximum shoulder ROM and arm function return. B) Procedures to repair the tear include open or arthroscopic approaches. Arm and shoulder immobilization occurs for the first 4-6 weeks after surgery and may include passive exercising. Active exercising begins during the next 4-6 weeks and progresses until full or maximum shoulder ROM and arm function return. C) Procedures to repair the tear include open or arthroscopic approaches. Arm and shoulder immobilization occurs for the first 4-6 weeks after surgery and may include passive exercising. Active exercising begins during the next 4-6 weeks and progresses until full or maximum shoulder ROM and arm function return. D) Procedures to repair the tear include open or arthroscopic approaches. Arm and shoulder immobilization occurs for the first 4-6 weeks after surgery and may include passive exercising. Active exercising begins during the next 4-6 weeks and progresses until full or maximum shoulder ROM and arm function return. Page Ref: 876 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Evaluation | Learning Outcome: 35.8 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of shoulder injuries and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of acute musculoskeletal disorders to diagnosis and treatment.

14) Which local indications is the nurse likely to assess in a patient with osteomyelitis of the hip? A) Bone pain, redness, and warmth B) Nausea, vomiting, anorexia C) Fever and chills D) Lymph node swelling, malaise Answer: A Explanation: A) Manifestations of osteomyelitis can be local or systemic. Local indications of a bone infection include bone pain, drainage and ulceration at the site, swelling, redness, warmth, and localized tenderness. B) Manifestations of osteomyelitis can be local or systemic. Lymph node swelling, fever with chills, general malaise, tachycardia, nausea, vomiting, and anorexia are manifestations of a systemic bone infection. C) Manifestations of osteomyelitis can be local or systemic. Lymph node swelling, fever with chills, general malaise, tachycardia, nausea, vomiting, and anorexia are manifestations of a systemic bone infection. D) Manifestations of osteomyelitis can be local or systemic. Lymph node swelling, fever with chills, general malaise, tachycardia, nausea, vomiting, and anorexia are manifestations of a systemic bone infection. Page Ref: 877 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 35.9 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of bone infections and tumors and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of acute musculoskeletal disorders.

15) Which of the following patients does the nurse recognize as being at highest risk for a benign bone tumor? A) A 42-year-old postmenopausal woman B) An 85-year-old man C) A 13-year-old child D) A 35-year-old pregnant woman Answer: C Explanation: A) Benign bone tumors occur in children and young adults up to age 30. The vast majority of benign tumors are affected by growth hormones and stop growing when the child's bones stop growing. B) Benign bone tumors occur in children and young adults up to age 30. The vast majority of benign tumors are affected by growth hormones and stop growing when the child's bones stop growing. C) Benign bone tumors occur in children and young adults up to age 30. The vast majority of benign tumors are affected by growth hormones and stop growing when the child's bones stop growing. D) Benign bone tumors occur in children and young adults up to age 30. The vast majority of benign tumors are affected by growth hormones and stop growing when the child's bones stop growing. Page Ref: 878 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 35.9 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of bone infections and tumors and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of acute musculoskeletal disorders.

16) When assessing a 17-year-old with Ewing sarcoma, the nurse understands that the most likely affected bones are: A) femur, tibia, humerus. B) pelvis, scapula. C) bone marrow. D) shaft of long bones, flat bones. Answer: D Explanation: A) Osteosarcoma occurs in the femur, tibia, and humerus. B) Chondrosarcoma occurs in the pelvis, scapula, and shaft of long bones. C) Multiple myeloma affects the bone marrow. D) Ewing sarcoma affects the shaft of long bones and flat bones. Page Ref: 878 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 35.9 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of bone infections and tumors and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of acute musculoskeletal disorders.

17) Which population does the nurse understand is most at risk for osteosarcoma? A) Older adults B) Young adult males C) Middle-aged females D) Female adolescents Answer: B Explanation: A) The incidence of osteosarcoma is highest in adolescents and young adults, and the incidence is higher in males than females. B) The incidence of osteosarcoma is highest in adolescents and young adults, and the incidence is higher in males than females. C) The incidence of osteosarcoma is highest in adolescents and young adults, and the incidence is higher in males than females. D) The incidence of osteosarcoma is highest in adolescents and young adults, and the incidence is higher in males than females. Page Ref: 878 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 35.9 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of bone infections and tumors and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of acute musculoskeletal disorders.

18) What is the best response by the nurse when a patient with a fractured femur asks the nurse to explain Buck traction? A) "Buck traction is a form of skin traction that will help align your bone ends." B) "Buck traction uses pins in your bone attached to weights to align the bones." C) "Buck traction is a form of skeletal traction." D) "Buck traction applies force directly to the bone. Answer: A Explanation: A) Traction is the application of a pulling force to maintain bone alignment during fracture healing. Skin traction applies force to the soft tissues through a pulley system attached to the bed, such as Buck traction. Skeletal traction applies force directly to the bone using pins or wires through the bone. B) Traction is the application of a pulling force to maintain bone alignment during fracture healing. Skin traction applies force to the soft tissues through a pulley system attached to the bed, such as Buck traction. Skeletal traction applies force directly to the bone using pins or wires through the bone. C) Traction is the application of a pulling force to maintain bone alignment during fracture healing. Skin traction applies force to the soft tissues through a pulley system attached to the bed, such as Buck traction. Skeletal traction applies force directly to the bone using pins or wires through the bone. D) Traction is the application of a pulling force to maintain bone alignment during fracture healing. Skin traction applies force to the soft tissues through a pulley system attached to the bed, such as Buck traction. Skeletal traction applies force directly to the bone using pins or wires through the bone. Page Ref: 869 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 35.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of fractures and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of acute musculoskeletal disorders to diagnosis and treatment.

19) Following a bone fracture, which of the following patients does the nurse identify as being at greatest risk for infection? A) A patient undergoing closed reduction of a fracture B) A patient in skin traction for a simple closed fracture C) A patient with a cast for a closed fracture D) A patient managed with surgical correction of a closed fracture Answer: D Explanation: A) Closed reduction occurs when the bone is repositioned externally, leaving the skin intact. B) The patient in skin traction for a simple closed fracture does not have any pins or wires creating a portal of entry for contamination. C) Casting does not impair skin integrity and does not create a portal of entry for contaminants. D) Impaired skin integrity as a result of surgical correction of a fracture increases the risk of bacterial contamination and development of an infection. Page Ref: 868-870 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 35.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of fractures and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of acute musculoskeletal disorders.

20) Which response should the nurse give when a parent of a child with a greenstick fracture asks the nurse to explain this type of fracture? A) "The bone fragments are partially joined." B) "The bone is broken in several places." C) "A fragment of the bone is separated from the rest of the bone." D) "The bone ends are out of alignment." Answer: A Explanation: A) A greenstick fracture, in which the bone ends are still partially joined, is more common in children. B) In a comminuted fracture, there are bone fragments in many places. This is common in people with brittle bones. C) In an avulsion, a fragment of bone is separated from the rest of the bone. D) In a displaced fracture, the broken bone ends move out of alignment. Page Ref: 867 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 35.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of fractures and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of acute musculoskeletal disorders.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 36 Chronic Musculoskeletal Disorders 1) The nurse should expect to assess which finding in a patient with intervertebral disc degeneration? A) Back and leg pain relieved by sitting B) Pain in the back that spreads to the buttocks C) Back pain that spreads to the neck D) Back pain with numbness and tingling of the fingers Answer: B Explanation: A) In intervertebral disc degeneration, sitting may exacerbate the pain and numbness. B) The most common manifestation of intervertebral disc degeneration is pain in the back that may spread to the buttocks and upper thighs. Additionally, the patient may experience numbness and tingling in the leg or foot. C) The most common manifestation of intervertebral disc degeneration is pain in the back that may spread to the buttocks and upper thighs. Additionally, the patient may experience numbness and tingling in the leg or foot. D) The most common manifestation of intervertebral disc degeneration is pain in the back that may spread to the buttocks and upper thighs. Additionally, the patient may experience numbness and tingling in the leg or foot. Page Ref: 886 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 36.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of lower back pain and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of chronic musculoskeletal disorders.

2) Which statement indicates to the nurse that the patient with lower back pain due to intervertebral disc degeneration does not understand the goal of physical therapy? A) "Physical therapy will help strengthen my core muscles." B) "Electrical stimulation may be used to relieve my back pain." C) "Physical therapy can reverse the disc degeneration." D) "Physical therapy will help strengthen back muscles weakened by bedrest." Answer: C Explanation: A) Physical therapy may be prescribed to help the patient with exercises to strengthen the core muscles and prevent back strain. B) A back brace may be suggested along with heat or ice, massage, ultrasound, and electrical stimulation. C) Physical therapy will not reduce or reverse disc generation. D) Physical therapy may be prescribed to help the patient with exercises to strengthen the core and back muscles that may have been weakened by bedrest. Page Ref: 886 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Evaluation | Learning Outcome: 36.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of lower back pain and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of chronic musculoskeletal disorders to diagnosis and treatment.

3) When assessing a patient with a herniated disc in the lumbar region, the nurse would expect to find: A) lower extremity paralysis. B) urinary incontinence. C) neck and shoulder pain radiating to hands. D) burning pain that radiates from the buttocks to the leg. Answer: D Explanation: A) Herniation of a thoracic disc is a medical emergency that can result in paralysis. B) Compression of the nerve roots of the cauda equina can lead to cauda equina syndrome (CES), which may result in permanent neurologic impairment, including urinary incontinence and paralysis. C) Pressure on one or more of the lumbar roots can affect the sciatic nerve, leading to pain, burning, tingling, and numbness that radiates from the buttock into the leg and foot. The neck, shoulders, and hands are not affected. D) A herniated disc in the lumbar region may cause a condition called sciatica. Pressure on one or more of the lumbar roots can affect the sciatic nerve, leading to pain, burning, tingling, and numbness that radiates from the buttock into the leg and foot. Page Ref: 886-887 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 36.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of lower back pain and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of chronic musculoskeletal disorders.

4) Which priority intervention should the nurse anticipate in the patient admitted with cauda equine syndrome? A) Prepare patient for urgent surgery. B) Place the patient on complete bedrest. C) Obtain equipment for skin traction. D) Obtain a physical therapy consult. Answer: A Explanation: A) Compression of the nerve roots of the cauda equina can lead to cauda equina syndrome (CES), which may result in permanent neurologic impairment, including urinary incontinence and paralysis. Causes of CES include massive lumbar disc herniation, spinal stenosis, epidural hematoma, epidural abscess, and trauma. CES is a medical emergency. Immediate surgery should be performed to relieve pressure on the nerves. B) Compression of the nerve roots of the cauda equina can lead to cauda equina syndrome (CES), which may result in permanent neurologic impairment, including urinary incontinence and paralysis. Causes of CES include massive lumbar disc herniation, spinal stenosis, epidural hematoma, epidural abscess, and trauma. CES is a medical emergency. Immediate surgery should be performed to relieve pressure on the nerves. C) Compression of the nerve roots of the cauda equina can lead to cauda equina syndrome (CES), which may result in permanent neurologic impairment, including urinary incontinence and paralysis. Causes of CES include massive lumbar disc herniation, spinal stenosis, epidural hematoma, epidural abscess, and trauma. CES is a medical emergency. Immediate surgery should be performed to relieve pressure on the nerves. D) Compression of the nerve roots of the cauda equina can lead to cauda equina syndrome (CES), which may result in permanent neurologic impairment, including urinary incontinence and paralysis. Causes of CES include massive lumbar disc herniation, spinal stenosis, epidural hematoma, epidural abscess, and trauma. CES is a medical emergency. Immediate surgery should be performed to relieve pressure on the nerves. Page Ref: 887 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 36.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of lower back pain and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of chronic musculoskeletal disorders to diagnosis and treatment.

5) When preparing a patient for a discectomy, the nurse explains that this procedure: A) removes the lamina to enlarge the spinal canal. B) removes all or part of the herniated disc. C) joins vertebrae together to prevent motion between the vertebra. D) vaporizes the tissue in the disc. Answer: B Explanation: A) A laminectomy is performed to remove the lamina, or the part of the vertebra that covers the spinal canal. This enlarges the spinal canal and relieves pressure on the associated nerves. B) A discectomy is performed to remove all or part of the herniated disc. Muscles and other tissues are dissected away from the spine to allow for surgical exposure of the ruptured disc. After removal of the disc, surrounding structures are returned to their natural positions. C) Spinal fusion is performed to join two or more vertebrae together using bone grafts, screws, and rods. This prevents motion between the two vertebrae and reduces pain. D) Newer technology has allowed the use of laser surgery to treat herniated discs. During laser surgery, the surgeon inserts a needle into the disc and delivers laser energy to vaporize the tissue in the disc. This reduces the size of the disc and relieves pressure on the nerves. Page Ref: 887-888 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 36.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of lower back pain and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of chronic musculoskeletal disorders to diagnosis and treatment.

6) How should the nurse respond when a 28-weeks-pregnant woman asks if she will need surgery after her baby is born to relieve the constant back pain she has been experiencing? A) "That depends, did you have a herniated disc before pregnancy?" B) "It's a possibility, have you seen a surgeon?" C) "Most often, back pain goes away after delivery." D) "Stay off your feet as much as possible and rest in bed." Answer: C Explanation: A) Nearly half of women report back pain during pregnancy. A herniated disc is rare, however, occurring in about 1 in 10,000 pregnancies. Most often, the symptoms resolve after delivery. B) Nearly half of women report back pain during pregnancy. A herniated disc is rare, however, occurring in about 1 in 10,000 pregnancies. Most often, the symptoms resolve after delivery. C) Nearly half of women report back pain during pregnancy. A herniated disc is rare, however, occurring in about 1 in 10,000 pregnancies. Most often, the symptoms resolve after delivery. D) Nearly half of women report back pain during pregnancy. A herniated disc is rare, however, occurring in about 1 in 10,000 pregnancies. Most often, the symptoms resolve after delivery. Page Ref: 888 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 36.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of lower back pain and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of chronic musculoskeletal disorders to diagnosis and treatment.

7) Which statement is typical of data collected on a patient with mild spinal stenosis? A) "Flexing my lower back relieves the pain." B) "Twisting side to side relieves the pain." C) "I sometimes experience loss of bladder control." D) "I have difficulty wiggling my toes." Answer: A Explanation: A) Narrowing of the spinal canal causes slow progressive manifestations such as numbness, weakness, cramping, or general pain that corresponds with the affected spinal segment. If the narrowed area places pressure on a nerve root, pain may radiate down an arm or a leg. Flexing the lower back helps to relieve the symptoms by enlarging the spinal spaces. Individuals who have more severe stenosis can experience bowel and bladder dysfunction and loss of motor and sensory control of the foot. B) Narrowing of the spinal canal causes slow progressive manifestations such as numbness, weakness, cramping, or general pain that corresponds with the affected spinal segment. If the narrowed area places pressure on a nerve root, pain may radiate down an arm or a leg. Flexing the lower back helps to relieve the symptoms by enlarging the spinal spaces. Individuals who have more severe stenosis can experience bowel and bladder dysfunction and loss of motor and sensory control of the foot. C) Narrowing of the spinal canal causes slow progressive manifestations such as numbness, weakness, cramping, or general pain that corresponds with the affected spinal segment. If the narrowed area places pressure on a nerve root, pain may radiate down an arm or a leg. Flexing the lower back helps to relieve the symptoms by enlarging the spinal spaces. Individuals who have more severe stenosis can experience bowel and bladder dysfunction and loss of motor and sensory control of the foot. D) Narrowing of the spinal canal causes slow progressive manifestations such as numbness, weakness, cramping, or general pain that corresponds with the affected spinal segment. If the narrowed area places pressure on a nerve root, pain may radiate down an arm or a leg. Flexing the lower back helps to relieve the symptoms by enlarging the spinal spaces. Individuals who have more severe stenosis can experience bowel and bladder dysfunction and loss of motor and sensory control of the foot. Page Ref: 888 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 36.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of lower back pain and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of chronic musculoskeletal disorders.

8) The nurse notices that a pregnant woman has an exaggerated concavity of her spine. The nurse documents this as: A) kyphosis. B) lordosis. C) scoliosis. D) rotoscoliosis. Answer: B Explanation: A) Kyphosis, which is common in older adults, is characterized by a spinal column that is convex. B) In lordosis, the spinal column is more concave; it is seen frequently in individuals who are pregnant or obese. Lordosis in pregnancy resolves after delivery. C) Scoliosis is a lateral, or sideways, curve of the spine; it can be C shaped or S shaped. D) Rotoscoliosis is the curvature of the vertebral column turned on its axis. Page Ref: 889-890 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 36.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of lower back pain and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of chronic musculoskeletal disorders.

9) When a baby is born with congenital scoliosis, the nurse should also assess for problems with which other organs? A) Heart and lungs B) Liver and kidneys C) Heart and kidneys D) Lungs and liver Answer: C Explanation: A) Congenital scoliosis occurs when the individual is born with a curved spine. This usually results from incomplete formation or separation of the vertebrae, and it can be associated with other health issues such as heart and kidney problems. B) Congenital scoliosis occurs when the individual is born with a curved spine. This usually results from incomplete formation or separation of the vertebrae, and it can be associated with other health issues such as heart and kidney problems. C) Congenital scoliosis occurs when the individual is born with a curved spine. This usually results from incomplete formation or separation of the vertebrae, and it can be associated with other health issues such as heart and kidney problems. D) Congenital scoliosis occurs when the individual is born with a curved spine. This usually results from incomplete formation or separation of the vertebrae, and it can be associated with other health issues such as heart and kidney problems. Page Ref: 889 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 36.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of lower back pain and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of chronic musculoskeletal disorders.

10) The school nurse is screening middle-school students for scoliosis and notes that one student has a curve of 15 degrees. The nurse tells the parents that their child has: A) prescoliosis. B) mild scoliosis. C) moderate scoliosis. D) severe scoliosis. Answer: B Explanation: A) Scoliosis is diagnosed if the sideways curvature measures more than 10 degrees. Mild scoliosis reflects a curve between 10 and 20 degrees, moderate scoliosis is a curve between 20 and 40 degrees, and severe scoliosis is a curve over 40 degrees. B) Scoliosis is diagnosed if the sideways curvature measures more than 10 degrees. Mild scoliosis reflects a curve between 10 and 20 degrees, moderate scoliosis is a curve between 20 and 40 degrees, and severe scoliosis is a curve over 40 degrees. C) Scoliosis is diagnosed if the sideways curvature measures more than 10 degrees. Mild scoliosis reflects a curve between 10 and 20 degrees, moderate scoliosis is a curve between 20 and 40 degrees, and severe scoliosis is a curve over 40 degrees. D) Scoliosis is diagnosed if the sideways curvature measures more than 10 degrees. Mild scoliosis reflects a curve between 10 and 20 degrees, moderate scoliosis is a curve between 20 and 40 degrees, and severe scoliosis is a curve over 40 degrees. Page Ref: 890 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 36.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of lower back pain and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of chronic musculoskeletal disorders.

11) To perform scoliosis screening using the Adam forward bend test, what action does the nurse take? A) The nurse asks the child to bend forward at the waist. B) The nurse asks the child to cross arms over the chest. C) The nurse stands at the child's side to exam the spine. D) The nurse stands at the child's head to examine the spine. Answer: A Explanation: A) One of the primary screening tests for scoliosis is the Adam forward bend test, in which the individual leans forward at the waist with the arms hanging straight down. This allows the clinician to see the spine more clearly. B) One of the primary screening tests for scoliosis is the Adam forward bend test, in which the individual leans forward at the waist with the arms hanging straight down. This allows the clinician to see the spine more clearly. C) One of the primary screening tests for scoliosis is the Adam forward bend test, in which the individual leans forward at the waist with the arms hanging straight down. This allows the clinician to see the spine more clearly. D) One of the primary screening tests for scoliosis is the Adam forward bend test, in which the individual leans forward at the waist with the arms hanging straight down. This allows the clinician to see the spine more clearly. Page Ref: 890 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 36.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of lower back pain and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of chronic musculoskeletal disorders.

12) Which finding should the nurse expect when assessing a patient with osteoarthritis? A) Pain that worsens with activity, relieved at rest B) Warm swollen joints C) Anorexia and weight loss D) Low grade fever Answer: A Explanation: A) Many patients with OA develop pain associated with joint degeneration; this pain is usually worsened by activity and relieved by rest. B) Joint manifestations of rheumatoid arthritis include joint swelling, stiffness, warmth, tenderness, and pain. C) Manifestations of rheumatoid arthritis are systemic and include fatigue, anorexia, weight loss, weakness, and a low grade fever. D) Manifestations of rheumatoid arthritis are systemic and include fatigue, anorexia, weight loss, weakness, and a low grade fever. Page Ref: 891, 894 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 36.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of rheumatic and arthritic disorders and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of chronic musculoskeletal disorders.

13) When preparing a community program on joint disease, the nurse recognizes that which group is most at risk for rheumatoid arthritis? A) Women between 40 and 60 years of age B) Men between 40 and 60 years of age C) Women between 20 and 40 years of age D) Men between 20 and 40 years of age Answer: A Explanation: A) Rheumatoid arthritis affects three times as many women as men, and although the typical age of onset is between 40 and 60 years, this disease strikes people of all ages. B) Rheumatoid arthritis affects three times as many women as men, and although the typical age of onset is between 40 and 60 years, this disease strikes people of all ages. C) Rheumatoid arthritis affects three times as many women as men, and although the typical age of onset is between 40 and 60 years, this disease strikes people of all ages. D) Rheumatoid arthritis affects three times as many women as men, and although the typical age of onset is between 40 and 60 years, this disease strikes people of all ages. Page Ref: 893 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 36.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of rheumatic and arthritic disorders and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of chronic musculoskeletal disorders.

14) Which laboratory values would the nurse expect to find in a patient with rheumatoid arthritis (RA)? A) Negative rheumatoid factor B) Low C-reactive protein C) Low erythrocyte sedimentation rate D) Antibodies to cyclic citrullinated peptide (anti-CCP) Answer: D Explanation: A) More than 70% of patients with rheumatoid arthritis (RA) test positive for rheumatoid factor. B) The erythrocyte sedimentation rate (ESR) typically is elevated with rheumatoid arthritis (RA) as is the C-reactive protein, a nonspecific indicator of inflammation. C) The erythrocyte sedimentation rate (ESR) typically is elevated with rheumatoid arthritis (RA) as is the C-reactive protein, a nonspecific indicator of inflammation. D) A marker for rheumatoid arthritis (RA) is antibodies to cyclic citrullinated peptide (CCP). The anti-CCP test detects these antibodies and may yield positive results even years before RA symptoms emerge. Page Ref: 894 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 36.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of rheumatic and arthritic disorders and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of chronic musculoskeletal disorders.

15) A patient with rheumatoid arthritis tells the nurse that the physician told him he has Felty syndrome and asks the nurse what it means. Which of the following conditions does the nurse include in her description of this syndrome? A) Low grade fever, weight loss, anorexia B) Vasculitis, pericarditis, pneumonitis C) Enlarged spleen, neutropenia, anemia D) Symmetric polyarticular joint swelling, joint redness, joint tenderness Answer: C Explanation: A) Low grade fever, weight loss, and anorexia occur with rheumatoid arthritis, but they are not part of Felty syndrome. B) Vasculitis, pericarditis, and pneumonitis occur with rheumatoid arthritis, but they are not part of Felty syndrome. C) Felty syndrome is a hematologic complication of long-standing rheumatoid arthritis that consists of splenomegaly, neutropenia, and anemia. D) Symmetric polyarticular joint swelling, joint redness, and joint tenderness occur with rheumatoid arthritis, but they are not part of Felty syndrome. Page Ref: 895 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 36.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of rheumatic and arthritic disorders and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of chronic musculoskeletal disorders.

16) Which assessment findings in a 7-year-old child suggests a diagnosis of psoriatic arthritis? A) Pain that started in the hips, knees, heels, or great toe followed later on by spine pain B) Red, scaly skin; pitted and yellowed toenails; joint pain C) Arthritis symptoms, intestinal inflammation D) Pain in the lower legs Answer: B Explanation: A) In ankylosing spondylitis, symptoms begin in the hips, knees, heels, or great toe before moving to the spine. B) Psoriatic arthritis manifestations include red, scaly skin that may or may not be in the joint areas; pitted and yellowed toe and fingernails; red and inflamed skin over the joint area; and stiffness, swelling, and pain in the joint. C) In enteropathic arthritis, arthritis symptoms appear before intestinal inflammation. D) In reactive arthritis, the patient experiences pain in the joints of the lower legs. Page Ref: 896 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 36.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of rheumatic and arthritic disorders and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of chronic musculoskeletal disorders.

17) Which statement by a female patient with osteopenia indicates that more teaching about risk factors is needed? A) "I need to take calcium and vitamin D." B) "Because exercise is good for me, I will try swimming." C) "I need to stop smoking." D) "I should stop drinking cola beverages." Answer: B Explanation: A) Diet therapy for osteopenia includes increasing the intake of calcium and vitamin D. B) In osteopenia, the patient is encouraged to increase weight-bearing exercises because bone forms in response to stress. Swimming is not a weight-bearing exercise. C) Smoking cessation and reduction of cola-based and alcoholic beverages are other actions to slow the loss of bone. D) Smoking cessation and reduction of cola-based and alcoholic beverages are other actions to slow the loss of bone. Page Ref: 897-898 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Evaluation | Learning Outcome: 36.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of metabolic bone disease and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of chronic musculoskeletal disorders to diagnosis and treatment.

18) Which statement by a patient with Paget disease indicates that the nurse needs to reinforce teaching? A) "Bisphosphonates and calcitonin will help strengthen the bone." B) "Exercise may cause fractures." C) "I will need to take calcium and vitamin D supplements." D) "I need to maintain a healthy body weight. Answer: B Explanation: A) Medications used for the disorder include bisphosphonates and calcitonin. B) Exercise is recommended in Paget disease to maintain healthy bones, maintain a healthy weight, and prevent fractures. C) Nutritional support includes calcium and vitamin D supplements. D) Exercise is recommended in Paget disease to maintain healthy bones, maintain a healthy weight, and prevent fractures. Page Ref: 898-899 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Evaluation | Learning Outcome: 36.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of metabolic bone disease and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of chronic musculoskeletal disorders to diagnosis and treatment.

19) The nurse is teaching the parents of a child with scoliosis about the disorder. What would the nurse explain is the recommended treatment for a 15-degree curve of the spine? A) "Spinal fusion will be needed after the child has stopped growing to correct the curve." B) "A brace will need to be worn to straighten the spine." C) "All that is needed for this degree of curvature is physical therapy." D) "Surgery for placement of a rod may be needed if the spinal curvature worsens." Answer: C Explanation: A) Patients with great than 40 degree angles may be considered for spinal fusion surgery. Surgery is usually performed only on patients whose curvature progression is not slowed by bracing and whose bones have stopped growing. B) For patients with angles between 20 and 40 degrees, medical management includes wearing a brace. C) Patients with angles of 15-25 degrees may be treated conservatively with physical therapy. D) If curve progression is severe (at least 45 degrees) before the child has stopped growing, surgeons may insert a rod that can be adjusted in length as the child grows; adjustments usually occur every 6 months. Page Ref: 890 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 36.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of lower back pain and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of chronic musculoskeletal disorders to diagnosis and treatment.

20) The nurse anticipates that a patient experiencing neuropathic pain caused by lumbar disc herniation may be treated with: A) Nonsteroidal anti-inflammatory drugs, which are specific for neuropathic pain B) Opioids for moderate pain C) Tramadol (Ultram) for mild pain D) Gabapentin (Neurontin), which is specific for neuropathic pain Answer: D Explanation: A) Treatment of a herniated disc begins with NSAIDs to reduce pain and swelling. NSAIDS are not specific for neuropathic pain. B) If the patient is experiencing neurologic problems such as numbness or sciatica, additional medications may include opioids for severe pain. Opioids are not specific for neuropathic pain. C) Tramadol (Ultram), which is a centrally acting opiate receptor agonist, may be used to treat moderate to severe pain. D) Medications used to treat neuropathic pain, such as gabapentin (Neurontin), pregabalin (Lyrica), and duloxetine (Cymbalta), may also be useful for reducing pain related to nerve damage and have milder side effects than those of opioids. Page Ref: 887 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Planning | Learning Outcome: 36.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of lower back pain and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of chronic musculoskeletal disorders to diagnosis and treatment.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 37 Diabetes Mellitus and Its Complications 1) When developing a care plan for a patient with type 1 diabetes, the nurse should consider which pathophysiological concept? A) In type 1 diabetes, there is a complete lack of insulin secretion. B) In type 1 diabetes, there is a relative deficiency in insulin. C) In type 1 diabetes, there is insulin resistance. D) In type 1 diabetes, there is an over secretion of insulin. Answer: A Explanation: A) People with type 1 diabetes have an almost complete lack of insulin secretion, and the insulin deficiency is considered total or absolute. People with type 2 diabetes have a relative insulin deficiency (i.e., the insulin secretion is too low in relation to the blood glucose level) and insulin resistance (i.e., the endogenous insulin is unable to produce its biological response). B) People with type 1 diabetes have an almost complete lack of insulin secretion, and the insulin deficiency is considered total or absolute. People with type 2 diabetes have a relative insulin deficiency (i.e., the insulin secretion is too low in relation to the blood glucose level) and insulin resistance (i.e., the endogenous insulin is unable to produce its biological response). C) People with type 1 diabetes have an almost complete lack of insulin secretion, and the insulin deficiency is considered total or absolute. People with type 2 diabetes have a relative insulin deficiency (i.e., the insulin secretion is too low in relation to the blood glucose level) and insulin resistance (i.e., the endogenous insulin is unable to produce its biological response). D) People with type 1 diabetes have an almost complete lack of insulin secretion, and the insulin deficiency is considered total or absolute. People with type 2 diabetes have a relative insulin deficiency (i.e., the insulin secretion is too low in relation to the blood glucose level) and insulin resistance (i.e., the endogenous insulin is unable to produce its biological response). Page Ref: 906 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 37.1 Describe the epidemiology of diabetes mellitus and concepts related to diabetes mellitus. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of diabetes mellitus.

2) Which patient statement indicates to the nurse that the patient needs more teaching about type 2 diabetes? A) "Type 2 diabetes is also call juvenile-onset diabetes." B) "I am not dependent on insulin to control my blood glucose levels." C) "Most people with diabetes have type 2 diabetes." D) "From time-to-time, I may need insulin to control my blood glucose levels." Answer: A Explanation: A) Type 2 diabetes is also called adult-onset diabetes and noninsulin-dependent diabetes. B) Individuals with type 2 diabetes are not dependent on exogenous insulin to sustain life; however, they may need insulin therapy and/or oral and other injectable medications to control hyperglycemia. C) Type 2 diabetes accounts for approximately 90-95% of cases of diabetes. D) Individuals with type 2 diabetes are not dependent on exogenous insulin to sustain life; however, they may need insulin therapy and/or oral and other injectable medications to control hyperglycemia. Page Ref: 907 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Evaluating | Learning Outcome: 37.2 Compare and contrast the four categories of diabetes mellitus. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Effective Communication MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of diabetes mellitus.

3) What is the most appropriate response by the nurse when a 20-year-old woman pregnant with her first child and diagnosed with gestational diabetes mellitus (GDM) asks if she will develop diabetes in the future? A) "There is a chance that you may develop diabetes in the next 10-20 years, so monitoring would be appropriate." B) "It is impossible to tell–we don't know anything about the risk factors for diabetes." C) "Your risk for developing diabetes in the future is high because you are young." D) "You cannot develop gestational diabetes (GDM) in future pregnancies, this only happens with your first pregnancy." Answer: A Explanation: A) Women with GDM have a 35-60% chance of developing DM in the 10-20 years following the pregnancy. Risk factors for GDM include previous GDM, advanced maternal age, obesity, family history of DM, and racial/ethnic origin (African American, Hispanic/Latino American, and American Indian). B) Women with GDM have a 35-60% chance of developing DM in the 10-20 years following the pregnancy. Risk factors for GDM include previous GDM, advanced maternal age, obesity, family history of DM, and racial/ethnic origin (African American, Hispanic/Latino American, and American Indian). C) Women with GDM have a 35-60% chance of developing DM in the 10-20 years following the pregnancy. Risk factors for GDM include previous GDM, advanced maternal age, obesity, family history of DM, and racial/ethnic origin (African American, Hispanic/Latino American, and American Indian). D) Women with GDM have a 35-60% chance of developing DM in the 10-20 years following the pregnancy. Risk factors for GDM include previous GDM, advanced maternal age, obesity, family history of DM, and racial/ethnic origin (African American, Hispanic/Latino American, and American Indian). Page Ref: 908 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 37.2 Compare and contrast the four categories of diabetes mellitus. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and selfcare | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Effective Communication MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of diabetes mellitus.

4) Which laboratory finding indicates to the nurse that a patient has an impaired fasting glucose (IFG)? A) Increased insulin and decreased glucagon levels two hours after fasting B) An blood glucose level 2 hours after an oral glucose tolerance test that is high but not diagnostic of diabetes C) A fasting blood glucose level is diagnostic for diabetes D) A fasting blood glucose level or A1c higher than normal but not diagnostic for diabetes Answer: D Explanation: A) Impaired fasting glucose (IFG) is a condition in which the fasting blood glucose level or hemoglobin A1C (a measure of glucose control over the previous 3 months) is higher than normal but not diagnostic of diabetes mellitus. Impaired glucose tolerance (IGT) is a condition in which the blood glucose level 2 hours after an oral glucose load (during an oral glucose tolerance test [OGTT]) is higher than normal but not diagnostic of diabetes mellitus. B) Impaired fasting glucose (IFG) is a condition in which the fasting blood glucose level or hemoglobin A1C (a measure of glucose control over the previous 3 months) is higher than normal but not diagnostic of diabetes mellitus. Impaired glucose tolerance (IGT) is a condition in which the blood glucose level 2 hours after an oral glucose load (during an oral glucose tolerance test [OGTT]) is higher than normal but not diagnostic of diabetes mellitus. C) Impaired fasting glucose (IFG) is a condition in which the fasting blood glucose level or hemoglobin A1C (a measure of glucose control over the previous 3 months) is higher than normal but not diagnostic of diabetes mellitus. Impaired glucose tolerance (IGT) is a condition in which the blood glucose level 2 hours after an oral glucose load (during an oral glucose tolerance test [OGTT]) is higher than normal but not diagnostic of diabetes mellitus. D) Impaired fasting glucose (IFG) is a condition in which the fasting blood glucose level or hemoglobin A1C (a measure of glucose control over the previous 3 months) is higher than normal but not diagnostic of diabetes mellitus. Impaired glucose tolerance (IGT) is a condition in which the blood glucose level 2 hours after an oral glucose load (during an oral glucose tolerance test [OGTT]) is higher than normal but not diagnostic of diabetes mellitus. Page Ref: 908 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 37.2 Compare and contrast the four categories of diabetes mellitus. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of diabetes mellitus.

5) The staff development nurse is teaching a class on diabetes to newly hired nurses at General Hospital. The nurse explains that during glycogenolysis which of the following occurs? A) Insulin increases, glucagon decreases. B) Insulin decreases, glucagon and norepinephrine/epinephrine increase. C) Insulin and growth hormone increase, cortisol decreases. D) Insulin decreases; glucagon, cortisol, growth hormone and epinephrine increase. Answer: B Explanation: A) In glycogenesis, insulin levels increase and glucagon levels decrease. B) In glycogenolysis, insulin levels fall, and glucagon and epinephrine/norepinephrine levels increase. C) In protein synthesis, insulin and growth hormone levels decrease and cortisol levels fall. D) In lipolysis, insulin levels decrease, and glucagon, cortisol, growth hormone, and epinephrine levels increase. Page Ref: 909 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 37.3 Identify the hormones and biochemical processes involved in fuel substrate metabolism. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: Communicate effectively with all members of the healthcare team, including the patient and the patient's support network NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of diabetes mellitus.

6) How should the nurse respond when a patient with diabetes asks about the role of beta cells in the pancreas? A) "Beta cells secrete glucagon." B) "Beta cells secrete insulin." C) "Beta cells secrete somatostatin." D) "Beta cells secrete pancreatic polypeptide." Answer: B Explanation: A) Glucagon is secreted by the alpha cells in the pancreas. B) Insulin is secreted by the beta cells in the pancreas. C) Somatostatin is secreted by the delta cells in the pancreas. D) Pancreatic polypeptide is secreted by the F cells in the pancreas. Page Ref: 910 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 37.3 Identify the hormones and biochemical processes involved in fuel substrate metabolism. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of diabetes mellitus.

7) When preparing a nursing care plan for an adolescent with diabetes, which concept should the nurse keep in mind? A) More insulin is needed as adolescents begin to engage in sports. B) More insulin is needed as more growth hormone is released during adolescence. C) More insulin is needed as the adolescents ingests less calories. D) More insulin is needed during sleep in adolescents. Answer: B Explanation: A) Growth hormone, released during puberty, is a counterregulatory hormone that opposes the effects of insulin. As a result, insulin needs during adolescence increase markedly. B) Growth hormone, released during puberty, is a counterregulatory hormone that opposes the effects of insulin. As a result, insulin needs during adolescence increase markedly. C) Growth hormone, released during puberty, is a counterregulatory hormone that opposes the effects of insulin. As a result, insulin needs during adolescence increase markedly. D) Growth hormone, released during puberty, is a counterregulatory hormone that opposes the effects of insulin. As a result, insulin needs during adolescence increase markedly. Page Ref: 910 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 37.3 Identify the hormones and biochemical processes involved in fuel substrate metabolism. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of diabetes mellitus.

8) Which statement by the parent of a child with an eating disorder indicates that more teaching is needed? A) "Diabetes is not connected to eating disorders in children." B) "Diabetic complications can be accelerated in children with eating disorders." C) "If my child develops diabetes, the rate of complications may be higher than usual." D) "My child may experience uncontrolled diabetes." Answer: A Explanation: A) Eating disorders, particularly in children and adolescents, can lead to uncontrolled DM and accelerated development of diabetic complications. B) Eating disorders, particularly in children and adolescents, can lead to uncontrolled DM and accelerated development of diabetic complications. C) Eating disorders, particularly in children and adolescents, can lead to uncontrolled DM and accelerated development of diabetic complications. D) Eating disorders, particularly in children and adolescents, can lead to uncontrolled DM and accelerated development of diabetic complications. Page Ref: 911 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 37.3 Identify the hormones and biochemical processes involved in fuel substrate metabolism. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of diabetes mellitus.

9) The public health nurse is conducting a community screening for diabetes. Which of the following people does the nurse identify as being at highest risk for type 1 diabetes? A) A person with an affected sibling B) A person with an affected father C) A person with multiple affected first-degree relatives D) A person with an affected mother Answer: C Explanation: A) People with an affected sibling have a 7% risk of developing T1D; those with an affected father have a 5% risk; those with an affected mother have a 3% risk; and those with multiple affected first-degree relatives have a 20% risk. The risk of developing T1D increases dramatically among identical twins. B) People with an affected sibling have a 7% risk of developing T1D; those with an affected father have a 5% risk; those with an affected mother have a 3% risk; and those with multiple affected first-degree relatives have a 20% risk. The risk of developing T1D increases dramatically among identical twins. C) People with an affected sibling have a 7% risk of developing T1D; those with an affected father have a 5% risk; those with an affected mother have a 3% risk; and those with multiple affected first-degree relatives have a 20% risk. The risk of developing T1D increases dramatically among identical twins. D) People with an affected sibling have a 7% risk of developing T1D; those with an affected father have a 5% risk; those with an affected mother have a 3% risk; and those with multiple affected first-degree relatives have a 20% risk. The risk of developing T1D increases dramatically among identical twins. Page Ref: 912 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 37.4 Differentiate the causes and underlying pathogenesis of type 1 diabetes mellitus. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and wellbeing, and self-care management | AACN Essential Competencies: VII.1 Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities and populations NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of diabetes mellitus.

10) A child diagnosed with type 1 diabetes six months ago is being seen in the clinic because the mother has questions about why her child has not needed insulin for the past week. Which response by the mother indicates that more teaching is needed? A) "I still need to check my child's blood glucose levels." B) "The honeymoon period will most likely end in a few months." C) "This period of insulin production is temporary." D) "My child no longer has diabetes." Answer: D Explanation: A) When the beta-cell mass is reduced by 80-90%, insulin production is markedly impaired, and overt T1D develops. A period of endogenous insulin secretory recovery, called the honeymoon period, follows for up to 1 year. Eventually, however, insulin production ceases. B) When the beta-cell mass is reduced by 80-90%, insulin production is markedly impaired, and overt T1D develops. A period of endogenous insulin secretory recovery, called the honeymoon period, follows for up to 1 year. Eventually, however, insulin production ceases. C) When the beta-cell mass is reduced by 80-90%, insulin production is markedly impaired, and overt T1D develops. A period of endogenous insulin secretory recovery, called the honeymoon period, follows for up to 1 year. Eventually, however, insulin production ceases. D) When the beta-cell mass is reduced by 80-90%, insulin production is markedly impaired, and overt T1D develops. A period of endogenous insulin secretory recovery, called the honeymoon period, follows for up to 1 year. Eventually, however, insulin production ceases. Page Ref: 913 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 37.4 Differentiate the causes and underlying pathogenesis of type 1 diabetes mellitus. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and wellbeing, and self-care management | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of diabetes mellitus to diagnosis and treatment.

11) The ethics committee at General Hospital is discussing issues involved in genomic screening of patients with type 2 diabetes. Which factor should be considered by the interdisciplinary team when making a decision about implementing genomic screening? A) Genomic screening is less costly than frequent HbA1c level testing. B) Genomic screening may reduce the time required to find the best treatment regimen. C) Nutrition and exercise programs do not offer better use of limited financial resources. D) HbA1c testing provides results that reduce the time required to find the best treatment regimen. Answer: B Explanation: A) Debates are ongoing regarding whether or not to perform genomic screening procedures before initiating treatment to determine the most effective antidiabetic drug for each individual. Genomic screening involves additional cost, while inexpensive blood tests such as HbA1c monitoring can easily serve as a treatment response indicator. However, using HbA1c as a tool for treatment response monitoring requires many months of time, which may be followed by many rounds of drug changes. Also controversial is whether existing financial resources should be redirected toward developing genomic screening techniques or toward offering innovative educational programs on nutrition and exercise to help patients with type 2 diabetes maintain glycemic control. B) Debates are ongoing regarding whether or not to perform genomic screening procedures before initiating treatment to determine the most effective antidiabetic drug for each individual. Genomic screening involves additional cost, while inexpensive blood tests such as HbA1c monitoring can easily serve as a treatment response indicator. However, using HbA1c as a tool for treatment response monitoring requires many months of time, which may be followed by many rounds of drug changes. Also controversial is whether existing financial resources should be redirected toward developing genomic screening techniques or toward offering innovative educational programs on nutrition and exercise to help patients with type 2 diabetes maintain glycemic control. C) Debates are ongoing regarding whether or not to perform genomic screening procedures before initiating treatment to determine the most effective antidiabetic drug for each individual. Genomic screening involves additional cost, while inexpensive blood tests such as HbA1c monitoring can easily serve as a treatment response indicator. However, using HbA1c as a tool for treatment response monitoring requires many months of time, which may be followed by many rounds of drug changes. Also controversial is whether existing financial resources should be redirected toward developing genomic screening techniques or toward offering innovative educational programs on nutrition and exercise to help patients with type 2 diabetes maintain glycemic control. D) Debates are ongoing regarding whether or not to perform genomic screening procedures before initiating treatment to determine the most effective antidiabetic drug for each individual. Genomic screening involves additional cost, while inexpensive blood tests such as HbA1c monitoring can easily serve as a treatment response indicator. However, using HbA1c as a tool for treatment response monitoring requires many months of time, which may be followed by many rounds of drug changes. Also controversial is whether existing financial resources should be redirected toward developing genomic screening techniques or toward offering innovative educational programs on nutrition and exercise to help patients with type 2 diabetes maintain glycemic control.

Page Ref: 914 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 37.5 Differentiate the causes and underlying pathogenesis of type 2 diabetes mellitus. | QSEN Competencies: II.B.8 Integrate the contributions of others who play a role in helping patient/family achieve health goals | AACN Essential Competencies: VII. 10. Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and prevention of illness, injury, disability and premature death NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of diabetes mellitus to diagnosis and treatment. 12) When conducting community screening for diabetes, which population should the community health nurse recognize as being at highest risk? A) Hispanics/Latinos B) Caucasians C) African Americans D) Asian Americans Answer: C Explanation: A) Diabetes disproportionately affects minority populations; 7.6% of non-Hispanic Whites, 9.0% of Asian Americans, 12.8% of Hispanics/Latinos, 13.2% of non-Hispanic Blacks, and 15.9% of American Indians/Alaskan Natives have diagnosed diabetes. B) Diabetes disproportionately affects minority populations; 7.6% of non-Hispanic Whites, 9.0% of Asian Americans, 12.8% of Hispanics/Latinos, 13.2% of non-Hispanic Blacks, and 15.9% of American Indians/Alaskan Natives have diagnosed diabetes. C) Diabetes disproportionately affects minority populations; 7.6% of non-Hispanic Whites, 9.0% of Asian Americans, 12.8% of Hispanics/Latinos, 13.2% of non-Hispanic Blacks, and 15.9% of American Indians/Alaskan Natives have diagnosed diabetes. D) Diabetes disproportionately affects minority populations; 7.6% of non-Hispanic Whites, 9.0% of Asian Americans, 12.8% of Hispanics/Latinos, 13.2% of non-Hispanic Blacks, and 15.9% of American Indians/Alaskan Natives have diagnosed diabetes. Page Ref: 914 Cognitive Level: Applying Client Need & Sub: Health Promotion and Risk Reduction Standards: Nursing Process: Assessment | Learning Outcome: 37.5 Differentiate the causes and underlying pathogenesis of type 2 diabetes mellitus. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and wellbeing, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, costeffectiveness and equity NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of diabetes mellitus. 12

13) Which data indicates a diagnosis of diabetes in a patient being assessed for unexplained weight loss? A) A1C > 6.5% B) Symptoms of diabetes plus casual plasma glucose concentration > 150mg/dL C) Fasting plasma glucose < 126 mg/dL D) 2-hour plasma glucose > 150 mg/dL Answer: A Explanation: A) The diagnosis of diabetes in nonpregnant adults should be restricted to those who have one of the following: A1C > 6.5%; symptoms of diabetes plus casual plasma glucose concentration > 200 mg/dL; fasting plasma glucose > 126 mg/dL; or 2-hour plasma glucose > 200 mg/dL during an oral glucose tolerance test. B) The diagnosis of diabetes in nonpregnant adults should be restricted to those who have one of the following: A1C > 6.5%; symptoms of diabetes plus casual plasma glucose concentration > 200 mg/dL; fasting plasma glucose > 126 mg/dL; or 2-hour plasma glucose > 200 mg/dL during an oral glucose tolerance test. C) The diagnosis of diabetes in nonpregnant adults should be restricted to those who have one of the following: A1C > 6.5%; symptoms of diabetes plus casual plasma glucose concentration > 200 mg/dL; fasting plasma glucose > 126 mg/dL; or 2-hour plasma glucose > 200 mg/dL during an oral glucose tolerance test. D) The diagnosis of diabetes in nonpregnant adults should be restricted to those who have one of the following: A1C > 6.5%; symptoms of diabetes plus casual plasma glucose concentration > 200 mg/dL; fasting plasma glucose > 126 mg/dL; or 2-hour plasma glucose > 200 mg/dL during an oral glucose tolerance test. Page Ref: 917 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 37.6 Describe the clinical manifestations of type 1 and type 2 diabetes mellitus, gestational diabetes mellitus, and prediabetes. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of diabetes mellitus to diagnosis and treatment.

14) A woman in her 26th week of pregnancy is undergoing a one-step 75-gram oral glucose tolerance test (OGTT). Which finding indicates that gestational diabetes is present? A) A fasting plasma glucose level of 92 mg/dL B) A 1-hour plasma glucose level of 160 mg/dL C) A 2-hour plasma glucose level of 145 mg/dL D) A 3-hour plasma glucose level of 135 mg/dL Answer: A Explanation: A) The diagnosis of gestational diabetes is made when any of the following plasma glucose values are met or exceeded: fasting level of 92 mg/dL, 1-hour level of 180 mg/dL, or 2hour level of 153 mg/dL. B) The diagnosis of gestational diabetes is made when any of the following plasma glucose values are met or exceeded: fasting level of 92 mg/dL, 1-hour level of 180 mg/dL, or 2-hour level of 153 mg/dL. C) The diagnosis of gestational diabetes is made when any of the following plasma glucose values are met or exceeded: fasting level of 92 mg/dL, 1-hour level of 180 mg/dL, or 2-hour level of 153 mg/dL. D) The diagnosis of gestational diabetes is made when any of the following plasma glucose values are met or exceeded: fasting level of 92 mg/dL, 1-hour level of 180 mg/dL, or 2-hour level of 153 mg/dL. Page Ref: 917 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 37.6 Describe the clinical manifestations of type 1 and type 2 diabetes mellitus, gestational diabetes mellitus, and prediabetes. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of diabetes mellitus to diagnosis and treatment.

15) The nurse caring for a patient with uncontrolled diabetes notes deep and rapid respirations. The nurse documents this respiratory pattern as: A) Kussmaul respiration. B) Cheyne-Stokes respiration. C) shortness of breath. D) orthopnea. Answer: A Explanation: A) During diabetic ketoacidosis, the developing ketonemia (excess ketones in the blood) leads to progressive metabolic acidosis, which in turn initiates the characteristic deep and rapid respirations accompanied by an acetone odor to the breath (Kussmaul respirations). B) In Cheyne-Stokes respiration, breathing is progressively shallow alternating with periods of progressively deep respiration, followed by periods of significant apnea. C) Shortness of breath is a subjective feeling of difficulty breathing. D) Orthopnea is difficulty breathing when lying flat. Page Ref: 919 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 37.7 Differentiate the causes, underlying pathogenesis, and clinical manifestations of acute complications of diabetes mellitus across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of diabetes mellitus.

16) Which laboratory values should the nurse expect in a patient with diabetic ketoacidosis? A) Plasma glucose level of 200 mg/dL B) Ketonuria C) Serum bicarbonate > 18 mEq/L D) Arterial pH > 7.3 Answer: B Explanation: A) The diagnosis of DKA is based on laboratory criteria that reflect hyperglycemia, ketosis, and metabolic acidosis, particularly these three: (1) plasma glucose greater than 250 mg/dL, (2) presence of ketones in serum or urine, and (3) presence of acidosis (serum bicarbonate < 18 mEq/L and/or an arterial pH 6 7.3 and an elevated anion gap). B) The diagnosis of DKA is based on laboratory criteria that reflect hyperglycemia, ketosis, and metabolic acidosis, particularly these three: (1) plasma glucose greater than 250 mg/dL, (2) presence of ketones in serum or urine, and (3) presence of acidosis (serum bicarbonate <18 mEq/L and/or an arterial pH 6 7.3 and an elevated anion gap). C) The diagnosis of DKA is based on laboratory criteria that reflect hyperglycemia, ketosis, and metabolic acidosis, particularly these three: (1) plasma glucose greater than 250 mg/dL, (2) presence of ketones in serum or urine, and (3) presence of acidosis (serum bicarbonate < 18 mEq/L and/or an arterial pH 6 7.3 and an elevated anion gap). D) The diagnosis of DKA is based on laboratory criteria that reflect hyperglycemia, ketosis, and metabolic acidosis, particularly these three: (1) plasma glucose greater than 250 mg/dL, (2) presence of ketones in serum or urine, and (3) presence of acidosis (serum bicarbonate <18 mEq/L and/or an arterial pH 6 7.3 and an elevated anion gap). Page Ref: 920 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 37.7 Differentiate the causes, underlying pathogenesis, and clinical manifestations of acute complications of diabetes mellitus across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of diabetes mellitus.

17) The plan of care for a patient in diabetic ketoacidosis, with a blood glucose level of 450 mg/dL, should include strategies for: A) administration of short-acting subcutaneous insulin. B) administration of long-acting subcutaneous insulin. C) administration of oral hypoglycemic agents. D) administration of intravenous short-acting insulin. Answer: D Explanation: A) The general treatment of DKA involves support measures to prevent cardiac, pulmonary, and neurologic decompensation; intravenous insulin therapy to reduce hyperglycemia and correct the acidosis; intravenous fluids correct the fluid volume deficits; and intravenous electrolyte replacements to correct electrolyte disturbances. B) The general treatment of DKA involves support measures to prevent cardiac, pulmonary, and neurologic decompensation; intravenous insulin therapy to reduce hyperglycemia and correct the acidosis; intravenous fluids correct the fluid volume deficits; and intravenous electrolyte replacements to correct electrolyte disturbances. C) The general treatment of DKA involves support measures to prevent cardiac, pulmonary, and neurologic decompensation; intravenous insulin therapy to reduce hyperglycemia and correct the acidosis; intravenous fluids correct the fluid volume deficits; and intravenous electrolyte replacements to correct electrolyte disturbances. D) The general treatment of DKA involves support measures to prevent cardiac, pulmonary, and neurologic decompensation; intravenous insulin therapy to reduce hyperglycemia and correct the acidosis; intravenous fluids correct the fluid volume deficits; and intravenous electrolyte replacements to correct electrolyte disturbances. Page Ref: 921 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Planning | Learning Outcome: 37.7 Differentiate the causes, underlying pathogenesis, and clinical manifestations of acute complications of diabetes mellitus across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of diabetes mellitus to diagnosis and treatment.

18) The nurse is assessing a patient with hyperglycemic hyperosmolar syndrome (HHS). Which finding would differentiate HHS from diabetic ketoacidosis (DKA)? A) Lack of ketonuria B) Electrolyte imbalances C) Fluid volume deficit D) Hyperglycemia Answer: A Explanation: A) Patients with HHS do not have clinical signs and symptoms related to metabolic acidosis and ketosis; however, the other clinical signs and symptoms related to hyperglycemia (fluid volume deficits and electrolyte imbalances) are often present. In HHS, the hyperglycemia, dehydration, and serum hyperosmolality are usually much more severe than in DKA. In addition to the clinical signs and symptoms detailed in DKA, the following may be present in HHS: neurologic symptoms and vascular thrombosis. B) Patients with HHS do not have clinical signs and symptoms related to metabolic acidosis and ketosis; however, the other clinical signs and symptoms related to hyperglycemia (fluid volume deficits and electrolyte imbalances) are often present. In HHS, the hyperglycemia, dehydration, and serum hyperosmolality are usually much more severe than in DKA. In addition to the clinical signs and symptoms detailed in DKA, the following may be present in HHS: neurologic symptoms and vascular thrombosis. C) Patients with HHS do not have clinical signs and symptoms related to metabolic acidosis and ketosis; however, the other clinical signs and symptoms related to hyperglycemia (fluid volume deficits and electrolyte imbalances) are often present. In HHS, the hyperglycemia, dehydration, and serum hyperosmolality are usually much more severe than in DKA. In addition to the clinical signs and symptoms detailed in DKA, the following may be present in HHS: neurologic symptoms and vascular thrombosis. D) Patients with HHS do not have clinical signs and symptoms related to metabolic acidosis and ketosis; however, the other clinical signs and symptoms related to hyperglycemia (fluid volume deficits and electrolyte imbalances) are often present. In HHS, the hyperglycemia, dehydration, and serum hyperosmolality are usually much more severe than in DKA. In addition to the clinical signs and symptoms detailed in DKA, the following may be present in HHS: neurologic symptoms and vascular thrombosis. Page Ref: 921 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 37.7 Differentiate the causes, underlying pathogenesis, and clinical manifestations of acute complications of diabetes mellitus across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of diabetes mellitus.

19) When teaching a patient newly diagnosed with type 1 diabetes about autonomic nervous system symptoms of hypoglycemia, which would the nurse include? A) Sweating and tremors B) Irritability and confusion C) Incoordination and difficulty speaking D) Visual disturbances and drowsiness Answer: A Explanation: A) Autonomic nervous system symptoms of hypoglycemia include sweating, palpitations, tremors, and hunger. Neuroglycopenic findings include difficulty speaking, incoordination, visual disturbances, atypical behavior, drowsiness, confusion, seizures, and coma. B) Autonomic nervous system symptoms of hypoglycemia include sweating, palpitations, tremors, and hunger. Neuroglycopenic findings include difficulty speaking, incoordination, visual disturbances, atypical behavior, drowsiness, confusion, seizures, and coma. C) Autonomic nervous system symptoms of hypoglycemia include sweating, palpitations, tremors, and hunger. Neuroglycopenic findings include difficulty speaking, incoordination, visual disturbances, atypical behavior, drowsiness, confusion, seizures, and coma. D) Autonomic nervous system symptoms of hypoglycemia include sweating, palpitations, tremors, and hunger. Neuroglycopenic findings include difficulty speaking, incoordination, visual disturbances, atypical behavior, drowsiness, confusion, seizures, and coma. Page Ref: 923 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 37.7 Differentiate the causes, underlying pathogenesis, and clinical manifestations of acute complications of diabetes mellitus across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of diabetes mellitus.

20) Which finding should the nurse expect when assessing a patient with symmetrical distal polyneuropathy due to diabetes? A) Distal sensory loss in one limb B) Distal pain in lower legs that worsens at night C) Sharp, shooting pain in the distal legs D) Leg pain that progresses from proximal to distal Answer: B Explanation: A) Symmetric distal polyneuropathy usually appears first in the distal portions of the extremities, moving proximally in a "stocking-glove" distribution, encompassing both sensory and motor nerve damage and affecting both limbs. Clinical symptoms associated with sensory nerve damage may include numbness, pain, burning, tingling, and eventual partial or total loss of sensation. The pain associated with symmetric distal polyneuropathy is first felt distally, in the lower legs, and usually worsens at night and is usually described as an aching or burning. B) Symmetric distal polyneuropathy usually appears first in the distal portions of the extremities, moving proximally in a "stocking-glove" distribution, encompassing both sensory and motor nerve damage and affecting both limbs. Clinical symptoms associated with sensory nerve damage may include numbness, pain, burning, tingling, and eventual partial or total loss of sensation. The pain associated with symmetric distal polyneuropathy is first felt distally, in the lower legs, and usually worsens at night and is usually described as an aching or burning. C) Symmetric distal polyneuropathy usually appears first in the distal portions of the extremities, moving proximally in a "stocking-glove" distribution, encompassing both sensory and motor nerve damage and affecting both limbs. Clinical symptoms associated with sensory nerve damage may include numbness, pain, burning, tingling, and eventual partial or total loss of sensation. The pain associated with symmetric distal polyneuropathy is first felt distally, in the lower legs, and usually worsens at night and is usually described as an aching or burning. D) Symmetric distal polyneuropathy usually appears first in the distal portions of the extremities, moving proximally in a "stocking-glove" distribution, encompassing both sensory and motor nerve damage and affecting both limbs. Clinical symptoms associated with sensory nerve damage may include numbness, pain, burning, tingling, and eventual partial or total loss of sensation. The pain associated with symmetric distal polyneuropathy is first felt distally, in the lower legs, and usually worsens at night and is usually described as an aching or burning. Page Ref: 928 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 37.8 Differentiate the causes, underlying pathogenesis, and clinical manifestations of chronic complications of diabetes mellitus. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of diabetes mellitus. 20

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 38 Thyroid, Parathyroid, and Adrenal Disorders 1) The nurse is caring for a client with a disorder of the endocrine system. The nurse understands that the endocrine system regulates which functions? Select all that apply. A) Cognition B) Growth C) Reproduction D) Metabolism E) Fluid and electrolyte balance Answer: B, C, D, E Explanation: A) Through hormones secreted by its glands, the endocrine system regulates functions such as growth, reproduction, metabolism, and fluid and electrolyte balance. Cognition is affected, but is not regulated, by the endocrine system. B) Through hormones secreted by its glands, the endocrine system regulates functions such as growth, reproduction, metabolism, and fluid and electrolyte balance. Cognition is affected, but is not regulated, by the endocrine system. C) Through hormones secreted by its glands, the endocrine system regulates functions such as growth, reproduction, metabolism, and fluid and electrolyte balance. Cognition is affected, but is not regulated, by the endocrine system. D) Through hormones secreted by its glands, the endocrine system regulates functions such as growth, reproduction, metabolism, and fluid and electrolyte balance. Cognition is affected, but is not regulated, by the endocrine system. E) Through hormones secreted by its glands, the endocrine system regulates functions such as growth, reproduction, metabolism, and fluid and electrolyte balance. Cognition is affected, but is not regulated, by the endocrine system. Page Ref: 934 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 38.1 Define hormones and concepts related to thyroid and adrenal regulation. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 38.1: Define hormones and concepts related to thyroid and adrenal regulation.

2) The nurse is performing an abdominal assessment on a client. The nurse understands that which endocrine gland is located in the abdomen? A) Pituitary B) Pancreas C) Liver D) Kidneys Answer: B Explanation: A) The pancreas is located in the abdomen. The pituitary gland is located in the cranium. The liver and kidneys are not considered endocrine glands. B) The pancreas is located in the abdomen. The pituitary gland is located in the cranium. The liver and kidneys are not considered endocrine glands. C) The pancreas is located in the abdomen. The pituitary gland is located in the cranium. The liver and kidneys are not considered endocrine glands. D) The pancreas is located in the abdomen. The pituitary gland is located in the cranium. The liver and kidneys are not considered endocrine glands. Page Ref: 934 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 38.1 Define hormones and concepts related to thyroid and adrenal regulation. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 38.1: Define hormones and concepts related to thyroid and adrenal regulation.

3) The nurse is caring for a client with a hormone imbalance. Which manifestations does the nurse attribute to this condition? Select all that apply. A) Hypertension B) Anxiety C) Weight gain D) Fluid retention E) Contusion Answer: A, B, C, D Explanation: A) Hypertension, anxiety, weight gain, and fluid retention are all findings that could be attributed to the client's hormone imbalance. While disorders of the endocrine system may contribute to easy bruising, the client's contusion cannot be directly attributed to a hormone imbalance. B) Hypertension, anxiety, weight gain, and fluid retention are all findings that could be attributed to the client's hormone imbalance. While disorders of the endocrine system may contribute to easy bruising, the client's contusion cannot be directly attributed to a hormone imbalance. C) Hypertension, anxiety, weight gain, and fluid retention are all findings that could be attributed to the client's hormone imbalance. While disorders of the endocrine system may contribute to easy bruising, the client's contusion cannot be directly attributed to a hormone imbalance. D) Hypertension, anxiety, weight gain, and fluid retention are all findings that could be attributed to the client's hormone imbalance. While disorders of the endocrine system may contribute to easy bruising, the client's contusion cannot be directly attributed to a hormone imbalance. E) Hypertension, anxiety, weight gain, and fluid retention are all findings that could be attributed to the client's hormone imbalance. While disorders of the endocrine system may contribute to easy bruising, the client's contusion cannot be directly attributed to a hormone imbalance. Page Ref: 934 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 38.1 Define hormones and concepts related to thyroid and adrenal regulation. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 38.1: Define hormones and concepts related to thyroid and adrenal regulation.

4) The nurse is reviewing the past medical history of a client diagnosed with Hashimoto thyroiditis. Which conditions does the nurse understand to be caused by thyroiditis? Select all that apply. A) Fatigue B) Weight gain C) Laryngitis D) Bacterial infection E) Constipation Answer: A, B, E Explanation: A) Fatigue, weight gain, and constipation are symptoms associated with thyroiditis. Although the client may have concomitant laryngitis and/or a bacterial infection, these findings are not associated with thyroiditis. B) Fatigue, weight gain, and constipation are symptoms associated with thyroiditis. Although the client may have concomitant laryngitis and/or a bacterial infection, these findings are not associated with thyroiditis. C) Fatigue, weight gain, and constipation are symptoms associated with thyroiditis. Although the client may have concomitant laryngitis and/or a bacterial infection, these findings are not associated with thyroiditis. D) Fatigue, weight gain, and constipation are symptoms associated with thyroiditis. Although the client may have concomitant laryngitis and/or a bacterial infection, these findings are not associated with thyroiditis. E) Fatigue, weight gain, and constipation are symptoms associated with thyroiditis. Although the client may have concomitant laryngitis and/or a bacterial infection, these findings are not associated with thyroiditis. Page Ref: 934 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 38.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the thyroid across the lifespan. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 38.1: Define hormones and concepts related to thyroid and adrenal regulation.

5) The nurse is reviewing the function of the thyroid with a client who has abnormal calcitonin levels. Which statement will the nurse include in the teaching? A) "Special cells within the thyroid secrete calcitonin." B) "Special cells with the thyroid absorb calcitonin." C) "Calcitonin is converted to a different hormone within the thyroid." D) "Calcitonin acts as a catalyst within the thyroid for chemical reactions." Answer: A Explanation: A) The thyroid gland produces two primary hormones: triiodothyronine (T3) and thyroxine (T4). Parafollicular cells called C cells are scattered throughout the thyroid gland and secrete a hormone called calcitonin. B) The thyroid gland produces two primary hormones: triiodothyronine (T3) and thyroxine (T4). Parafollicular cells called C cells are scattered throughout the thyroid gland and secrete a hormone called calcitonin. Cells within the thyroid do not absorb calcitonin. C) The thyroid gland produces two primary hormones: triiodothyronine (T3) and thyroxine (T4). Parafollicular cells called C cells are scattered throughout the thyroid gland and secrete a hormone called calcitonin. Calcitonin is not converted to another hormone within the thyroid. D) The thyroid gland produces two primary hormones: triiodothyronine (T3) and thyroxine (T4). Parafollicular cells called C cells are scattered throughout the thyroid gland and secrete a hormone called calcitonin. Calcitonin is not a catalyst for chemical reactions within the thyroid. Page Ref: 935 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 38.2 Outline the mechanisms of hormonal alterations, including hormone excess, hormone deficiency, and levels of hormone dysfunction across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 38.2: Outline the mechanisms of hormonal alterations, including hormone excess, hormone deficiency, and levels of hormone dysfunction across the lifespan.

6) The nurse is performing an assessment on a client with Graves disease. Which assessment manifestation does the nurse expect to assess? A) Dry, cold skin B) Orbital tissue inflammation C) Hair loss D) Weight gain Answer: B Explanation: A) Inflammation of the orbital tissues is a symptom associated with Graves disease. Dry, cold skin, hair loss, and weight gain are associated with Hashimoto thyroiditis. B) Inflammation of the orbital tissues is a symptom associated with Graves disease. Dry, cold skin, hair loss, and weight gain are associated with Hashimoto thyroiditis. C) Inflammation of the orbital tissues is a symptom associated with Graves disease. Dry, cold skin, hair loss, and weight gain are associated with Hashimoto thyroiditis. D) Inflammation of the orbital tissues is a symptom associated with Graves disease. Dry, cold skin, hair loss, and weight gain are associated with Hashimoto thyroiditis. Page Ref: 935Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 38.2 Outline the mechanisms of hormonal alterations, including hormone excess, hormone deficiency, and levels of hormone dysfunction across the lifespan. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 38.2: Outline the mechanisms of hormonal alterations, including hormone excess, hormone deficiency, and levels of hormone dysfunction across the lifespan.

7) The nurse is providing education about prenatal nutrition to a client who is 25 weeks pregnant. Which nutrient will the nurse review as being critical for maternal and fetal euthyroidism? A) Calcium B) Vitamin D C) Folic acid D) Iodine Answer: D Explanation: A) Iodine is essential for the synthesis of thyroid hormones; optimal maternal iodine intake is essential for fetal development. Calcium, vitamin D, and folic acid are important nutrients for the prenatal client, but are not linked with maternal and fetal euthyroidism. B) Iodine is essential for the synthesis of thyroid hormones; optimal maternal iodine intake is essential for fetal development. Calcium, vitamin D, and folic acid are important nutrients for the prenatal client, but are not linked with maternal and fetal euthyroidism. C) Iodine is essential for the synthesis of thyroid hormones; optimal maternal iodine intake is essential for fetal development. Calcium, vitamin D, and folic acid are important nutrients for the prenatal client, but are not linked with maternal and fetal euthyroidism. D) Iodine is essential for the synthesis of thyroid hormones; optimal maternal iodine intake is essential for fetal development. Calcium, vitamin D, and folic acid are important nutrients for the prenatal client, but are not linked with maternal and fetal euthyroidism. Page Ref: 936 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 38.2 Outline the mechanisms of hormonal alterations, including hormone excess, hormone deficiency, and levels of hormone dysfunction across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 38.2: Outline the mechanisms of hormonal alterations, including hormone excess, hormone deficiency, and levels of hormone dysfunction across the lifespan.

8) The nurse is caring for a client with thyroid dysfunction. Which statement about the normal function of the thyroid does the nurse know to be true? A) Thyroid releasing hormone and thyroid stimulating hormone are released by the thyroid. B) The functional unit of the thyroid is the thyroid follicle. C) Hormone secretion of the thyroid is regulated through positive feedback mechanisms. D) Thyroid function is regulated by the hypothalamus and amygdala. Answer: B Explanation: A) The functional unit of the thyroid is the thyroid follicle. The two primary hormones released by the thyroid are triiodothyronine (T3) and thyroxine (T4). Thyroid releasing hormone (TRH) is hypothalamus and thyroid stimulating hormone (TSH) is released by the pituitary, not the thyroid. Hormone secretion of the thyroid is regulated through negative feedback mechanisms, not positive feedback mechanisms. Thyroid function is regulated by the hypothalamic-anterior pituitary-thyroid gland axis, not the hypothalamus and amygdala. B) The functional unit of the thyroid is the thyroid follicle. The two primary hormones released by the thyroid are triiodothyronine (T3) and thyroxine (T4). Thyroid releasing hormone (TRH) is hypothalamus and thyroid stimulating hormone (TSH) is released by the pituitary, not the thyroid. Hormone secretion of the thyroid is regulated through negative feedback mechanisms, not positive feedback mechanisms. Thyroid function is regulated by the hypothalamic-anterior pituitary-thyroid gland axis, not the hypothalamus and amygdala. C) The functional unit of the thyroid is the thyroid follicle. The two primary hormones released by the thyroid are triiodothyronine (T3) and thyroxine (T4). Thyroid releasing hormone (TRH) is hypothalamus and thyroid stimulating hormone (TSH) is released by the pituitary, not the thyroid. Hormone secretion of the thyroid is regulated through negative feedback mechanisms, not positive feedback mechanisms. Thyroid function is regulated by the hypothalamic-anterior pituitary-thyroid gland axis, not the hypothalamus and amygdala. D) The functional unit of the thyroid is the thyroid follicle. The two primary hormones released by the thyroid are triiodothyronine (T3) and thyroxine (T4). Thyroid releasing hormone (TRH) is hypothalamus and thyroid stimulating hormone (TSH) is released by the pituitary, not the thyroid. Hormone secretion of the thyroid is regulated through negative feedback mechanisms, not positive feedback mechanisms. Thyroid function is regulated by the hypothalamic-anterior pituitary-thyroid gland axis, not the hypothalamus and amygdala. Page Ref: 935 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 38.2 Outline the mechanisms of hormonal alterations, including hormone excess, hormone deficiency, and levels of hormone dysfunction across the lifespan. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. 1.Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 38.2: Outline the mechanisms of hormonal alterations, including hormone excess, hormone deficiency, and levels of hormone dysfunction across the lifespan.

9) During a head and neck assessment, the nurse notes that the client's neck is enlarged, which is later confirmed to be due to a goiter. The client's serum thyroid levels are within normal limits. Which type of goiter does the nurse suspect? A) Toxic multinodular goiter B) Endemic goiter C) Nontoxic diffuse goiter D) Chronic autoimmune thyroiditis Answer: C Explanation: A) Specific types of goiters include nontoxic diffuse goiters, nontoxic multinodular goiters, endemic goiter, chronic autoimmune (Hashimoto) thyroiditis, and toxic multinodular goiter (Graves disease). Toxic multinodular goiter (Graves disease) is the most common cause of hyperthyroidism. A client with this condition would have serum thyroid levels reflecting hyperthyroidism. B) Specific types of goiters include nontoxic diffuse goiters, nontoxic multinodular goiters, endemic goiter, chronic autoimmune (Hashimoto) thyroiditis, and toxic multinodular goiter (Graves disease). Endemic goiter is caused by iodine deficiency, leading to increased TSH secretion. The client's TSH would be elevated, not within normal limits. C) Specific types of goiters include nontoxic diffuse goiters, nontoxic multinodular goiters, endemic goiter, chronic autoimmune (Hashimoto) thyroiditis, and toxic multinodular goiter (Graves disease). Nontoxic diffuse goiter causes a diffuse enlargement of the neck with normal TSH levels. This best describes the client's clinical presentation. D) Specific types of goiters include nontoxic diffuse goiters, nontoxic multinodular goiters, endemic goiter, chronic autoimmune (Hashimoto) thyroiditis, and toxic multinodular goiter (Graves disease). Hashimoto thyroiditis is the most common cause of hypothyroidism. The client's TSH would be increased in this condition, not within normal limits. Page Ref: 936-937 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 38.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the thyroid across the lifespan. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 38.3: Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the thyroid across the lifespan.

10) The nurse is reviewing the mechanism of goiter development in a client with nontoxic multinodular goiters. Which statement best describes this process? A) Thyroid enlargement occurs due to several growth factors, in addition to thyroid stimulating hormone (TSH), that cause some thyroid follicles to proliferate more than others. B) Overall thyroid enlargement occurs without associated hypo- or hyperthyroidism, and is not induced by cysts, inflammation, or neoplasia. C) Iodine deficiency causes some thyroid follicles to grow more quickly than to others, resulting in nodular changes and sequelae. D) TSH receptor antibodies (TRAb) stimulate the TSH receptor to cause thyroid growth, goiter formation, and excessive secretion of thyroid hormones. Answer: A Explanation: A) Nontoxic multinodular goiters develop when thyroid enlargement occurs due to several growth factors, in addition to thyroid stimulating hormone (TSH), that cause some thyroid follicles to proliferate more than others. Overall thyroid enlargement occurring without associated hypo- or hyperthyroidism, not induced by cysts, inflammation, or neoplasia describes nontoxic diffuse goiters. Endemic goiters occur when iodine deficiency causes some thyroid follicles to grow more quickly than to others, resulting in nodular changes and sequelae. Graves disease occurs when TSH receptor antibodies (TRAb) stimulate the TSH receptor to cause thyroid growth, goiter formation, and excessive secretion of thyroid hormones. B) Nontoxic multinodular goiters develop when thyroid enlargement occurs due to several growth factors, in addition to thyroid stimulating hormone (TSH), that cause some thyroid follicles to proliferate more than others. Overall thyroid enlargement occurring without associated hypo- or hyperthyroidism, not induced by cysts, inflammation, or neoplasia describes nontoxic diffuse goiters. Endemic goiters occur when iodine deficiency causes some thyroid follicles to grow more quickly than to others, resulting in nodular changes and sequelae. Graves disease occurs when TSH receptor antibodies (TRAb) stimulate the TSH receptor to cause thyroid growth, goiter formation, and excessive secretion of thyroid hormones. C) Nontoxic multinodular goiters develop when thyroid enlargement occurs due to several growth factors, in addition to thyroid stimulating hormone (TSH), that cause some thyroid follicles to proliferate more than others. Overall thyroid enlargement occurring without associated hypo- or hyperthyroidism, not induced by cysts, inflammation, or neoplasia describes nontoxic diffuse goiters. Endemic goiters occur when iodine deficiency causes some thyroid follicles to grow more quickly than to others, resulting in nodular changes and sequelae. Graves disease occurs when TSH receptor antibodies (TRAb) stimulate the TSH receptor to cause thyroid growth, goiter formation, and excessive secretion of thyroid hormones. D) Nontoxic multinodular goiters develop when thyroid enlargement occurs due to several growth factors, in addition to thyroid stimulating hormone (TSH), that cause some thyroid follicles to proliferate more than others. Overall thyroid enlargement occurring without associated hypo- or hyperthyroidism, not induced by cysts, inflammation, or neoplasia describes nontoxic diffuse goiters. Endemic goiters occur when iodine deficiency causes some thyroid follicles to grow more quickly than to others, resulting in nodular changes and sequelae. Graves disease occurs when TSH receptor antibodies (TRAb) stimulate the TSH receptor to cause thyroid growth, goiter formation, and excessive secretion of thyroid hormones. Page Ref: 936 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation 10

Standards: Nursing Process: Planning | Learning Outcome: 38.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the thyroid across the lifespan. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. 1.Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 38.3: Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the thyroid across the lifespan.

11) The nurse is teaching a community health class about thyroid disorders. Which statement about the prevalence of thyroid disorders will the nurse include in the teaching? Select all that apply. A) "An estimated 20 million people in the United States have some form of thyroid disease." B) "Women are 5-8 times more likely than men to have thyroid problems." C) "About one third of people who have thyroid disorders are asymptomatic." D) "One woman in eight will develop a thyroid disorder before the age of 18." E) "Up to 60% of people with thyroid disease are unaware of their condition." Answer: A, B, E Explanation: A) According the American Thyroid Association, an estimated 20 million people in the United States have some form of thyroid disease, and more than 12% of the U.S. population will develop a thyroid condition during their lifetime. Women are 5-8 times more likely than men to have thyroid problems, and one woman in eight will develop a thyroid disorder during her lifetime regardless of age. Additionally, up to 60% of people with thyroid disease are unaware of their condition, placing them at risk for other chronic conditions such as cardiovascular disease. Thyroid disorders are rarely asymptomatic. B) According the American Thyroid Association, an estimated 20 million people in the United States have some form of thyroid disease, and more than 12% of the U.S. population will develop a thyroid condition during their lifetime. Women are 5-8 times more likely than men to have thyroid problems, and one woman in eight will develop a thyroid disorder during her lifetime regardless of age. Additionally, up to 60% of people with thyroid disease are unaware of their condition, placing them at risk for other chronic conditions such as cardiovascular disease. Thyroid disorders are rarely asymptomatic. C) According the American Thyroid Association, an estimated 20 million people in the United States have some form of thyroid disease, and more than 12% of the U.S. population will develop a thyroid condition during their lifetime. Women are 5-8 times more likely than men to have thyroid problems, and one woman in eight will develop a thyroid disorder during her lifetime regardless of age. Additionally, up to 60% of people with thyroid disease are unaware of their condition, placing them at risk for other chronic conditions such as cardiovascular disease. Thyroid disorders are rarely asymptomatic. D) According the American Thyroid Association, an estimated 20 million people in the United States have some form of thyroid disease, and more than 12% of the U.S. population will develop a thyroid condition during their lifetime. Women are 5-8 times more likely than men to have thyroid problems, and one woman in eight will develop a thyroid disorder during her lifetime regardless of age. Additionally, up to 60% of people with thyroid disease are unaware of their condition, placing them at risk for other chronic conditions such as cardiovascular disease. Thyroid disorders are rarely asymptomatic. E) According the American Thyroid Association, an estimated 20 million people in the United States have some form of thyroid disease, and more than 12% of the U.S. population will develop a thyroid condition during their lifetime. Women are 5-8 times more likely than men to have thyroid problems, and one woman in eight will develop a thyroid disorder during her lifetime regardless of age. Additionally, up to 60% of people with thyroid disease are unaware of their condition, placing them at risk for other chronic conditions such as cardiovascular disease. Thyroid disorders are rarely asymptomatic. Page Ref: 936 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance 12

Standards: Nursing Process: Planning | Learning Outcome: 38.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the thyroid across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 38.3: Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the thyroid across the lifespan. 12) The nurse is providing education to a client about the most common causes of goiters. Which causative factor will the nurse review in the teaching? A) Thyroiditis B) Tumors C) Iodine deficiency D) Infiltrative disease Answer: C Explanation: A) While thyroiditis, tumors, and infiltrative disease are causes of goiters, the most common cause is iodine deficiency. B) While thyroiditis, tumors, and infiltrative disease are causes of goiters, the most common cause is iodine deficiency. C) While thyroiditis, tumors, and infiltrative disease are causes of goiters, the most common cause is iodine deficiency. D) While thyroiditis, tumors, and infiltrative disease are causes of goiters, the most common cause is iodine deficiency. Page Ref: 937 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 38.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the thyroid across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 38.3: Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the thyroid across the lifespan.

13) The nurse is providing education to a client with a parathyroid disorder about the function of parathyroid hormone (PTH) in the body. Which statements will the nurse include in the teaching? Select all that apply. A) "PTH decreases intestinal calcium resorption." B) "PTH increases renal calcium resorption." C) "PTH promotes the release of calcium from the bone." D) "PTH directly affects calcium resorption in the small bowel." E) "PTH stimulates the production of vitamin D metabolite 1,25-(OH)2D." Answer: B, C, E Explanation: A) The primary effect of PTH is to maintain the normal serum calcium concentration. PTH has direct effects on the kidney and bone. In the kidney, PTH promotes calcium reabsorption in the distal tubule and the medullary thick ascending limb of the loop of Henle. PTH stimulates the release of calcium from a rapidly exchangeable pool of calcium in bone. These processes act together to maintain normal serum calcium concentrations. The effect of PTH on the intestinal mucosa is indirect, not direct; PTH stimulates the production of the vitamin D metabolite 1,25-(OH)2D, which increases, not decreases, the intestinal absorption of calcium. B) The primary effect of PTH is to maintain the normal serum calcium concentration. PTH has direct effects on the kidney and bone. In the kidney, PTH promotes calcium reabsorption in the distal tubule and the medullary thick ascending limb of the loop of Henle. PTH stimulates the release of calcium from a rapidly exchangeable pool of calcium in bone. These processes act together to maintain normal serum calcium concentrations. The effect of PTH on the intestinal mucosa is indirect, not direct; PTH stimulates the production of the vitamin D metabolite 1,25(OH)2D, which increases, not decreases, the intestinal absorption of calcium. C) The primary effect of PTH is to maintain the normal serum calcium concentration. PTH has direct effects on the kidney and bone. In the kidney, PTH promotes calcium reabsorption in the distal tubule and the medullary thick ascending limb of the loop of Henle. PTH stimulates the release of calcium from a rapidly exchangeable pool of calcium in bone. These processes act together to maintain normal serum calcium concentrations. The effect of PTH on the intestinal mucosa is indirect, not direct; PTH stimulates the production of the vitamin D metabolite 1,25(OH)2D, which increases, not decreases, the intestinal absorption of calcium. D) The primary effect of PTH is to maintain the normal serum calcium concentration. PTH has direct effects on the kidney and bone. In the kidney, PTH promotes calcium reabsorption in the distal tubule and the medullary thick ascending limb of the loop of Henle. PTH stimulates the release of calcium from a rapidly exchangeable pool of calcium in bone. These processes act together to maintain normal serum calcium concentrations. The effect of PTH on the intestinal mucosa is indirect, not direct; PTH stimulates the production of the vitamin D metabolite 1,25(OH)2D, which increases, not decreases, the intestinal absorption of calcium. E) The primary effect of PTH is to maintain the normal serum calcium concentration. PTH has direct effects on the kidney and bone. In the kidney, PTH promotes calcium reabsorption in the distal tubule and the medullary thick ascending limb of the loop of Henle. PTH stimulates the release of calcium from a rapidly exchangeable pool of calcium in bone. These processes act together to maintain normal serum calcium concentrations. The effect of PTH on the intestinal mucosa is indirect, not direct; PTH stimulates the production of the vitamin D metabolite 1,25(OH)2D, which increases, not decreases, the intestinal absorption of calcium. Page Ref: 941 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation 14

Standards: Nursing Process: Planning | Learning Outcome: 38.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the parathyroid across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 38.4: Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the parathyroid across the lifespan. 14) The nurse is caring for a client diagnosed with hyperparathyroidism. Which potential causes does the nurse identify for this condition? Select all that apply. A) Adenomas B) Hypercalcemia C) Hypothyroidism D) Hyperplasia E) Chronic kidney disease Answer: A, D Explanation: A) Adenomas and hyperplasia are among the most common causes of hyperparathyroidism. Hypercalcemia, hypothyroidism, and chronic kidney disease are not causative factors of hyperparathyroidism. B) Adenomas and hyperplasia are among the most common causes of hyperparathyroidism. Hypercalcemia, hypothyroidism, and chronic kidney disease are not causative factors of hyperparathyroidism. C) Adenomas and hyperplasia are among the most common causes of hyperparathyroidism. Hypercalcemia, hypothyroidism, and chronic kidney disease are not causative factors of hyperparathyroidism. D) Adenomas and hyperplasia are among the most common causes of hyperparathyroidism. Hypercalcemia, hypothyroidism, and chronic kidney disease are not causative factors of hyperparathyroidism. E) Adenomas and hyperplasia are among the most common causes of hyperparathyroidism. Hypercalcemia, hypothyroidism, and chronic kidney disease are not causative factors of hyperparathyroidism. Page Ref: 942 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 38.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the parathyroid across the lifespan. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 38.4: Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the parathyroid across the lifespan. 15

15) The nurse is assessing a client with primary hyperparathyroidism. Which signs and symptoms will the nurse anticipate to assess? Select all that apply. A) Exophthalmos B) Weakness C) Fatigue D) Depression E) Neuropathy Answer: B, C, D, E Explanation: A) Weakness, fatigue, depression, and neuropathy are considered signs and symptoms of hyperparathyroidism. Exophthalmos is a symptom of hyperthyroidism, not hyperparathyroidism. B) Weakness, fatigue, depression, and neuropathy are considered signs and symptoms of hyperparathyroidism. Exophthalmos is a symptom of hyperthyroidism, not hyperparathyroidism. C) Weakness, fatigue, depression, and neuropathy are considered signs and symptoms of hyperparathyroidism. Exophthalmos is a symptom of hyperthyroidism, not hyperparathyroidism. D) Weakness, fatigue, depression, and neuropathy are considered signs and symptoms of hyperparathyroidism. Exophthalmos is a symptom of hyperthyroidism, not hyperparathyroidism. E) Weakness, fatigue, depression, and neuropathy are considered signs and symptoms of hyperparathyroidism. Exophthalmos is a symptom of hyperthyroidism, not hyperparathyroidism. Page Ref: 943 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 38.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the parathyroid across the lifespan. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. 1.Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 38.4: Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the parathyroid across the lifespan.

16) The nurse is caring for a client about to undergo treatment for hyperparathyroidism. Which priority intervention can the nurse anticipate while caring for this client? A) Educating the client regarding medication adherence B) Supporting the management of the client's symptoms C) Recommending self-care and exercise techniques D) Reviewing pre- and post-operative instructions Answer: D Explanation: A) The primary treatment for hyperparathyroidism is surgery. The purpose of surgical treatment is to reduce the parathyroid mass and cell number and thus normalize the serum calcium concentration. While educating the client regarding medication adherence, supporting the management of the client's symptoms, and recommending self-care and exercise techniques may be included in the client's plan of care, they are not considered a higher priority than preparing the client for upcoming surgery. B) The primary treatment for hyperparathyroidism is surgery. The purpose of surgical treatment is to reduce the parathyroid mass and cell number and thus normalize the serum calcium concentration. While educating the client regarding medication adherence, supporting the management of the client's symptoms, and recommending self-care and exercise techniques may be included in the client's plan of care, they are not considered a higher priority than preparing the client for upcoming surgery. C) The primary treatment for hyperparathyroidism is surgery. The purpose of surgical treatment is to reduce the parathyroid mass and cell number and thus normalize the serum calcium concentration. While educating the client regarding medication adherence, supporting the management of the client's symptoms, and recommending self-care and exercise techniques may be included in the client's plan of care, they are not considered a higher priority than preparing the client for upcoming surgery. D) The primary treatment for hyperparathyroidism is surgery. The purpose of surgical treatment is to reduce the parathyroid mass and cell number and thus normalize the serum calcium concentration. While educating the client regarding medication adherence, supporting the management of the client's symptoms, and recommending self-care and exercise techniques may be included in the client's plan of care, they are not considered a higher priority than preparing the client for upcoming surgery. Page Ref: 943 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 38.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the parathyroid across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 38.4: Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the parathyroid across the lifespan.

17) The nurse is providing education for a client with adrenal insufficiency about the anatomy and function of the adrenal glands. Which statements will the nurse include in the material? Select all that apply. A) "The outer layer of the adrenal gland is referred to as the zona reticularis." B) "The adrenal gland's inner layer is responsible for the production of adrenaline." C) "The adrenal cortex layers include the zona glomerulosa, zona fasciculata, and zona reticularis." D) "The zona glomerulosa is responsible for the production of aldosterone." E) "The adrenal gland produces cortisol, which increases gluconeogenesis." Answer: C, D, E Explanation: A) The adrenal cortex is divided into three layers. The inner layer is the zona reticularis; the middle layer is the zona fasciculata; and the outer layer is the zona glomerulosa, not the zona reticularis. The zona glomerulosa produces aldosterone, a mineralocorticoid. The zona fasciculata produces glucocorticoids, primarily cortisol, which have diverse effects on a variety of tissues, and ultimately increases gluconeogenesis. The adrenal gland's inner layer is not responsible for the production of adrenaline. B) The adrenal cortex is divided into three layers. The inner layer is the zona reticularis; the middle layer is the zona fasciculata; and the outer layer is the zona glomerulosa, not the zona reticularis. The zona glomerulosa produces aldosterone, a mineralocorticoid. The zona fasciculata produces glucocorticoids, primarily cortisol, which have diverse effects on a variety of tissues, and ultimately increases gluconeogenesis. The adrenal gland's inner layer is not responsible for the production of adrenaline. C) The adrenal cortex is divided into three layers. The inner layer is the zona reticularis; the middle layer is the zona fasciculata; and the outer layer is the zona glomerulosa, not the zona reticularis. The zona glomerulosa produces aldosterone, a mineralocorticoid. The zona fasciculata produces glucocorticoids, primarily cortisol, which have diverse effects on a variety of tissues, and ultimately increases gluconeogenesis. The adrenal gland's inner layer is not responsible for the production of adrenaline. D) The adrenal cortex is divided into three layers. The inner layer is the zona reticularis; the middle layer is the zona fasciculata; and the outer layer is the zona glomerulosa, not the zona reticularis. The zona glomerulosa produces aldosterone, a mineralocorticoid. The zona fasciculata produces glucocorticoids, primarily cortisol, which have diverse effects on a variety of tissues, and ultimately increases gluconeogenesis. The adrenal gland's inner layer is not responsible for the production of adrenaline. E) The adrenal cortex is divided into three layers. The inner layer is the zona reticularis; the middle layer is the zona fasciculata; and the outer layer is the zona glomerulosa, not the zona reticularis. The zona glomerulosa produces aldosterone, a mineralocorticoid. The zona fasciculata produces glucocorticoids, primarily cortisol, which have diverse effects on a variety of tissues, and ultimately increases gluconeogenesis. The adrenal gland's inner layer is not responsible for the production of adrenaline. Page Ref: 943 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation

Standards: Nursing Process: Implementation | Learning Outcome: 38.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of adrenocortical function across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 38.5: Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of adrenocortical function across the lifespan.

18) The nurse is reviewing a client's medication and learns that the client has been taking prednisone. What is the nurse's understanding of the effect of prednisone on the adrenal glands? A) Prednisone therapy results in destruction of the adrenal medulla, thereby decreasing corticotropin releasing hormone. B) Prednisone therapy can lead to significant toxicity, resulting in dehydration, fever, and hyponatremia. C) Prednisone therapy increases cortisol and decreases adrenocorticotropic hormone via negative feedback principles. D) Prednisone therapy increases sodium and water resorption and potassium and hydrogen excretion. Answer: C Explanation: A) Prednisone therapy increases cortisol and decreases adrenocorticotropic hormone via negative feedback principles. Prednisone therapy results in destruction of the adrenal cortex, thereby resulting in deficiency of adrenocortical hormones, not corticotropin releasing hormone. Dehydration, fever, hyponatremia, and vascular collapse can result from acute adrenocortical insufficiency (adrenal crisis), not prednisone therapy. Prednisone therapy does not increase sodium and water resorption or potassium and hydrogen excretion. B) Prednisone therapy increases cortisol and decreases adrenocorticotropic hormone via negative feedback principles. Prednisone therapy results in destruction of the adrenal cortex, thereby resulting in deficiency of adrenocortical hormones, not corticotropin releasing hormone. Dehydration, fever, hyponatremia, and vascular collapse can result from acute adrenocortical insufficiency (adrenal crisis), not prednisone therapy. Prednisone therapy does not increase sodium and water resorption or potassium and hydrogen excretion. C) Prednisone therapy increases cortisol and decreases adrenocorticotropic hormone via negative feedback principles. Prednisone therapy results in destruction of the adrenal cortex, thereby resulting in deficiency of adrenocortical hormones, not corticotropin releasing hormone. Dehydration, fever, hyponatremia, and vascular collapse can result from acute adrenocortical insufficiency (adrenal crisis), not prednisone therapy. Prednisone therapy does not increase sodium and water resorption or potassium and hydrogen excretion. D) Prednisone therapy increases cortisol and decreases adrenocorticotropic hormone via negative feedback principles. Prednisone therapy results in destruction of the adrenal cortex, thereby resulting in deficiency of adrenocortical hormones, not corticotropin releasing hormone. Dehydration, fever, hyponatremia, and vascular collapse can result from acute adrenocortical insufficiency (adrenal crisis), not prednisone therapy. Prednisone therapy does not increase sodium and water resorption or potassium and hydrogen excretion. Page Ref: 945 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Assessment | Learning Outcome: 38.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of adrenocortical function across the lifespan. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care 20

MNL Learning Outcome: LO 38.5: Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of adrenocortical function across the lifespan.

19) While the nurse is collecting the client's personal history, the client states, "I've been taking prednisone for years and I hate it. I am stopping it today." How will the nurse respond? A) "Continuing with therapy is a personal choice." B) "You may no longer experience the benefits of treatment." C) "The side effects of prednisone are difficult for you." D) "Discontinuing treatment suddenly is extremely dangerous." Answer: D Explanation: A) Abrupt discontinuation of prednisone therapy in a client with a history of longterm corticosteroid use places the client at risk for an adrenal crisis, a life-threatening complication characterized by dehydration, fever, hyponatremia, hyperkalemia, vascular collapse, and death. Although it is important for the nurse to provide therapeutic communication and reinforce the patient's sense of autonomy, the nurse's best response is to educate the client about the risks of suddenly discontinuing prednisone treatment. B) Abrupt discontinuation of prednisone therapy in a client with a history of long-term corticosteroid use places the client at risk for an adrenal crisis, a life-threatening complication characterized by dehydration, fever, hyponatremia, hyperkalemia, vascular collapse, and death. Although it is important for the nurse to provide therapeutic communication and reinforce the patient's sense of autonomy, the nurse's best response is to educate the client about the risks of suddenly discontinuing prednisone treatment. C) Abrupt discontinuation of prednisone therapy in a client with a history of long-term corticosteroid use places the client at risk for an adrenal crisis, a life-threatening complication characterized by dehydration, fever, hyponatremia, hyperkalemia, vascular collapse, and death. Although it is important for the nurse to provide therapeutic communication and reinforce the patient's sense of autonomy, the nurse's best response is to educate the client about the risks of suddenly discontinuing prednisone treatment. D) Abrupt discontinuation of prednisone therapy in a client with a history of long-term corticosteroid use places the client at risk for an adrenal crisis, a life-threatening complication characterized by dehydration, fever, hyponatremia, hyperkalemia, vascular collapse, and death. Although it is important for the nurse to provide therapeutic communication and reinforce the patient's sense of autonomy, the nurse's best response is to educate the client about the risks of suddenly discontinuing prednisone treatment. Page Ref: 945 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Planning | Learning Outcome: 38.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of adrenocortical function across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 38.5: Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of adrenocortical function across the lifespan.

20) The nurse is assessing a client diagnosed with Cushing disease. Which findings are consistent with the client's diagnosis? A) Round, red face B) Buffalo hump C) Bruising D) Poor wound healing E) Hyperactivity Answer: A, B, C, D Explanation: A) The symptoms of Cushing disease include, but are not limited to, round, red face; buffalo hump; bruising; poor wound healing; and fatigue. Hyperactivity is not a symptom associated with Cushing disease. B) The symptoms of Cushing disease include, but are not limited to, round, red face; buffalo hump; bruising; poor wound healing; and fatigue. Hyperactivity is not a symptom associated with Cushing disease. C) The symptoms of Cushing disease include, but are not limited to, round, red face; buffalo hump; bruising; poor wound healing; and fatigue. Hyperactivity is not a symptom associated with Cushing disease. D) The symptoms of Cushing disease include, but are not limited to, round, red face; buffalo hump; bruising; poor wound healing; and fatigue. Hyperactivity is not a symptom associated with Cushing disease. E) The symptoms of Cushing disease include, but are not limited to, round, red face; buffalo hump; bruising; poor wound healing; and fatigue. Hyperactivity is not a symptom associated with Cushing disease. Page Ref: 946 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 38.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of adrenocortical function across the lifespan. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 38.5: Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of adrenocortical function across the lifespan.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 39 Tissue and Wound Healing 1) Which finding would the nurse expect when assessing a full thickness wound? A) Dermis remains intact. B) Epidermis remains intact. C) Epidermis and full thickness of dermis is destroyed. D) Only epidermis is destroyed. Answer: C Explanation: A) When the epidermis and all or a portion of the dermis stays intact, it is called a partial thickness wound. B) When the epidermis remains intact, it is neither a partial thickness nor full thickness. The epidermis is the top portion of visible skin. C) A full thickness wound is one in which the epidermis and the entire thickness of the dermis, possibly extending into subcutaneous tissue, muscle, and bone, are lost or destroyed. D) When the epidermis only is destroyed, it is a partial thickness wound. Page Ref: 955 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 39.1 Classify wounds on the basis of acute/chronic and partial/full thickness criteria and describe concepts related to tissue and wound healing. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of tissue and wound healing.

2) Which instruction should be included in the teaching plan for a patient with a chronic wound? A) Limit fluids to prevent edema. B) Limit food intake to reduce obesity. C) Stop smoking to improve wound healing. D) Maintain bedrest to avoid wound disruption. Answer: C Explanation: A) Inadequate hydration status places an individual at risk for impaired wound healing through the loss of skin turgor. B) Nutritional deficits place an individual at risk for impaired wound healing through the loss of skin turgor and necessary vitamins necessary for proper wound healing. C) Lifestyle risk factors (e.g., obesity, smoking) and environmental risk factors (e.g., medications, radiation, exposure to heat) influence the success of wound healing; therefore, it is recommended that patients stop smoking to enhance wound healing. D) Increasing activity improves circulation and reduces pressure on skin; therefore preventing decubitus ulcers or arterial/venous decrease. Page Ref: 955 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 39.1 Classify wounds on the basis of acute/chronic and partial/full thickness criteria and describe concepts related to tissue and wound healing. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of injury of tissue and delayed wound healing.

3) When assessing a patient's skin, the nurse needs to keep in mind that: A) light-skinned people do not have melanocytes. B) light-skinned and dark-skinned people have the same number of melanocytes. C) melanocytes in light-skinned people do not produce melanin. D) dark-skinned people have more melanocytes than light-skinned people. Answer: B Explanation: A) Melanocytes produce a dark pigment called melanin that is phagocytized by the keratinocytes, where it provides protection from ultraviolet rays from the sun. Light-skinned and dark-skinned individuals have the same number of melanocytes, but in darker skin and freckles, each melanocyte produces more melanin. B) Light-skinned and dark-skinned individuals have the same number of melanocytes, but in darker skin and freckles, each melanocyte produces more melanin. C) Light-skinned and dark-skinned individuals have the same number of melanocytes, but in darker skin and freckles, each melanocyte produces more melanin. D) Light-skinned and dark-skinned individuals have the same number of melanocytes, but in darker skin, each melanocyte produces more melanin. Page Ref: 957 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 39.2 Describe the structural components of each layer of skin and their functions in maintaining homeostasis. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of tissue and wound healing.

4) What type of wound would the nurse expect to find in a patient who has a wound healing by primary intention? A) A surgical wound with a large amount of exudate B) A large abraded area that is infected C) A pressure ulcer with pink granulation tissue in the wound bed D) A surgical wound that is clean and well-approximated Answer: D Explanation: A) Wound healing by secondary intention (secondary or spontaneous closure) occurs when a full thickness wound is allowed to heal without closure. Reasons for leaving a wound open include the following: the size of the tissue injury or the wide irregular wound margins prevent approximation of the wound edges, a large amount of exudate is present, or infection, tissue necrosis, or contamination of the wound is present. B) Abrasions and wounds with infection, tissue necrosis, or contamination of the wound usually heal by secondary intention. C) Pressure ulcers heal by secondary intention because the size of the tissue injury or the wide irregular wound margins prevent approximation of the wound edges. D) Wound healing by primary intention (primary closure) typically occurs after surgical closure of a wound. It may also occur in wounds that involve minimal loss of tissue, that are not infected or contaminated, and in which the edges of the wound can be approximated and closed. Page Ref: 961 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 39.3 Differentiate the types of cutaneous wound healing by intention and the phases of wound healing. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of tissue and wound healing to diagnosis and treatment.

5) In formulating a plan of care for a patient with colon cancer who will be having a colon resection, which local factor should the nurse recognize as affecting wound healing? A) Smoking B) Poor nutrition C) Advanced age D) Reduced blood flow and hypoxia Answer: D Explanation: A) Both local and systemic factors can affect wound healing. Systemic factors include advanced age, malnutrition, nutritional status (vitamins A, C, E, and K; minerals zinc, magnesium, copper, and iron), immune deficiency, smoking, medications (corticosteroids, antineoplastics), and metabolic status (diabetes mellitus). B) Both local and systemic factors can affect wound healing. Systemic factors include advanced age, malnutrition, nutritional status (vitamins A, C, E, and K; minerals zinc, magnesium, copper, and iron), immune deficiency, smoking, medications (corticosteroids, antineoplastics), and metabolic status (diabetes mellitus). C) Both local and systemic factors can affect wound healing. Systemic factors include advanced age, malnutrition, nutritional status (vitamins A, C, E, and K; minerals zinc, magnesium, copper, and iron), immune deficiency, smoking, medications (corticosteroids, antineoplastics), and metabolic status (diabetes mellitus). D) Both local and systemic factors can affect wound healing. Local factors include blood flow and hypoxia. Blood flow to the injury site is one of the most important factors affecting the healing process. Hypoxia can significantly delay or even stop the wound healing process. Page Ref: 969 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 39.4 Analyze the impact of local and systemic factors on wound healing. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of tissue and wound healing to diagnosis and treatment.

6) The nurse in preadmission testing is taking a health history from a patient who will be having an elective hysterectomy. Which vitamin deficiency should be addressed before surgery to ensure proper blood clotting during surgery? A) Vitamin A deficiency B) Vitamin C deficiency C) Vitamin K deficiency D) Vitamin E deficiency Answer: C Explanation: A) Vitamin A is needed to help reepithelialization and collagen needed for strength and stability of the healing wound. If deficient, it can impede the inflammatory process, reduce antimicrobial activity and impede new capillaries in the wound bed. B) Vitamin C is needed in all phases of wound healing. A deficiency can hinder the inflammatory process, decreasing complement activity, inhibit collagen secretion, decrease ability to wall off bacteria, and localize infection. Most important, a deficiency of Vitamin C can decrease angiogenesis, which causes prolonged hypoxia and impairs granulation of tissue formation. C) Vitamin K is required for synthesis of four coagulation factors: II, VII, IX, and X. Vitamin K deficiency affects hemostasis and formation of the fibrin clot. As a result, hemorrhage, impaired wound healing, and infection may occur. D) Vitamin E acts as an antioxidant that limits lipid peroxidation, maintains and stabilizes the cell membrane, and protects against oxidative injury associated with prolonged or overwhelming inflammation. Page Ref: 971 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 39.4 Analyze the impact of local and systemic factors on wound healing. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of injury of tissue and delayed wound healing

7) Which nutritional deficiencies should the plan of care address to improve oxygen delivery and wound healing in the patient with a pressure ulcer? A) Copper deficiency B) Iron deficiency C) Magnesium deficiency D) Zinc deficiency Answer: B Explanation: A) Copper is required for protein synthesis and cellular proliferation for normal wound healing. These minerals are critical in collagen synthesis and cross-linking, and deficiencies impair wound tensile strength and stability. B) Iron is required for oxygen transport in the hemoglobin molecule, and severe deficiencies can impair oxygen delivery to cells and tissues and result in wound hypoxia. C) Magnesium is required for protein synthesis and cellular proliferation for normal wound healing, as well as strength and stability of the healing. D) Zinc is required for facilitating optimal wound healing and fibroblast proliferation and collagen synthesis as well as epidermal cell proliferation to prevent decreased wound strength and stability and a delay in reepithelialization. Page Ref: 971 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 39.4 Analyze the impact of local and systemic factors on wound healing. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of injury of tissue and delayed wound healing.

8) Which response by a parent of a 24-week-old fetus undergoing intrauterine surgery indicates that the parent understands fetal wound healing? A) "My baby should have little or no scarring if we do the surgery now." B) "If we wait for 32 weeks' gestation, my baby will have little or no scarring." C) "Due to a weak inflammatory response, the wound will not heal as strongly as a wound in an adult." D) "Fetal wounds heal slower than adult wounds." Answer: A Explanation: A) Cutaneous wounds in a fetus younger than 24 weeks of gestation, referred to as an early-gestation fetus, healed with little or no scarring. B) As the gestational age of the fetus increases, healing proceeds from no scar to barely visible to faint mark to obvious scar. C) The likelihood of scar development during fetal wound healing is associated with an increasing inflammatory response. Scarless fetal wounds heal with minimal inflammation. The weak inflammatory response in scarless healing is thought to be related to the diminished function of early fetal neutrophils, macrophages, and platelets. D) Apparently, as the immune system matures and the inflammatory response strengthens, the likelihood of fetal scar formation increases. Cutaneous fetal wounds tend to heal not only without a scar but also more rapidly than adult wounds. Page Ref: 972 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 39.5 Compare the mechanisms of the continuum of wound healing, from scarless fetal wound healing to abnormal wound healing. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of tissue and wound healing.

9) What characteristics would the nurse expect to assess in a patient with a keloid scar? A) Scar is within boundaries of original injury. B) Scar extends beyond border of original injury. C) Scar develops within 1 month of injury. D) Scar is pruritic and edematous. Answer: B Explanation: A) Keloid scars are raised above the level of the surrounding skin and extend beyond the boundary of the original injury. Hypertrophic scars are raised above the level of the surrounding skin. However, unlike keloids, hypertrophic scars grow within the boundaries of the original injury and often regress spontaneously. B) Keloid scars are raised above the level of the surrounding skin and extend beyond the boundary of the original injury. C) Keloids usually appear from 6 months to 1 year after wounding. They tend to grow over time, do not regress spontaneously, and almost always recur after simple excision. Hypertrophic scars develop within the first month after wounding. D) Unlike keloids, hypertrophic scars may be pruritic and edematous but are often less painful than keloids. Page Ref: 973 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 39.5 Compare the mechanisms of the continuum of wound healing, from scarless fetal wound healing to abnormal wound healing. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of tissue and wound healing.

10) The nurse is caring for four patients who have abdominal surgical wounds. Which patient in this surgical nurse's assignment does the nurse assess to be at greatest risk for wound dehiscence? A) A 68-year-old-man with diabetes on postoperative day 5 B) A 60-year-old man on low-dose corticosteroids prior to surgery on postoperative day 1 C) A 40-year-old woman with no past medical history on postoperative day 5 D) A 40-year-old obese woman on postoperative day 2 Answer: A Explanation: A) Three factors that are commonly associated with wound dehiscence are diabetes mellitus, high-dose corticosteroid use, and infection. Some additional individual factors that favor dehiscence are increased mechanical strain on the wound, age greater than 65 years, dehydration, malnutrition, hypoproteinemia, malignancy, and obesity. The incidence of dehiscence peaks at approximately 5-9 days after surgery. Therefore, the 65-year-old man with diabetes on postoperative day 5 is at greatest risk. B) Three factors that are commonly associated with wound dehiscence are diabetes mellitus, high-dose corticosteroid use, and infection. This patient is taking low-dose corticosteroids and is under 65 years of age, placing him at a lower risk for wound dehiscence than a 68-year-old man. Also, the risk for dehiscence peaks at 5-9 days after surgery, this patient is on the first postoperative day. C) This woman is within the 5-9 day postoperative range for the incidence of dehiscence but has none of the factors that are associated with wound dehiscence. D) Obesity is an individual factor that favors dehiscence, but this patient is only 40 years of age and on postoperative day 2. The incidence of dehiscence peaks at approximately 5-9 days after surgery. Because of her obese state, this patient still needs to be monitored for proper wound healing without complications. Page Ref: 975 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessing | Learning Outcome: 39.5 Compare the mechanisms of the continuum of wound healing, from scarless fetal wound healing to abnormal wound healing. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of injury of tissue and delayed wound healing.

11) Which assessment findings would alert the nurse of an impending wound dehiscence on a patient with an abdominal incision on postoperative day 5? A) Incision edges are well-approximated. B) Abdominal dressing has purulent drainage. C) Incision has a healing ridge. D) Incision is pink with scant serous drainage. Answer: B Explanation: A) Well-approximated wound edges is a sign of a well-healed incision. B) Clinical manifestations of impending wound disruption include noticeable signs of infection, absence of a healing ridge by the fifth to ninth postoperative day, seroma or hematoma formation, and an increase in serous discharge. In some instances, individuals may report that they felt something "give way or pop." Purulent drainage is a sign of infection, placing the patient at risk for dehiscence. C) An incision with a healing ridge within the 5th-9th days is a sign of a well-healed incision. D) A pink incision indicates granulation tissue and is a sign of a well-healed incision. While an increase in serous drainage may increase the risk for dehiscence, a scant amount of serous drainage may be expected. Page Ref: 975 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 39.5 Compare the mechanisms of the continuum of wound healing, from scarless fetal wound healing to abnormal wound healing. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of injury of tissue and delayed wound healing.

12) When assessing a patient's skin, which of the following characteristics of skin should the nurse keep in mind? A) The epidermis is highly vascular. B) Lymphatic vessels drain the epidermis. C) Blood vessels in the dermis nourish the epidermis. D) Hair follicles originate in the dermis. Answer: C Explanation: A) The epidermis is avascular and contains no lymphatic vessels. It is sustained by nutrients from the blood vessels in the dermis that diffuse through the basement membrane. B) The epidermis is avascular and contains no lymphatic vessels. C) The epidermis is avascular and is sustained by nutrients from the blood vessels in the dermis that diffuse through the basement membrane. D) Skin appendages, including sweat glands, sebaceous glands, hair follicles, and nail roots are also present in the dermis but derive from the epidermis. Page Ref: 957 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 39.2 Describe the structural components of each layer of skin and their functions in maintaining homeostasis. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of tissue and wound healing.

13) When changing the dressing on a wound healing by secondary intention, what finding would the nurse expect to observe? A) An incision closed by sutures B) A clean incision C) Minimal granulation tissue D) A large amount of exudate Answer: D Explanation: A) Closure of wounds by primary intention can be achieved by suture, staple, butterfly closure, or fibrin glue, which is a type of "superglue" for the skin. B) Wounds that that heal by primary intention involve minimal loss of tissue, that are not infected or contaminated, and in which the edges of the wound can be approximated and closed. C) As the body attempts to close a wound by secondary intention, a large amount of granulation tissue is generated. D) Wound healing by secondary intention (secondary or spontaneous closure) occurs when a full thickness wound is allowed to heal without a closure attempt. A wound may be left open to heal by secondary intention when a large amount of exudate is present. Page Ref: 961 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 39.3 Differentiate the types of cutaneous wound healing by intention and the phases of wound healing. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of tissue and wound healing to diagnosis and treatment.

14) The nurse is providing discharge instructions to a patient with multiple lacerations and puncture wounds following a motor vehicle accident. Which statement by the patient indicates an understanding of the instructions? A) "I should remove any scabs that form." B) "The scab helps with wound repair." C) "Scabs interfere with healing." D) "Scabs prevent the wound edges from coming together." Answer: B Explanation: A) The scab that forms during the repair process provides a natural "dressing" for the surface of the wound while repair and regeneration occur underneath; therefore, it should not be removed. B) During the inflammatory phase of wound healing, an inflammatory exudate seeps out of the wound bed. As it dries over the provisional matrix, it forms a scab (eschar) that contracts, pulling the wound edges closer together and preventing surface microorganisms from penetrating the wound bed. This scab provides a natural "dressing" for the surface of the wound while repair and regeneration occur underneath. C) A scab (eschar) contracts, pulling the wound edges closer together and preventing surface microorganisms from penetrating the wound bed. It does not interfere with healing, but rather, acts as a natural "dressing" for the surface of the wound while repair and regeneration occur underneath. D) During the inflammatory phase of wound healing, an inflammatory exudate seeps out of the wound bed. As it dries over the provisional matrix, it forms a scab (eschar) that contracts, pulling the wound edges closer together and preventing surface microorganisms from penetrating the wound bed. This scab provides a natural "dressing" for the surface of the wound while repair and regeneration occur underneath. Page Ref: 956-966 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 39.3 Differentiate the types of cutaneous wound healing by intention and the phases of wound healing. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of tissue and wound healing.

15) When assessing a surgical wound healing by tertiary intention, the nurse expects granulation tissue to begin to appear during which time period? A) 1-3 days after surgery B) 3-5 days after surgery C) A week after surgery D) Two weeks after surgery Answer: B Explanation: A) The amount of granulation tissue depends on the extent of injury. In wounds that heal by primary intention, the tissue loss is minimal, so little granulation tissue is produced. On the other hand, in wounds that heal by secondary or tertiary intention, the tissue defect is greater, and the amount of granulation tissue needed is larger. The synthesis of granulation tissue begins approximately 3-5 days after injury and overlaps the inflammatory phase. B) The amount of granulation tissue depends on the extent of injury. In wounds that heal by primary intention, the tissue loss is minimal, so little granulation tissue is produced. On the other hand, in wounds that heal by secondary or tertiary intention, the tissue defect is greater, and the amount of granulation tissue needed is larger. The synthesis of granulation tissue begins approximately 3-5 days after injury and overlaps the inflammatory phase. C) The amount of granulation tissue depends on the extent of injury. In wounds that heal by primary intention, the tissue loss is minimal, so little granulation tissue is produced. On the other hand, in wounds that heal by secondary or tertiary intention, the tissue defect is greater, and the amount of granulation tissue needed is larger. The synthesis of granulation tissue begins approximately 3-5 days after injury and overlaps the inflammatory phase. D) The amount of granulation tissue depends on the extent of injury. In wounds that heal by primary intention, the tissue loss is minimal, so little granulation tissue is produced. On the other hand, in wounds that heal by secondary or tertiary intention, the tissue defect is greater, and the amount of granulation tissue needed is larger. The synthesis of granulation tissue begins approximately 3-5 days after injury and overlaps the inflammatory phase. Page Ref: 967 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 39.3 Differentiate the types of cutaneous wound healing by intention and the phases of wound healing. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of tissue and wound healing to diagnosis and treatment.

16) Following change-of-shift report, the nurse on a surgical unit is reviewing the assignment. Which 70-year-old patient does the nurse assess as being at greatest risk for impeded wound healing? A) A man with diabetes mellitus B) A woman who quit smoking 10 years ago C) A man with hyperlipidemia D) A woman on antihypertensive medication Answer: A Explanation: A) Systemic risk factors that impede wound healing include advanced age, malnutrition, nutritional status (vitamins A, C, E, and K; minerals zinc, magnesium, copper, and iron), immune deficiency, smoking, medications (corticosteroids, antineoplastics), and metabolic status (diabetes mellitus). Therefore, the 70-year-old man has two systemic risk factors, diabetes mellitus and advanced age. B) The 70-year-old woman who quit smoking 10 years ago has lowered her risk of impairing wound healing. C) Hyperlipidemia is not one of the systemic risk factors for impaired wound healing. D) Taking antihypertensive medications does not increase the risk of impaired wound healing. Page Ref: 969 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 39.4 Analyze the impact of local and systemic factors on wound healing. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of injury of tissue and delayed wound healing.

17) The nurse is reviewing the medication list of a patient with impaired wound healing. Which medication would be of concern to the nurse? A) NPH insulin B) Prednisone C) Cefazolin D) Vitamin C Answer: B Explanation: A) While diabetes mellitus may impair wound healing, the use of insulin does not have a negative effect on healing. B) Corticosteroids, such as prednisone, promote the breakdown of carbohydrates, fats, and proteins, impairing the anabolic processes needed for cell growth and proliferation during wound healing. Corticosteroids also exert an anti-inflammatory action that may impede the inflammatory phase of wound healing. Negative effects of corticosteroids include reduced phagocytosis, reduction in fibroblast proliferation and collagen synthesis, and decreased angiogenesis. These actions lead to prolonged wound hypoxia, increased susceptibility to wound infection, reduced granulation tissue formation, decreased wound tensile strength and stability, increased incidence of wound dehiscence, and reduced wound contraction. C) Cefazolin, a cephalosporin antibiotic, does not negatively affect wound healing and may help wound healing when infection is present. D) Vitamin C has a positive effect on wound healing and a deficiency can effect wound healing in all phases. Page Ref: 972 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Assessment | Learning Outcome: 39.4 Analyze the impact of local and systemic factors on wound healing. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of tissue and wound healing to diagnosis and treatment.

18) Which finding would the nurse expect when assessing a patient with a hypertrophic scar following second degree burns? A) Scarring that grows outside boundaries of original injury B) Scarring raised above the surface of surrounding skin C) A scar that develops 2 to 3 months after injury D) Painless scaring Answer: B Explanation: A) Hypertrophic scars are characterized by an excess of fibrotic tissue. They are associated with wounds such as trauma and burns and are raised above the level of the surrounding skin, but grow within the boundaries of the original injury. B) Hypertrophic scars are characterized by an excess of fibrotic tissue. They are associated with wounds such as trauma and burns and are raised above the level of the surrounding skin, but grow within the boundaries of the original injury. C) Hypertrophic scars develop within the first month after wounding and may be pruritic and edematous. D) Hypertrophic scars may be pruritic and edematous but are often less painful than keloids. Page Ref: 974 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 39.5 Compare the mechanisms of the continuum of wound healing, from scarless fetal wound healing to abnormal wound healing. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.1 Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of tissue and wound healing to diagnosis and treatment.

19) In evaluating the effectiveness of negative pressure wound therapy in patients with high-risk surgical wounds, the nurse should expect: A) healing by secondary intention. B) greater risk of wound infection. C) less wound dehiscence. D) stronger scar formation. Answer: C Explanation: A) Negative pressure wound therapy (NPWT) heals wounds through primary intention. B) In patients with high-risk surgical incisions, those who received negative pressure wound therapy (NPWT) had fewer postoperative infections in comparison to those who received standard postoperative dressings. C) In a study of patients with high-risk surgical incisions who received negative pressure wound therapy (NPWT), there were fewer cases of wound dehiscence in those treated with NPWT than in patients who received standard postoperative dressings. D) Scar formation is not strengthened with the use of NPWT. Page Ref: 974 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Evaluation | Learning Outcome: 39.5 Compare the mechanisms of the continuum of wound healing, from scarless fetal wound healing to abnormal wound healing. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of tissue and wound healing to diagnosis and treatment.

20) When assessing a wound in the remodeling phase of healing, the nurse would expect to find: A) scar tissue formation. B) acute inflammation. C) a fibrin clot. D) granulation tissue. Answer: A Explanation: A) Remodeling is the final phase of wound healing. The goal of this phase is to restore the structural and functional integrity of the skin. However, the dermal matrix is not regenerated as is the epidermis; it is mended. Slowly, the granulation tissue laid down in the provisional matrix is replaced with a more stable collagen-based matrix. Although collagen deposition into the matrix began in the proliferative phase, it continues in the remodeling phase. The outcome of this dermal repair process is scar or fibrotic tissue, which brings the edges of the wound together. B) The first phase of wound healing is acute inflammation. The goal of the inflammatory phase is to minimize tissue damage, prevent additional tissue injury, and prepare the wound for healing and regeneration. C) Hemostasis, the first step in the inflammatory phase, controls hemorrhage and maintains vascular integrity. Two physiologic processes are involved: formation of a platelet plug and generation of a fibrin-based clot. D) Granulation tissue forms during the proliferative phase. Granulation tissue is a mass of new connective tissue that forms on the surface of a healing wound. Granulation tissue serves as a foundation for the collagen-based matrix that will eventually replace the fibrin-based provisional matrix. Page Ref: 968 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 39.3 Differentiate the types of cutaneous wound healing by intention and the phases of wound healing | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of tissue and wound healing to diagnosis and treatment.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 40 Acute Skin Disorders 1) Which statement by the parent of a child with impetigo indicates to the nurse that more teaching is needed? A) "Antibiotics may be used to treat severe impetigo." B) "Everyone in the family needs to use good hand hygiene." C) "Tight dressings are best to help heal the blisters." D) "Towels and washcloths should not be shared." Answer: C Explanation: A) For severe cases of impetigo, oral forms of antibiotics are ordered. B) The patient's family should be taught that the infection is contagious and that precautions need to be taken. Good hand hygiene, use of antibacterial soap and water, and use of a separate washcloth and hand towel are necessary. C) Airflow is needed for healing; therefore, loose dressings may be used. D) The patient's family should be taught that the infection is contagious and that precautions need to be taken. Good hand hygiene, use of antibacterial soap and water, and use of a separate washcloth and hand towel are necessary. Page Ref: 986 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Evaluation | Learning Outcome: 40.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of bacterial skin infections and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of acute skin disorders to diagnosis and treatment.

2) Which findings is the nurse most likely to observe in the patient with cellulitis? A) Red pimples, fluid-filled blisters, oozing rash with yellow crusts B) Small papules and pustules with red base and a single hair follicle through center C) A firm, extremely tender swollen mass with purulent drainage D) Red, hot, painful swollen area Answer: D Explanation: A) Typical manifestations of impetigo include red pimples, fluid-filled blisters, and an oozing rash with yellow crusts. B) Signs and symptoms of folliculitis include pruritus, burning, or mild discomfort. Multiple small papules and pustules present with a red base that has a single hair follicle through the center. C) A carbuncle is firm, red, and painful mass that is extremely painful with purulent drainage. D) Cellulitis manifests as a painful, red, swollen area of the skin that is hot and tender to touch. Page Ref: 985-988 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 40.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of bacterial skin infections and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of acute skin disorders.

3) The nurse notes that a patient has a white coating on the tongue and that the patient reports a sore throat. Which question would be most appropriate for the nurse to ask? A) "Have you been taking antibiotics?" B) "How is your nutrition?" C) "Do you have anemia?" D) "Have you recently had a tick bite?" Answer: A Explanation: A) Individuals who are immunosuppressed, have neutropenia, are taking certain antibiotics, or are being treated for cancer are at risk for candidiasis. Other risk factors include poor hygiene, extensive antibiotic or corticosteroid use, chemotherapy drugs, surgery, poorly cleaned dentures, obesity, low-birth-weight infants, burns, prolonged hospitalization, invasive procedures (intravenous lines, Foley catheters, chest ports, etc.), mechanical ventilation, and organ transplants. B) Individuals who are immunosuppressed, have neutropenia, are taking certain antibiotics, or are being treated for cancer are at risk for candidiasis. Other risk factors include poor hygiene, extensive antibiotic or corticosteroid use, chemotherapy drugs, surgery, poorly cleaned dentures, obesity, low-birth-weight infants, burns, prolonged hospitalization, invasive procedures (intravenous lines, Foley catheters, chest ports, etc.), mechanical ventilation, and organ transplants. C) Individuals who are immunosuppressed, have neutropenia, are taking certain antibiotics, or are being treated for cancer are at risk for candidiasis. Other risk factors include poor hygiene, extensive antibiotic or corticosteroid use, chemotherapy drugs, surgery, poorly cleaned dentures, obesity, low-birth-weight infants, burns, prolonged hospitalization, invasive procedures (intravenous lines, Foley catheters, chest ports, etc.), mechanical ventilation, and organ transplants. D) Individuals who are immunosuppressed, have neutropenia, are taking certain antibiotics, or are being treated for cancer are at risk for candidiasis. Other risk factors include poor hygiene, extensive antibiotic or corticosteroid use, chemotherapy drugs, surgery, poorly cleaned dentures, obesity, low-birth-weight infants, burns, prolonged hospitalization, invasive procedures (intravenous lines, Foley catheters, chest ports, etc.), mechanical ventilation, and organ transplants. Page Ref: 989 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 40.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of fungal skin infections and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of acute skin disorders.

4) The nurse notes a child scratching the scalp and observes dry, brittle hair and bald patches. The nurse tells the parent that the child has: A) tinea capitis. B) tinea pedis. C) tinea corporus. D) tinea cruris. Answer: A Explanation: A) Slight itching, dry and brittle hair, and bald patches are seen in tinea capitis. B) In tinea pedis, the skin becomes soft, white and peels away, especially between the toes; itching, unpleasant odor and blistering may also occur. C) Tinea corporis begins as a scaly plaque with erythema that may worsen rapidly. Crust, papules, vesicles, and bullae may develop also. D) Tinea cruris (jock itch) is a red, itchy rash found on the groin. Page Ref: 990 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 40.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of fungal skin infections and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of acute skin disorders.

5) Which condition is a priority for the nurse planning care for a patient with exfoliative dermatitis? A) Fluid volume deficit B) Self-image issues C) Comfort D) Altered nutrition Answer: A Explanation: A) The increased rate at which normal epidermis is turned over increases in exfoliative dermatitis. Therefore, the exfoliated scales contain material that the skin normally retains (proteins, amino acids, and nucleic acids), and the result may be a negative nitrogen balance. The insensible fluid loss along with the nitrogen level should be monitored. B) Because the skin is erythematous and scaly, self-image may be a problem, but it is not the issue that the nurse should first address. C) Exfoliative dermatitis can cause pruritus so, although comfort is an issue, it is not the first issue that the nurse should address. D) In exfoliative dermatitis, the skin sloughs, and widespread sloughing leads to abnormal thermoregulation, nutritional deficiencies, increased metabolic rate, and hypovolemia. Although nutritional deficiencies may occur, they are not the nurse's highest priority. Page Ref: 992-993 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 40.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of dermatitis and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of acute skin disorders to diagnosis and treatment.

6) Which of the following should the nurse include in the teaching plan for a patient with lichen planus? A) Identify and avoid triggers for this condition. B) All patients with lichen planus have hepatitis C. C) With treatment, lichen planus can be cured. D) Ultraviolet light worsens the symptoms. Answer: A Explanation: A) Patients should get to know the trigger or risk factor that seems to cause lichen planus in their case. B) While hepatitis C is a trigger for lichen planus, it does not mean the patient has hepatitis C. C) There is no cure for lichen planus. D) Ultraviolet light therapy (PUVA therapy) may be helpful in the treatment of lichen planus. Page Ref: 994 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 40.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of dermatitis and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of acute skin disorders to diagnosis and treatment.

7) When assessing a patient with Stevens-Johnson syndrome, the nurse would expect to observe: A) less than 10% of the body surface is affected. B) 10-30% of the body surface is affected. C) 30-50 % of the body surface is affected. D) greater than 50% of the body surface is affected. Answer: A Explanation: A) Stevens-Johnson syndrome (SJS) is a rare disorder of the skin and mucous membranes in which cell death causes the epidermis to separate from the dermis. In SJS, less than 10% of the body surface area is involved. B) Stevens-Johnson syndrome (SJS) is a rare disorder of the skin and mucous membranes in which cell death causes the epidermis to separate from the dermis. In SJS, less than 10% of the body surface area is involved. C) Stevens-Johnson syndrome (SJS) is a rare disorder of the skin and mucous membranes in which cell death causes the epidermis to separate from the dermis. In SJS, less than 10% of the body surface area is involved. D) Stevens-Johnson syndrome (SJS) is a rare disorder of the skin and mucous membranes in which cell death causes the epidermis to separate from the dermis. In SJS, less than 10% of the body surface area is involved. Page Ref: 996 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 40.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of life-threatening inflammatory disorders and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of acute skin disorders.

8) When assessing a patient with toxic epidermal necrolysis, the nurse would expect to observe: A) less than 5% of the body surface is affected. B) 5-10% of the body surface is affected. C) 10-20% of the body surface is affected. D) greater than 30% of the body surface is affected. Answer: D Explanation: A) Although similar to SJS, TEN is more extensive. TEN with spots is widespread with detachment of the epidermis and erosion involving more than 30% of the body surface area. B) Although similar to SJS, TEN is more extensive. TEN with spots is widespread with detachment of the epidermis and erosion involving more than 30% of the body surface area. C) Although similar to SJS, TEN is more extensive. TEN with spots is widespread with detachment of the epidermis and erosion involving more than 30% of the body surface area. D) Although similar to SJS, TEN is more extensive. TEN with spots is widespread with detachment of the epidermis and erosion involving more than 30% of the body surface area. Page Ref: 996 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 40.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of life-threatening inflammatory disorders and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of acute skin disorders.

9) When taking a history from a patient with toxic epidermal necrolysis, the nurse would expect to find that the patient was taking which medications? A) Bronchodilators, antihypertensives B) Antibiotics, anticonvulsants C) Opioids, diuretics D) Antiarrhythmics, statins Answer: B Explanation: A) Antibiotics and anticonvulsants by systemic or topical application usually cause the drug reaction. Other drugs include sulfa drugs and some drugs used for gout. B) Antibiotics and anticonvulsants by systemic or topical application usually cause the drug reaction. Other drugs include sulfa drugs and some drugs used for gout. C) Antibiotics and anticonvulsants by systemic or topical application usually cause the drug reaction. Other drugs include sulfa drugs and some drugs used for gout. D) Antibiotics and anticonvulsants by systemic or topical application usually cause the drug reaction. Other drugs include sulfa drugs and some drugs used for gout. Page Ref: 996-997 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Assessment | Learning Outcome: 40.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of life-threatening inflammatory disorders and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of acute skin disorders.

10) When planning care for the patient with toxic epidermal necrolysis, the nurse gives priority to: A) maintaining musculoskeletal function. B) supporting urinary and bowel function. C) managing nutrition. D) discontinuing the offending drug. Answer: D Explanation: A) Supportive care is used for management of nutrition, fluids, temperature, urinary and bowel function, musculoskeletal function, and skin and wound care. B) Supportive care is used for management of nutrition, fluids, temperature, urinary and bowel function, musculoskeletal function, and skin and wound care. C) Supportive care is used for management of nutrition, fluids, temperature, urinary and bowel function, musculoskeletal function, and skin and wound care. D) Treatment includes immediate discontinuation of the offending drug. Page Ref: 997 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 40.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of life-threatening inflammatory disorders and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of acute skin disorders to diagnosis and treatment.

11) Which statement by a parent of a child with an allergy to bee stings indicates that more teaching is needed? A) "My child should carry an autoinjector with epinephrine in case of a bee sting." B) "If we do not have access to an epinephrine autoinjector, I will take my child to the emergency department." C) "If my child is stung by a bee, it will probably not be necessary to use the epinephrine autoinjector." D) "Adrenalin is the drug of choice for severe symptoms of a bee sting." Answer: C Explanation: A) Victims with a known allergy to bee and wasp stings should use their autoinjector (Adrenaclick or EpiPen), which contains epinephrine. If victims do not know of an allergy or do not have access to an autoinjector, they should be taken to the emergency department. B) If victims do not know of an allergy or do not have access to an autoinjector, they should be taken to the emergency department. C) Victims with a known allergy to bee and wasp stings should use immediately use their autoinjector (Adrenaclick or EpiPen), which contains epinephrine. If victims do not know of an allergy or do not have access to an autoinjector, they should be taken to the emergency department. D) The teacher and school nurse should be notified of the child's allergy so they can prevent bee stings or treat appropriately if an allergic reaction develops. Page Ref: 998 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 40.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of insect stings and bites and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of acute skin disorders to diagnosis and treatment.

12) The nurse is assessing a child brought to the urgent care clinic by her mother who removed a tick from the child's back and is concerned about Lyme disease. If the child has Lyme disease, which manifestations is the nurse most likely to observe? A) Swelling, redness, itching B) A red bump with a red bull's-eye rash C) Red dots on the ankles and wrists D) A rash with itching that is more intense at night Answer: B Explanation: A) Most common reactions to bee and wasp stings are mild and include swelling, redness, itching, and mild pain. B) A red bump with a ringed red rash that resembles a bull's-eye is typical of Lyme disease. C) Red dots on the ankles and wrists are typical in Rocky Mountain spotted fever. D) The most common symptom of scabies is a rash and itching that is more intense at night, interrupting sleep. Page Ref: 998-1000 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 40.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of insect stings and bites and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of acute skin disorders.

13) Which statement by the parent of a middle-school student indicates to the school nurse that more teaching on tick prevention is needed? A) "I should spray my child with an insect repellant containing at least 10-20% DEET." B) "I should check my child's skin for ticks when he comes in from playing outdoors." C) "I don't need to check his hair because ticks do not like hair." D) "I should dress my child in long sleeves and long pants." Answer: C Explanation: A) Use of an insect repellant with at least 10-20% DEET in children older than 2 years of age can help prevent tick bites. B) Prevention includes checking the child's skin and hair after playing outside. C) Prevention includes checking the child's skin and hair after playing outside. D) Long sleeves and long pants with socks should be worn when in wooded areas. Tucking the shirt into the pants and the pants into the socks helps to prevent the possibility of a tick bite. Page Ref: 998 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Evaluation | Learning Outcome: 40.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of insect stings and bites and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of acute skin disorders.

14) Which instruction about the use of a pediculicide should the nurse give to the parent of a child with head lice? A) Do not use shampoo after treatment. B) Wash the hair normally the day after treatment. C) Retreat the hair two weeks after the first treatment. D) If the lice are not dead 12 hours after treatment, retreat the hair. Answer: A Explanation: A) After treatment, a cream rinse or shampoo/conditioner should not be used. B) The hair should not be rewashed for 1-2 days after treatment. C) Retreatment is usually recommended in 7-10 days after the first OTC treatment. D) If the lice are not dead or moving slowly 8-12 hours after treatment, a professional should be seen. Page Ref: 1000 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 40.7 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders caused by infestations and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of acute skin disorders to diagnosis and treatment.

15) Which statement by the parent of two children with head lice indicates an understanding of the nurses' instructions to rid the home of lice? A) "I will put the stuffed animals in a sealed plastic bag for 1 week." B) "Combs and brushes will be rid of lice after soaking in alcohol." C) "If I find lice in the eyelashes I will use a pediculicide on them." D) "I will wash the bed sheets in hot water and dry on a hot cycle for at least 20 minutes." Answer: D Explanation: A) Anything nonwashable (e.g., certain fabrics, stuffed animals, cloth toys) should be placed in a sealed plastic bag for 2 weeks, enough time to kill the lice. B) Combs and brushes should be soaked with rubbing alcohol, Lysol or washed with soap and hot water, then placed in a bag and left in the freezer for 2 days. C) If lice are found on eyelashes, petroleum jelly applied 3 times a day for several days can help in plucking the nits using a tweezers. The petroleum jelly works by suffocating the lice, and OTC lice treatments should not be used around the eyes. D) The clothing and bed linens of the infected person should be washed in hot water and dried with the hot cycle for at least 20 minutes. Page Ref: 1000 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 40.7 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders caused by infestations and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of acute skin disorders to diagnosis and treatment.

16) Which statement by a patient with acne vulgaris indicates to the nurse that more teaching is needed about retinoid therapy? A) "I should limit my time in the sun when taking a retinoid drug." B) "Sunlight can help my acne, as long as I am not taking a retinoid drug." C) "I need to use sunscreen while I am taking a retinoid drug." D) "Being in the sun enhances the retinoid drug effects." Answer: D Explanation: A) Sun sensitivity may be a side effect of many of the prescription retinoid-like agents for acne. Individuals taking these medications should avoid long periods of time in the sun or use extra sun protection. B) Acne may disappear in the summer months because the sunlight has anti-inflammatory effects. C) Sun sensitivity may be a side effect of many of the prescription retinoid-like agents for acne. Individuals taking these medications should avoid long periods of time in the sun or use extra sun protection. D) Sun sensitivity may be a side effect of many of the prescription retinoid-like agents for acne. Individuals taking these medications should avoid long periods of time in the sun or use extra sun protection. Page Ref: 1003 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Evaluation | Learning Outcome: 40.8 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders associated with adolescent/adult skin and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of acute skin disorders to diagnosis and treatment.

17) How should the nurse respond when the patient with rosacea asks why his physician referred him to an ophthalmologist? A) "The eye doctor can help you with your dry eyes and irritation." B) "This condition can affect your eyesight." C) "Cataracts are common with rosacea." D) "Rosacea increases the risk of blindness." Answer: A Explanation: A) Rosacea can lead to eye problems, such as dryness, irritation, swelling, reddened eyelids, styes, conjunctivitis. B) Rosacea does not lead to vision problems. C) Rosacea does not lead to cataracts. D) Rosacea does not lead to blindness. Page Ref: 1003 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 40.8 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders associated with adolescent/adult skin and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of acute skin disorders to diagnosis and treatment.

18) Which statement by a patient with brittle nails indicates that more teaching is needed? A) "I need to avoid nail polish remover with acetone." B) "Washing dishes without gloves will help moisturize my hands." C) "Taking biotin will help strengthen my nails." D) "Clear nail polish with protein can strengthen my nails." Answer: B Explanation: A) To prevent nails from splitting if brittle, keep the nails short and avoid nail polish remover with acetone. B) Using gloves to avoid getting nails wet will also help, as will using an emollient after washing or bathing. C) Biotin in high doses is recommended, but it may take 6 months for results to be seen. D) Clear nail polish containing protein can help strengthen the nails. Page Ref: 1004 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 40.9 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the nail and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of acute skin disorders to diagnosis and treatment.

19) Which statement made by a patient with a fungal nail infection does the nurse need to correct? A) "Fungal nail infections are easily cured with an antifungal cream used daily for two weeks." B) "Fungal infections often reappear after treatment." C) "Fungal nail infections can take up to a year to be cured." D) "Fungal nail infections may need both oral antifungal and topical antifungal agents." Answer: A Explanation: A) Nail infections are often difficult to cure. It may take months to a year for the infection to be cured, and it may reappear. B) Nail infections are often difficult to cure. It may take months to a year for the infection to be cured, and it may reappear. C) Nail infections are often difficult to cure. It may take months to a year for the infection to be cured, and it may reappear. D) Treatment might include an oral antifungal (e.g., terbinafine [Lamisil], fluconazole [Diflucan]), a topical antifungal, medicated nail polish (ciclopirox [Penlac]), and antifungal cream. Page Ref: 1004 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 40.9 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the nail and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of acute skin disorders to diagnosis and treatment.

20) The nurse is teaching a patient newly diagnosed with diabetes about self-care. Which statement by the patient should the nurse clarify? A) "I should seek regular care for my nails." B) "I should see a podiatrist if I have a toe injury that doesn't heal." C) "I need to check my feet and nails every week." D) "I should not walk barefoot." Answer: C Explanation: A) When educating patients newly diagnosed with diabetes about checking their feet daily, it is important to include complications with the toenails. Emphasize getting treatment early treatment rather than waiting. B) When educating patients newly diagnosed with diabetes about checking their feet daily, it is important to include complications with the toenails. Emphasize getting treatment early treatment rather than waiting. C) When educating patients newly diagnosed with diabetes about checking their feet daily, it is important to include complications with the toenails. Emphasize getting treatment early treatment rather than waiting. D) When educating patients newly diagnosed with diabetes about checking their feet daily, it is important to include complications with the toenails. Emphasize the importance of wearing shoes to prevent foot injury. Page Ref: 1005 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Evaluation | Learning Outcome: 40.9 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the nail and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of acute skin disorders to diagnosis and treatment.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 41 Chronic Skin Disorders 1) The nurse is teaching a client with herpes simplex virus type 2 (HSV-2) about reducing transmission of the virus to others. Which patient statement indicates understanding of the teaching? A) "A mouth rash occurs between 2 and 20 days after first virus contact." B) "Viral shedding only occurs with open lesions." C) "HSV-2 can be spread through oral contact." D) "The incubation period for HSV-2 is 2 weeks." Answer: C Explanation: A) The first HSV-1 infection erupts into a rash in or around the mouth in 2-20 days after contact with the virus. B) Periodic viral shedding may occur with HSV-2 even when there are no skin lesions. C) HSV-2 is spread via oral, vaginal, or anal sexual contact with an individual who is shedding the virus. D) The incubation period (time between contracting the virus and appearance of symptoms) is 212 days with an average of 4 days. Page Ref: 1014 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Evaluation | Learning Outcome: 41.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of viral skin infections and approaches to diagnosis and treatment for those conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of chronic skin disorders.

2) A pregnant woman with a primary genital infection HSV-2 is seen at the health clinic for prenatal care at 12 weeks. What is the best response by the nurse when the client begins crying and asks how her baby will be affected? A) "HSV-2 can severely affect your baby. Let's talk about it." B) "Why did you get pregnant while you had an active infection?" C) "I'll come back when you are done crying and we can discuss this." D) "I am sure things will be fine." Answer: A Explanation: A) By offering to talk with the client about the risks her baby may face, the nurse is acknowledging the client's concerns, providing support, and educating the client about the possible outcomes so that the client can make educated decisions regarding care. Women with primary genital infection with HSV-1 or HSV-2 at the time of birth have a 57% risk for transmitting the virus to the neonate. Although rare, neonatal herpes has a high mortality rate. Infants who survive neurologic or disseminated herpes are severely affected. B) Asking "why" questions is not therapeutic or supportive and, in this case, projects a tone of disapproval and may make the client defensive. C) Walking out while the client is crying does not offer support. D) Telling the client that "things will be fine" are dismissive and may offer false hope. Page Ref: 1014 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity Standards: Nursing Process: Implementation | Learning Outcome: 41.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of viral skin infections and approaches to diagnosis and treatment for those conditions across the lifespan. | QSEN Competencies: I.C.10 Value active partnership with patients or designated surrogates in planning, implementation, and evaluation of care | AACN Essential Competencies: IX.21. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of chronic skin disorders to diagnosis and treatment.

3) Which information should the nurse include when providing education to a client undergoing antigen testing for herpes simplex? A) False positives may occur. B) False negatives may occur. C) The test is very sensitive and specific. D) Results take several days. Answer: A Explanation: A) There are more false positives (positive test results that are inaccurate) with antigen testing (microscopic examination of fluid from lesions for antigens, such as glycoprotein G, found on the viral cells) than other options. B) There are more false positives (positive test results that are inaccurate) with antigen testing (microscopic examination of fluid from lesions for antigens, such as glycoprotein G, found on the viral cells) than other options. C) Polymerase chain reaction (PCR) assays (technique for reproducing DNA or RNA from minute quantities of DNA or RNA) for HSV DNA are very sensitive and specific. PCR tests are used for testing lesions and is the preferred test for finding HSV in spinal fluid. D) Antigen testing is more rapid than a culture, taking only 2-12 hours for results. Page Ref: 1015 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 41.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of viral skin infections and approaches to diagnosis and treatment for those conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of chronic skin disorders to diagnosis and treatment.

4) The nurse is teaching the parents of a 1-month-old infant who has contracted varicella-zoster virus (VZV). What information should the nurse include? A) The child will be at increased risk of contracting herpes zoster after age 60. B) The child will be at increased risk of contracting herpes zoster in adolescence. C) The child is at increased risk of another outbreak of VZV. D) The child will be immune to contracting herpes zoster. Answer: B Explanation: A) Children who contract VZV in utero or during the first months after birth are at risk for HZ during childhood or adolescence. B) Children who contract VZV in utero or during the first months after birth are at risk for HZ during childhood or adolescence. C) Children who contract VZV in utero or during the first months after birth are at risk for HZ during childhood or adolescence. D) Children who contract VZV in utero or during the first months after birth are at risk for HZ during childhood or adolescence. Page Ref: 1015 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 41.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of viral skin infections and approaches to diagnosis and treatment for those conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of chronic skin disorders.

5) In the prodromal phase of herpes zoster, the client is most likely to report: A) pain on one side of the body. B) a rash at varying stages of eruption. C) a rash on both sides of the body. D) inflamed eyes. Answer: A Explanation: A) Shingles is usually preceded by a prodrome of malaise, fever, chills, myalgia, headache, or nausea. In addition, the area where the rash will erupt will tingle, itch, burn, feel numb, or be painful or very sensitive to touch. The rash is usually on one side of the body. B) A rash at varying stages of eruption on one side of the body and eye inflammation occur in the stage of herpes zoster outbreak, not the prodromal phase. C) A rash at varying stages of eruption on one side of the body and eye inflammation occur in the stage of herpes zoster outbreak, not the prodromal phase. D) A rash at varying stages of eruption on one side of the body and eye inflammation occur in the stage of herpes zoster outbreak, not the prodromal phase. Page Ref: 1016 Cognitive Level: Remembering Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 41.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of viral skin infections and approaches to diagnosis and treatment for those conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of chronic skin disorders.

6) A client with a flare-up of atopic dermatitis is exhibiting xerosis. Which action by the nurse will be most helpful? A) Place the client in a hot bath. B) Apply moisturizer liberally. C) Wrap affected areas in dry dressings. D) Use a warm-mist humidifier. Answer: B Explanation: A) A lukewarm bath may be helpful to remove scale, crusts, and allergens, not a hot bath, which is drying. B) Moisturizers applied liberally will reduce inflammation and frequency of flare-ups of xerosis. C) Moist wraps, not dry, may be soothing for xerosis. D) Cool-mist humidifiers used year-round may provide relief from xerosis. Page Ref: 1019 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Implementation | Learning Outcome: 41.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of skin disorders with a genetic basis and approaches to diagnosis and treatment for those conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of chronic skin disorders to diagnosis and treatment.

7) When taking the health history of a young client with newly diagnosed guttate psoriasis, the nurse would expect to find: A) a history of life-threatening complications. B) recent trauma. C) the abrupt removal of corticosteroid medication. D) a recent beta-hemolytic streptococcal upper respiratory infection. Answer: D Explanation: A) Pustular psoriasis may cause life-threatening complications in the severe acute form. B) Inverse psoriasis may be precipitated by heat, trauma, and infection. C) Erythrodermic psoriasis, the least common form of psoriasis, may be precipitated by abrupt removal of corticosteroid medication. D) Guttate psoriasis is more common in younger patients and manifests as pink papules with fine scaling that appear after group A beta-hemolytic streptococcal upper respiratory infection. Page Ref: 1019 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 41.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of skin disorders with a genetic basis and approaches to diagnosis and treatment for those conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of chronic skin disorders.

8) A client with plaque psoriasis reports pinpoint bleeding if he lifts his scales. The nurse explains that this is called: A) Koebner phenomenon. B) Auspitz sign. C) café au lait spots. D) lichenification. Answer: B Explanation: A) Koebner phenomenon occurs in clients with plaque psoriasis when injury to normal skin leads to plaque formation. B) Increased vascularization of the lesions leads to Auspitz sign, where pinpoint bleeding will occur when the scale is lifted. C) Café au lait spots are hyperpigmented spots on the skin. D) Lichenification (thick leathery skin) occurs in acute dermatitis due to increased rubbing and scratching. Page Ref: 1020 Cognitive Level: Remembering Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 41.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of skin disorders with a genetic basis and approaches to diagnosis and treatment for those conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of chronic skin disorders.

9) Which statement by a client with psoriasis indicates that more teaching is needed about flareup prevention? A) "Stress reduction will help reduce flare-ups." B) "Trauma to my skin can cause my psoriasis to worsen." C) "NSAIDs are preferred for aches and pains." D) "I should stay out of the sun." Answer: C Explanation: A) Psoriasis exacerbations or flare-ups may occur spontaneously or be triggered by stress; trauma to the skin; infection; sunburn; and use of drugs such as antimalarials, betablockers, aspirin, or NSAIDs. Flare-ups are disfiguring and uncomfortable for the patient. During these episodes, the disease may spread and worsen. B) Psoriasis exacerbations or flare-ups may occur spontaneously or be triggered by stress; trauma to the skin; infection; sunburn; and use of drugs such as antimalarials, beta-blockers, aspirin, or NSAIDs. Flare-ups are disfiguring and uncomfortable for the patient. During these episodes, the disease may spread and worsen. C) Psoriasis exacerbations or flare-ups may occur spontaneously or be triggered by stress; trauma to the skin; infection; sunburn; and use of drugs such as antimalarials, beta-blockers, aspirin, or NSAIDs. Flare-ups are disfiguring and uncomfortable for the patient. During these episodes, the disease may spread and worsen. D) Psoriasis exacerbations or flare-ups may occur spontaneously or be triggered by stress; trauma to the skin; infection; sunburn; and use of drugs such as antimalarials, beta-blockers, aspirin, or NSAIDs. Flare-ups are disfiguring and uncomfortable for the patient. During these episodes, the disease may spread and worsen. Page Ref: 1021 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Evaluation | Learning Outcome: 41.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of skin disorders with a genetic basis and approaches to diagnosis and treatment for those conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of chronic skin disorders to diagnosis and treatment.

10) A client with psoriasis is receiving a vitamin D analog. Which instruction should the nurse give the client? A) "The drug can be can be taken long term to maintain remission." B) "The drug will be tapered after symptoms subside." C) "The drug should not be taken during pregnancy." D) "The drug may cause burning and itching." Answer: A Explanation: A) Vitamin D analogs can be introduced into treatment before corticosteroids are tapered and may be continued afterward to give a longer time of remission than corticosteroids. B) Vitamin D can be used to provide a longer remission after symptoms subside. C) Vitamin D may be used during pregnancy. D) Topical retinoids (vitamin A derivative that reduces skin cell proliferation and reduces inflammation) are teratogenic (cause fetal death or anomalies) and often cause itching and burning when applied. Page Ref: 1021 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Implementation | Learning Outcome: 41.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of skin disorders with a genetic basis and approaches to diagnosis and treatment for those conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of chronic skin disorders to diagnosis and treatment.

11) The nurse is planning care for a client with hidradenitis suppurativa (HS). What is a reasonable long-term goal for this client? A) Complete remission by age 40 B) An increase in the length of remissions throughout life C) Remissions will begin in adolescence D) Corticosteroids will induce remission Answer: A Explanation: A) HS develops during adolescence or the early 20s, becomes more severe after about 6-7 years, then decreases in severity until complete remission between the ages of 35 and 49. Rarely, the disorder will continue into old age. B) HS develops during adolescence or the early 20s, becomes more severe after about 6-7 years, then decreases in severity until complete remission between the ages of 35 and 49. Rarely, the disorder will continue into old age. C) HS develops during adolescence or the early 20s, becomes more severe after about 6-7 years, then decreases in severity until complete remission between the ages of 35 and 49. Rarely, the disorder will continue into old age. D) Corticosteroids may be injected into lesions, in Hurley stages I and II, to reduce local inflammation, but this therapy does not induce remission. In Hurley stage III, oral corticosteroids may be used to control lesions. Page Ref: 1022 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 41.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of skin FVBG disorders with a genetic basis and approaches to diagnosis and treatment for those conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of chronic skin disorders.

12) A community health nurse is performing skin examinations at a public health fair. Which of the following people are most likely to have polymorphous light eruptions (PMLEs)? A) A man taking tetracycline B) A man with systemic lupus erythematosus C) A woman with chemical exposure D) A woman from a cold climate Answer: D Explanation: A) Polymorphous light eruptions are reactions to light that are not associated with drugs or systemic disease. PMLEs are more common in women in colder climates. Chemical exposure does not lead to PMLEs. B) Polymorphous light eruptions are reactions to light that are not associated with drugs or systemic disease. PMLEs are more common in women in colder climates. Chemical exposure does not lead to PMLEs. C) Polymorphous light eruptions are reactions to light that are not associated with drugs or systemic disease. PMLEs are more common in women in colder climates. Chemical exposure does not lead to PMLEs. D) Polymorphous light eruptions are reactions to light that are not associated with drugs or systemic disease. PMLEs are more common in women in colder climates. Chemical exposure does not lead to PMLEs. Page Ref: 1024 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 41-4 Differentiate the causes, classification underlying pathogenesis, and clinical manifestations of benign neoplasms of the skin and approaches to diagnosis and treatment for those conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of chronic skin disorders.

13) When assessing the skin of a client for squamous cell carcinoma (SCC), the nurse would observe for: A) a lesion with a telangiectasis. B) a nonhealing sore that bleeds easily. C) a blue, brown, or black lesion. D) a mole with an irregular border. Answer: B Explanation: A) Lesions from basal cell carcinoma may have telangiectases (spider veins, dilated capillaries at the surface of the skin) on or near them, a lower center area, and the color may be blue, brown, or black. B) Squamous cell carcinoma appears as firm, smooth, or hyperkeratotic papules or plaques with an ulcer in the center on sun-exposed skin. Often, SCC is a nonhealing sore that bleeds easily. C) Lesions from basal cell carcinoma may have telangiectases (spider veins, dilated capillaries at the surface of the skin) on or near them, a lower center area, and the color may be blue, brown, or black. D) The borders of a malignant melanoma may be irregular, uneven, notched, or scalloped. Page Ref: 1029 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 41.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of skin cancer and approaches to diagnosis and treatment for those conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of chronic skin disorders.

14) The nurse is caring for a client following surgical removal of a malignant melanoma. The client was found to have a mutation of the BRAF oncogene. What is the best response by the nurse when the client's sister asks if she is at increased risk for this form of melanoma? A) "This mutation often runs in families, so you are at increased risk." B) "Mutation of the BRAF oncogene isn't inherited, so this form of melanoma doesn't increase your risk." C) "Your brother's melanoma was caused by excessive sun exposure, so you aren't at increased risk." D) "Your fair skin, light hair, and freckles place you at high risk for melanoma." Answer: B Explanation: A) The BRAF oncogene is not an inherited mutation. Gene mutations that are inherited are CDKN2A or CDK4 B) Because the BRAF oncogene is not an inherited mutation, the sister is not at an increased risk for this type of melanoma. She may be at risk for melanoma due to other causes and should follow preventative measures such as avoiding tanning salons and getting sunburned. C) Because the BRAF oncogene is not an inherited mutation, the sister is not at an increased risk for this type of melanoma. She may be at risk for melanoma due to other causes and should follow preventative measures such as avoiding tanning salons and getting sunburned. D) Because the BRAF oncogene is not an inherited mutation, the sister is not at an increased risk for this type of melanoma. She may be at risk for melanoma due to other causes and should follow preventative measures such as avoiding tanning salons and getting sunburned. Page Ref: 1029 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 41.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of skin cancer and approaches to diagnosis and treatment for those conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII.1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities and populations NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of chronic skin disorders.

15) When preparing a plan of care for a client with vitiligo, the nurse should give priority to which problem? A) Risk of infection B) Impaired wound healing C) Chronic pain D) Low self-esteem Answer: D Explanation: A) Vitiligo does not increase a person's risk for infection, wound healing, or pain. B) Vitiligo does not increase a person's risk for infection, wound healing, or pain. C) Vitiligo does not increase a person's risk for infection, wound healing, or pain. D) Pigmentary changes have the potential for affecting self-esteem, confidence, and emotional health. In fact, some cultures will marginalize people with pigmentary changes, causing them to feel isolated and to have difficulty in finding a mate. Page Ref: 1030 Cognitive Level: Applying Client Need & Sub: Psychological Integrity Standards: Nursing Process: Planning | Learning Outcome: 41.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of changes in pigmentation of the skin and approaches to diagnosis and treatment for those conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 10. Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and prevention of illness, injury, disability and premature death NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of chronic skin disorders to diagnosis and treatment.

16) When assessing the client with multiple café au lait macules (CALMs), the nurse should also be alert for: A) neurofibromas. B) patches of unpigmented skin. C) alopecia. D) psoriasis. Answer: A Explanation: A) Multiple CALMs may indicate genetic disorders. The genetic disorder most often associated with CALMs is neurofibromatosis type 1 (NF1), an autosomal dominant disorder. B) Vitiligo is an acquired pigmentary disorder where patches of skin, hair, or mucous membranes lose color. C) Comorbidities of vitiligo, not CALMs include thyroid disorders, psoriasis, pernicious anemia, alopecia areata, inflammatory bowel disease, and systemic lupus erythematosus. D) Comorbidities of vitiligo, not CALMs include thyroid disorders, psoriasis, pernicious anemia, alopecia areata, inflammatory bowel disease, and systemic lupus erythematosus. Page Ref: 1031 Cognitive Level: Remembering Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 41.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of changes in pigmentation of the skin and approaches to diagnosis and treatment for those conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities and populations NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of chronic skin disorders.

17) What response should the nurse give to a woman who gave birth three months ago and is concerned about excessive hair loss? A) "This is normal following childbirth and may last up to a year." B) "This is of concern, and you should follow up with your physician." C) "This hair loss is permanent." D) "This may be the sign of a serious disease." Answer: A Explanation: A) Pregnancy usually produces a prolonged anagen phase, followed in postpartum by a prolonged telogen phase; telogen effluvium may persist for up to 1 year. B) Pregnancy usually produces a prolonged anagen phase, followed in postpartum by a prolonged telogen phase; telogen effluvium may persist for up to 1 year. C) Pregnancy usually produces a prolonged anagen phase, followed in postpartum by a prolonged telogen phase; telogen effluvium may persist for up to 1 year. D) Pregnancy usually produces a prolonged anagen phase, followed in postpartum by a prolonged telogen phase; telogen effluvium may persist for up to 1 year. Page Ref: 1033 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 41.7 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the hair and scalp and approaches to diagnosis and treatment for those conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of chronic skin disorders.

18) Which client statement indicates understanding of the nurse's teaching about taking finasteride for male-pattern baldness? A) "I should rub the ointment on my head where I want the hair to grow." B) "I should start to notice hair growth in about 6 to 8 weeks." C) "I will report serious adverse effects to the doctor immediately." D) "My hair regrowth will be permanent." Answer: C Explanation: A) Minoxidil, not finasteride, is a topical medication that helps with hair regrowth in clients with alopecia. B) Finasteride takes 6-8 months to work fully, not 6-8 weeks. C) Finasteride has serious side effects that should be reported to the physician immediately. D) When finasteride is discontinued, the hair loss returns. Page Ref: 1033 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Evaluation | Learning Outcome: 41.7 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the hair and scalp and approaches to diagnosis and treatment for those conditions across the lifespan. | QSEN Competencies: 41.7 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the hair and scalp and approaches to diagnosis and treatment for those conditions across the lifespan. | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of chronic skin disorders to diagnosis and treatment.

19) What is the best response for the nurse to make when a client with alopecia areata asks if the hair loss is permanent? A) "The longer the hair loss persists, the more likely it will be permanent." B) "Yes, the hair loss is permanent." C) "The older you are at the onset of the disorder, the more likely the hair loss will be permanent." D) "Widespread hair loss typically grows back." Answer: A Explanation: A) The more widespread the hair loss and the longer it persists, the more likely the baldness will be permanent. B) The hair may begin to grow back spontaneously or it may start to grow with treatment. C) If the patient is very young at onset of the disorder, the more likely the baldness will persist. D) The more widespread the hair loss, the more likely the baldness will be permanent. Page Ref: 1034 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 41.7 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the hair and scalp and approaches to diagnosis and treatment for those conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of chronic skin disorders.

20) What finding would the nurse expect when assessing the client with basal cell carcinoma (BCC)? A) Previous ultraviolet light exposure B) Dark pigmented skin C) Female gender D) Family history of BCC Answer: A Explanation: A) Risk factors for BCC include ultraviolet light exposure; radiation therapy as a child; having light-colored skin; personal history of skin cancer; older age; male gender; exposure to arsenic, coal tar, some pesticides, or oils; long-term or severe inflammatory skin disease; burn injury; treatment with PUVA; and reduced immunity. B) Risk factors for BCC include ultraviolet light exposure; radiation therapy as a child; having light-colored skin; personal history of skin cancer; older age; male gender; exposure to arsenic, coal tar, some pesticides, or oils; long-term or severe inflammatory skin disease; burn injury; treatment with PUVA; and reduced immunity. C) Risk factors for BCC include ultraviolet light exposure; radiation therapy as a child; having light-colored skin; personal history of skin cancer; older age; male gender; exposure to arsenic, coal tar, some pesticides, or oils; long-term or severe inflammatory skin disease; burn injury; treatment with PUVA; and reduced immunity. D) Risk factors for BCC include ultraviolet light exposure; radiation therapy as a child; having light-colored skin; personal history of skin cancer; older age; male gender; exposure to arsenic, coal tar, some pesticides, or oils; long-term or severe inflammatory skin disease; burn injury; treatment with PUVA; and reduced immunity. Page Ref: 1027 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 41.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of skin cancer and approaches to diagnosis and treatment for those conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of chronic skin disorders.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 42 Disorders of Upper and Lower Gastrointestinal Systems 1) The nurse is assessing a patient with globus sensation. Which symptom would this patient describe? A) Pressure in the mid-chest B) Gnawing discomfort of the upper abdomen C) Pain with swallowing D) A fullness or lump in the throat Answer: D Explanation: A) Esophageal chest pain, like heartburn, is experienced as a pressure-like sensation felt in the mid-chest. B) Dyspepsia is an uncomfortable feeling associated with pathophysiology of the upper GIT such as mild, gnawing discomfort of the chest or upper abdomen, fullness, bloating, early satiety, and nausea. C) Odynophagia is pain caused by swallowing. D) Globus sensation, also known as globus pharyngis, is a fullness or a lump in the throat. Page Ref: 1044 Cognitive Level: Remembering Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 42.1 Outline the four cardinal symptoms of disorders of the upper and lower gastrointestinal systems and concepts related to GI alterations. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of disorders of the upper and lower GI system.

2) Which manifestation would the nurse expect to assess in the patient with regurgitation? A) Sour taste in the mouth B) Forceful evacuation of gastric contents C) Difficulty swallowing D) Pain with swallowing Answer: A Explanation: A) Regurgitation is the effortless return of food and fluids into the pharynx without nausea or retching. Patients complain of a burning sensation in the throat and a sour taste in the mouth. They may report undigested food returning to the mouth. Clinically, patients may present with halitosis (bad breath). B) Vomiting is the forceful evacuation of gastric contents. C) Dysphagia, difficulty swallowing food and liquids, is often described as the feeling of food "sticking" in the throat or chest. D) Odynophagia is pain caused by swallowing. Page Ref: 1044 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 42.1 Outline the four cardinal symptoms of disorders of the upper and lower gastrointestinal systems and concepts related to GI alterations. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of disorders of the upper and lower GI system.

3) A patient, with an inability to swallow following a stroke, is receiving full-strength formula through a nasogastric feeding tube and is experiencing diarrhea. Which is the most likely cause of the diarrhea? A) Osmotic causes B) Secretory causes C) Inflammatory bowel D) Motility causes Answer: A Explanation: A) In osmotic causes of diarrhea, nonabsorbable substances in the lumen of the bowel draw water into the bowel (e.g., ingestion of synthetic sugars, such as sorbitol or fullstrength tube feeding formulas). B) In secretory causes, excessive mucosal secretion interferes with chloride and sodium transport, decreasing water absorption (e.g., bacterial and viral infections). C) In inflammatory bowel causes, inflammation causes smooth muscle contraction, cramping, urgency, and frequency of elimination (e.g., ulcerative colitis, Crohn disease). D) In motility causes, excessive motility decreases mucosal surface contact time, decreasing opportunity for absorption (e.g., short bowel syndrome, laxative abuse). Page Ref: 1044 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 42.1 Outline the four cardinal symptoms of disorders of the upper and lower gastrointestinal systems and concepts related to GI alterations. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of disorders of the upper and lower GI system.

4) When planning care for a patient with melena, the nurse expects which appearance of the stool? A) Coffee ground appearance of the stool B) Black and tarry stools C) Bright red blood in the stool D) Visually undetectable blood Answer: B Explanation: A) Hematemesis (vomitus) may contain frank, bright red (undigested) blood or dark, grainy (digested) blood, described as having a coffee ground appearance. B) Upper GI bleeding may present as blood in the patient's stool, known as melena. Melena is black, tarry stools caused by digestion of blood in the GIT. C) Lower GI bleeding is bleeding from the small intestine, large intestine, colon, or rectum and may present as melena or frank, bright red blood in the stool (hematochezia). D) Both upper and lower GI bleeding may present as occult bleeding. Occult blood is due to slow, chronic bleeding and is not detectable by routine inspection of the stool or gastric secretions. Occult blood is detected only through a guaiac test. Page Ref: 1045 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 42.1 Outline the four cardinal symptoms of disorders of the upper and lower gastrointestinal systems and concepts related to GI alterations. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of disorders of the upper and lower GI system.

5) Which of the cardinal symptoms of GI disorders would be expected in a patient with a defect of the esophagus? A) Pain, altered ingestion, bleeding B) Altered motility, altered ingestion, bleeding C) Pain, altered ingestion, vomiting D) Vomiting, altered swallowing, bleeding Answer: A Explanation: A) Patients with disorders that alter the GI system present with any combination of the four cardinal signs and symptoms: pain (the concept of pain and comfort), altered ingestion (the concept of digestion and nutrition), altered motility (the concept of elimination), and bleeding (the concept of perfusion). Disorders of the esophagus commonly cause three of the four cardinal symptoms of GI disorders: pain, alteration in ingestion, and bleeding. B) Patients with disorders that alter the GI system present with any combination of the four cardinal signs and symptoms: pain (the concept of pain and comfort), altered ingestion (the concept of digestion and nutrition), altered motility (the concept of elimination), and bleeding (the concept of perfusion). Disorders of the esophagus commonly cause three of the four cardinal symptoms of GI disorders: pain, alteration in ingestion, and bleeding. C) Patients with disorders that alter the GI system present with any combination of the four cardinal signs and symptoms: pain (the concept of pain and comfort), altered ingestion (the concept of digestion and nutrition), altered motility (the concept of elimination), and bleeding (the concept of perfusion). Disorders of the esophagus commonly cause three of the four cardinal symptoms of GI disorders: pain, alteration in ingestion, and bleeding. D) Patients with disorders that alter the GI system present with any combination of the four cardinal signs and symptoms: pain (the concept of pain and comfort), altered ingestion (the concept of digestion and nutrition), altered motility (the concept of elimination), and bleeding (the concept of perfusion). Disorders of the esophagus commonly cause three of the four cardinal symptoms of GI disorders: pain, alteration in ingestion, and bleeding. Page Ref: 1045 Cognitive Level: Remembering Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 42.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the esophagus and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of the upper and lower GI system.

6) A child with corrosive esophagitis following ingestion of a corrosive liquid is treated with esophageal dilation. The nurse is providing discharge instructions to the parent. Which of the following statements indicates to the nurse that the parent needs more teaching? A) "More dilations may be needed as my child grows." B) "No further dilations will be needed." C) "My child should be evaluated if he develops swallowing problems." D) "I need to childproof my house." Answer: A Explanation: A) Repeated esophageal dilations may be needed to treat esophageal stenosis caused by scarring. B) Repeated esophageal dilations may be needed to treat esophageal stenosis caused by scarring. C) The parent should monitor the child for dysphagia, an indication of esophageal stenosis. D) Childproofing a house with young children is an important safety measure to prevent accidental poisoning and other injuries, such as corrosive esophagitis. Page Ref: 1047 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 42.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the esophagus and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of disorders of the upper and lower GI system.

7) A patient with hypopharyngeal diverticula will most likely report: A) regurgitation of undigested food. B) regurgitation of digested food. C) vomiting of digested food. D) nausea. Answer: A Explanation: A) Esophageal diverticula in the upper esophagus are termed hypopharyngeal diverticula. The most common type is Zenker's diverticulum, which occurs at the junction between the pharynx and the esophagus in an area known as the Killian triangle. Regurgitation of undigested food is characteristic of hypopharyngeal diverticula because the food has not reached the digestive enzymes of the stomach. B) Esophageal diverticula in the upper esophagus are termed hypopharyngeal diverticula. The most common type is Zenker's diverticulum, which occurs at the junction between the pharynx and the esophagus in an area known as the Killian triangle. Regurgitation of undigested food is characteristic of hypopharyngeal diverticula because the food has not reached the digestive enzymes of the stomach. C) Esophageal diverticula in the upper esophagus are termed hypopharyngeal diverticula. The most common type is Zenker's diverticulum, which occurs at the junction between the pharynx and the esophagus in an area known as the Killian triangle. Regurgitation of undigested food is characteristic of hypopharyngeal diverticula because the food has not reached the digestive enzymes of the stomach. D) Esophageal diverticula in the upper esophagus are termed hypopharyngeal diverticula. The most common type is Zenker's diverticulum, which occurs at the junction between the pharynx and the esophagus in an area known as the Killian triangle. Regurgitation of undigested food is characteristic of hypopharyngeal diverticula because the food has not reached the digestive enzymes of the stomach. Page Ref: 1048 Cognitive Level: Remembering Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 42.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the esophagus and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of the upper and lower GI system.

8) To detect crepitus in a patient with an esophageal perforation, the nurse should: A) palpate the chest. B) inspect the chest. C) percuss the chest. D) auscultate the chest. Answer: A Explanation: A) Crepitus of the chest may be palpable due to subcutaneous emphysema. B) Crepitus cannot be seen on inspection or detected by percussion or auscultation. C) Crepitus cannot be seen on inspection or detected by percussion or auscultation. D) Crepitus cannot be seen on inspection or detected by percussion or auscultation. Page Ref: 1049 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 42.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the esophagus and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of the upper and lower GI system.

9) Which manifestations would the nurse expect to assess in the patient with a type IV paraesophageal hernia? A) Dyspnea, reduced exercise tolerance, bowels sounds heard at left lung base B) Occasional heartburn, sour taste in throat, reduced exercise tolerance C) Sour taste in throat, dyspnea, halitosis D) Halitosis, epigastric pain, burning in throat Answer: A Explanation: A) With type IV paraesophageal hernias, the fundus as well as other abdominal structures, such as the omentum, colon, or small bowel herniate through the diaphragmatic hiatus. Patients may experience dyspnea, reduced exercise tolerance, and possible syncope. Bowel sounds may be audible at the left lung base. B) With type IV paraesophageal hernias, the fundus as well as other abdominal structures, such as the omentum, colon, or small bowel herniate through the diaphragmatic hiatus. Patients may experience dyspnea, reduced exercise tolerance, and possible syncope. Bowel sounds may be audible at the left lung base. C) With type IV paraesophageal hernias, the fundus as well as other abdominal structures, such as the omentum, colon, or small bowel herniate through the diaphragmatic hiatus. Patients may experience dyspnea, reduced exercise tolerance, and possible syncope. Bowel sounds may be audible at the left lung base. D) With type IV paraesophageal hernias, the fundus as well as other abdominal structures, such as the omentum, colon, or small bowel herniate through the diaphragmatic hiatus. Patients may experience dyspnea, reduced exercise tolerance, and possible syncope. Bowel sounds may be audible at the left lung base. Page Ref: 1049 Cognitive Level: Remembering Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 42.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the esophagus and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of upper and lower GI system to diagnosis and treatment.

10) The nurse is recommending lifestyle changes to reduce symptoms in a patient with GERD. Which response indicates to the nurse that more teaching is needed? A) "I am overweight and need to lose weight." B) "I love my morning coffee so I am glad I don't need to eliminate it." C) "Smaller meals may reduce my reflux." D) "I should remain upright for a while after meals." Answer: B Explanation: A) Patients may be taught lifestyle modifications to reduce GERD, which include diet changes and adoption of behaviors that may minimize reflux. Behavior changes include weight loss in obese patients, smaller meals, and avoidance of the supine position immediately after meals. Diet changes include avoiding foods and drinks that are known to lower LES tone (such as fat, chocolate, peppermint, alcohol, coffee, and tea) and avoiding acidic foods. B) Patients may be taught lifestyle modifications to reduce GERD, which include diet changes and adoption of behaviors that may minimize reflux. Behavior changes include weight loss in obese patients, smaller meals, and avoidance of the supine position immediately after meals. Diet changes include avoiding foods and drinks that are known to lower LES tone (such as fat, chocolate, peppermint, alcohol, coffee, and tea) and avoiding acidic foods. C) Patients may be taught lifestyle modifications to reduce GERD, which include diet changes and adoption of behaviors that may minimize reflux. Behavior changes include weight loss in obese patients, smaller meals, and avoidance of the supine position immediately after meals. Diet changes include avoiding foods and drinks that are known to lower LES tone (such as fat, chocolate, peppermint, alcohol, coffee, and tea) and avoiding acidic foods. D) Patients may be taught lifestyle modifications to reduce GERD, which include diet changes and adoption of behaviors that may minimize reflux. Behavior changes include weight loss in obese patients, smaller meals, and avoidance of the supine position immediately after meals. Diet changes include avoiding foods and drinks that are known to lower LES tone (such as fat, chocolate, peppermint, alcohol, coffee, and tea) and avoiding acidic foods. Page Ref: 1052 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Evaluation | Learning Outcome: 42.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the esophagus and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of upper and lower GI system to diagnosis and treatment.

11) Which finding would the nurse expect in a patient with a gastric ulcer? A) Burning pain during the night B) Burning pain on an empty stomach C) Burning pain precipitated by food D) Burning pain relieved by food Answer: C Explanation: A) Characteristics of a gastric ulcer include burning or gnawing discomfort often precipitated by food, nausea, and weight loss. In contrast, the characteristics of a duodenal ulcer include burning or gnawing discomfort often on an empty stomach and during the night, usually relieved by food or antacids. B) Characteristics of a gastric ulcer include burning or gnawing discomfort often precipitated by food, nausea, and weight loss. In contrast, the characteristics of a duodenal ulcer include burning or gnawing discomfort often on an empty stomach and during the night, usually relieved by food or antacids. C) Characteristics of a gastric ulcer include burning or gnawing discomfort often precipitated by food, nausea, and weight loss. In contrast, the characteristics of a duodenal ulcer include burning or gnawing discomfort often on an empty stomach and during the night, usually relieved by food or antacids. D) Characteristics of a gastric ulcer include burning or gnawing discomfort often precipitated by food, nausea, and weight loss. In contrast, the characteristics of a duodenal ulcer include burning or gnawing discomfort often on an empty stomach and during the night, usually relieved by food or antacids. Page Ref: 1054 Cognitive Level: Remembering Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 42.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the stomach and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of the upper and lower GI system.

12) The nurse should expect to administer which medication regimen to a patient with an ulcer that is H. pylori positive? A) Proton pump inhibitors, clarithromycin, amoxicillin B) Proton pump inhibitors, bismuth salts, metronidazole C) H2 receptor antagonist, proton pump inhibitors, clarithromycin D) H2 receptor antagonist, amoxicillin, clarithromycin Answer: A Explanation: A) If the ulcer is H. pylori positive, the treatment of choice is H. pylori eradication with a combination of acid-inhibiting therapy for 10-14 days. Treatments may be either triple therapy (PPIs, clarithromycin, and amoxicillin or metronidazole) or quadruple therapy (PPIs, bismuth salts, tetracycline, and metronidazole), depending on the prevalence of antibiotic resistance in an area. H2-receptor antagonists are used to heal NSAID-induced ulcers. B) If the ulcer is H. pylori positive, the treatment of choice is H. pylori eradication with a combination of acid-inhibiting therapy for 10-14 days. Treatments may be either triple therapy (PPIs, clarithromycin, and amoxicillin or metronidazole) or quadruple therapy (PPIs, bismuth salts, tetracycline, and metronidazole), depending on the prevalence of antibiotic resistance in an area. H2-receptor antagonists are used to heal NSAID-induced ulcers. C) If the ulcer is H. pylori positive, the treatment of choice is H. pylori eradication with a combination of acid-inhibiting therapy for 10-14 days. Treatments may be either triple therapy (PPIs, clarithromycin, and amoxicillin or metronidazole) or quadruple therapy (PPIs, bismuth salts, tetracycline, and metronidazole), depending on the prevalence of antibiotic resistance in an area. H2-receptor antagonists are used to heal NSAID-induced ulcers. D) If the ulcer is H. pylori positive, the treatment of choice is H. pylori eradication with a combination of acid-inhibiting therapy for 10-14 days. Treatments may be either triple therapy (PPIs, clarithromycin, and amoxicillin or metronidazole) or quadruple therapy (PPIs, bismuth salts, tetracycline, and metronidazole), depending on the prevalence of antibiotic resistance in an area. H2-receptor antagonists are used to heal NSAID-induced ulcers. Page Ref: 1055 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Implementation | Learning Outcome: 42.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the stomach and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of upper and lower GI system to diagnosis and treatment.

13) In planning care for a patient with chronic gastritis, the nurse would anticipate which of the following vitamin deficiencies? A) Vitamin B1 B) Vitamin B3 C) Vitamin B7 D) Vitamin B12 Answer: D Explanation: A) In chronic gastritis, damaged secretory glands lead to decreased acid production and decreased intrinsic factor production. Intrinsic factor is necessary for intestinal absorption of vitamin B12. B) In chronic gastritis, damaged secretory glands lead to decreased acid production and decreased intrinsic factor production. Intrinsic factor is necessary for intestinal absorption of vitamin B12. C) In chronic gastritis, damaged secretory glands lead to decreased acid production and decreased intrinsic factor production. Intrinsic factor is necessary for intestinal absorption of vitamin B12. D) In chronic gastritis, damaged secretory glands lead to decreased acid production and decreased intrinsic factor production. Intrinsic factor is necessary for intestinal absorption of vitamin B12. Page Ref: 1055 Cognitive Level: Remembering Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 42.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the stomach and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of upper and lower GI system to diagnosis and treatment.

14) When performing a succession splash in a patient suspected of having a gastric outlet obstruction, which result would suggest this diagnosis? A) A splashing sound auscultated in upper abdomen 1 hour after a meal B) A splashing sound auscultated in upper abdomen 3 hours after a meal C) No splashing sound auscultated in upper abdomen 3 hours after a meal D) No splashing sound auscultated in upper abdomen 1 hour after a meal Answer: B Explanation: A) If gastric outlet obstruction is suspected, a succussion splash should be performed. With a stethoscope placed over the stomach (upper abdomen), the patient logrolls back and forth. A splashing sound indicates retained gastric contents. If it occurs more than 3 hours after a meal, it suggests gastric outlet obstruction. B) If gastric outlet obstruction is suspected, a succussion splash should be performed. With a stethoscope placed over the stomach (upper abdomen), the patient logrolls back and forth. A splashing sound indicates retained gastric contents. If it occurs more than 3 hours after a meal, it suggests gastric outlet obstruction. C) If gastric outlet obstruction is suspected, a succussion splash should be performed. With a stethoscope placed over the stomach (upper abdomen), the patient logrolls back and forth. A splashing sound indicates retained gastric contents. If it occurs more than 3 hours after a meal, it suggests gastric outlet obstruction. D) If gastric outlet obstruction is suspected, a succussion splash should be performed. With a stethoscope placed over the stomach (upper abdomen), the patient logrolls back and forth. A splashing sound indicates retained gastric contents. If it occurs more than 3 hours after a meal, it suggests gastric outlet obstruction. Page Ref: 1056 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 42.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the stomach and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of upper and lower GI system to diagnosis and treatment.

15) Which finding would lead the nurse to suspect infantile hypertrophic pyloric stenosis (IHPS) in a 4-week-old infant? A) Diarrhea B) No visible peristalsis C) Projectile vomiting D) Lack of stool Answer: C Explanation: A) The classic presentation of IHPS includes gradual onset of worsening nonbilious projectile vomiting beginning at 4-6 weeks of age, dehydration or weight loss, and possibly visible peristalsis in the upper abdomen. B) The classic presentation of IHPS includes gradual onset of worsening nonbilious projectile vomiting beginning at 4-6 weeks of age, dehydration or weight loss, and possibly visible peristalsis in the upper abdomen. C) The classic presentation of IHPS includes gradual onset of worsening nonbilious projectile vomiting beginning at 4-6 weeks of age, dehydration or weight loss, and possibly visible peristalsis in the upper abdomen. D) The classic presentation of IHPS includes gradual onset of worsening nonbilious projectile vomiting beginning at 4-6 weeks of age, dehydration or weight loss, and possibly visible peristalsis in the upper abdomen. Page Ref: 1056 Cognitive Level: Remembering Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 42.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the stomach and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of the upper and lower GI system.

16) Which of the following laboratory findings should the nurse anticipate in the infant with infantile hypertrophic pyloric stenosis (IHPS)? A) Respiratory alkalosis B) Respiratory acidosis C) Metabolic alkalosis D) Metabolic acidosis Answer: C Explanation: A) Laboratory findings in IHPS include hypochloremia, hypokalemia, and metabolic alkalosis. B) Laboratory findings in IHPS include hypochloremia, hypokalemia, and metabolic alkalosis. C) Laboratory findings in IHPS include hypochloremia, hypokalemia, and metabolic alkalosis. D) Laboratory findings in IHPS include hypochloremia, hypokalemia, and metabolic alkalosis. Page Ref: 1056 Cognitive Level: Remembering Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 42.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the stomach and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of the upper and lower GI system.

17) On initial diagnosis, the patient with stomach cancer will most likely have which findings? A) Dysphagia and nausea B) Weight loss and abdominal pain C) Early satiety and occult bleeding D) A palpable right upper quadrant mass and severe pain Answer: B Explanation: A) Weight loss and abdominal pain are the most common symptoms of stomach cancer at initial diagnosis. Abdominal pain tends to be vague and mild early in the disease and worsens as the disease progresses. Patients may present with dysphagia from tumors of the gastroesophageal junction or proximal stomach or gastric outlet obstruction from tumors of the distal stomach. Other manifestations include nausea, early satiety, and occult GI bleeding. A mass may be palpable in the upper right quadrant of the abdomen. B) Weight loss and abdominal pain are the most common symptoms of stomach cancer at initial diagnosis. Abdominal pain tends to be vague and mild early in the disease and worsens as the disease progresses. Patients may present with dysphagia from tumors of the gastroesophageal junction or proximal stomach or gastric outlet obstruction from tumors of the distal stomach. Other manifestations include nausea, early satiety, and occult GI bleeding. A mass may be palpable in the upper right quadrant of the abdomen. C) Weight loss and abdominal pain are the most common symptoms of stomach cancer at initial diagnosis. Abdominal pain tends to be vague and mild early in the disease and worsens as the disease progresses. Patients may present with dysphagia from tumors of the gastroesophageal junction or proximal stomach or gastric outlet obstruction from tumors of the distal stomach. Other manifestations include nausea, early satiety, and occult GI bleeding. A mass may be palpable in the upper right quadrant of the abdomen. D) Weight loss and abdominal pain are the most common symptoms of stomach cancer at initial diagnosis. Abdominal pain tends to be vague and mild early in the disease and worsens as the disease progresses. Patients may present with dysphagia from tumors of the gastroesophageal junction or proximal stomach or gastric outlet obstruction from tumors of the distal stomach. Other manifestations include nausea, early satiety, and occult GI bleeding. A mass may be palpable in the upper right quadrant of the abdomen. Page Ref: 1057 Cognitive Level: Remembering Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 42.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the stomach and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of the upper and lower GI system.

18) What is the most appropriate action for the nurse to take when a patient with ulcerative colitis develops excessive episodes of bloody diarrhea? A) Send a stool sample to the laboratory to rule out infectious causes. B) Encourage increased fluid intake to prevent dehydration. C) Administer anti-inflammatory drugs to reduce inflammation. D) Call the physician, as this is a life-threatening condition. Answer: D Explanation: A) Although it may be appropriate to send a stool sample to the laboratory, increase fluid intake, and administer anti-inflammatory drugs, the priority is to notify the physician because the patient may have megacolon, a potentially life-threatening condition. B) Although it may be appropriate to send a stool sample to the laboratory, increase fluid intake, and administer anti-inflammatory drugs, the priority is to notify the physician because the patient may have megacolon, a potentially life-threatening condition. C) Although it may be appropriate to send a stool sample to the laboratory, increase fluid intake, and administer anti-inflammatory drugs, the priority is to notify the physician because the patient may have megacolon, a potentially life-threatening condition. D) Patients with UC may develop a rare condition known as toxic megacolon. This condition is a life-threatening emergency characterized by dilation of the colon and excessive episodes of bloody diarrhea that may lead to the need for blood transfusions. If this condition cannot be managed with aggressive medical treatment, emergent bowel surgery may be indicated. Page Ref: 1058 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 42.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the small and large intestines and the rectum and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of upper and lower GI system to diagnosis and treatment.

19) What characteristic of pain would the nurse expect in a patient with acute appendicitis? A) Dull, achy upper abdominal pain B) Intermittent and sharp upper left quadrant pain C) Crampy and steady right lower quadrant pain D) Sharp central abdominal pain Answer: C Explanation: A) Patients with appendicitis may present with crampy and steady central abdominal pain that migrates to the right lower quadrant of the abdomen. The pain is usually vague at first, increasing in intensity as the condition progresses. B) Patients with appendicitis may present with crampy and steady central abdominal pain that migrates to the right lower quadrant of the abdomen. The pain is usually vague at first, increasing in intensity as the condition progresses. C) Patients with appendicitis may present with crampy and steady central abdominal pain that migrates to the right lower quadrant of the abdomen. The pain is usually vague at first, increasing in intensity as the condition progresses. D) Patients with appendicitis may present with crampy and steady central abdominal pain that migrates to the right lower quadrant of the abdomen. The pain is usually vague at first, increasing in intensity as the condition progresses. Page Ref: 1060 Cognitive Level: Remembering Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 42.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the small and large intestines and the rectum and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of the upper and lower GI system.

20) Auscultation of bowel sounds in a patient with a small bowel obstruction will most likely reveal: A) hyperactive, high-pitched bowel sounds. B) absence of bowel sounds. C) intermittent gurgles and clicks. D) hypoactive, infrequent bowel sounds. Answer: A Explanation: A) On auscultation, patients with small bowel obstruction demonstrate hyperactive, high-pitched bowel sounds ("rushes and tinkles"). B) On auscultation, patients with small bowel obstruction demonstrate hyperactive, high-pitched bowel sounds ("rushes and tinkles"). C) On auscultation, patients with small bowel obstruction demonstrate hyperactive, high-pitched bowel sounds ("rushes and tinkles"). D) On auscultation, patients with small bowel obstruction demonstrate hyperactive, high-pitched bowel sounds ("rushes and tinkles"). Page Ref: 1061 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 42.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the small and large intestines and the rectum and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of the upper and lower GI system.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 43 Disorders of the Exocrine Pancreatic and Hepatobiliary Systems 1) The nurse palpates a client's abdomen and notes the liver below the costal margin. What does this finding indicate? A) Hepatomegaly B) Atrophy of the liver C) Normal liver placement D) Portal hypertension Answer: A Explanation: A) Palpation of the liver below the costal margin indicates hepatomegaly, enlargement of the liver. This finding does not indicate atrophy of the liver. Normal liver placement is at the costal margin, not below it. Portal hypertension is the increased pressure within the vessels of the liver. B) Palpation of the liver below the costal margin indicates hepatomegaly, enlargement of the liver. This finding does not indicate atrophy of the liver. Normal liver placement is at the costal margin, not below it. Portal hypertension is the increased pressure within the vessels of the liver. C) Palpation of the liver below the costal margin indicates hepatomegaly, enlargement of the liver. This finding does not indicate atrophy of the liver. Normal liver placement is at the costal margin, not below it. Portal hypertension is the increased pressure within the vessels of the liver. D) Palpation of the liver below the costal margin indicates hepatomegaly, enlargement of the liver. This finding does not indicate atrophy of the liver. Normal liver placement is at the costal margin, not below it. Portal hypertension is the increased pressure within the vessels of the liver. Page Ref: 1072 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 43.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the liver and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the exocrine pancreatic and hepatobiliary systems to diagnosis and treatment.

2) When palpating an infant's liver, what does the nurse understand is true? A) The infant's liver is located deeper than an adult. B) Palpation of the infant's liver is easier than palpation of an adult. C) The infant's liver is small in comparison to other abdominal organs. D) Palpation of the infant's liver is not recommended. Answer: B Explanation: A) The infant's liver is a relatively large organ in the abdomen, occupying a larger portion of the abdomen than it does in adults. As a result, the liver extends farther below the rib cage than it does in adults. Because the abdominal muscles of infants are weak, the abdomen normally tends to protrude. The weak abdominal muscles make palpation of the liver easier. Palpation of an infant's liver is acceptable, using correct technique. B) The infant's liver is a relatively large organ in the abdomen, occupying a larger portion of the abdomen than it does in adults. As a result, the liver extends farther below the rib cage than it does in adults. Because the abdominal muscles of infants are weak, the abdomen normally tends to protrude. The weak abdominal muscles make palpation of the liver easier. Palpation of an infant's liver is acceptable, using correct technique. C) The infant's liver is a relatively large organ in the abdomen, occupying a larger portion of the abdomen than it does in adults. As a result, the liver extends farther below the rib cage than it does in adults. Because the abdominal muscles of infants are weak, the abdomen normally tends to protrude. The weak abdominal muscles make palpation of the liver easier. Palpation of an infant's liver is acceptable, using correct technique. D) The infant's liver is a relatively large organ in the abdomen, occupying a larger portion of the abdomen than it does in adults. As a result, the liver extends farther below the rib cage than it does in adults. Because the abdominal muscles of infants are weak, the abdomen normally tends to protrude. The weak abdominal muscles make palpation of the liver easier. Palpation of an infant's liver is acceptable, using correct technique. Page Ref: 1072 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 43.1 Describe the normal function, epidemiology of alterations, and concepts related to the exocrine pancreatic and hepatobiliary systems. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the exocrine pancreatic and hepatobiliary systems to diagnosis and treatment.

3) The nurse cares for a client with impaired liver function. Impaired metabolism of which substances may occur based on the client's condition? Select all that apply. A) Carbohydrates B) Vitamins C) Minerals D) Proteins E) Fats Answer: A, D, E Explanation: A) Metabolism of carbohydrate, protein, and fat occurs in the liver. B) Vitamin B12 and the minerals iron and copper are stored in the liver; however, these are not metabolized there. C) Vitamin B12 and the minerals iron and copper are stored in the liver; however, these are not metabolized there. D) Metabolism of carbohydrate, protein, and fat occurs in the liver. E) Metabolism of carbohydrate, protein, and fat occurs in the liver. Page Ref: 1073 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 43.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the liver and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the exocrine pancreatic and hepatobiliary systems to diagnosis and treatment.

4) A client with end-stage liver failure is admitted with severe cirrhosis. What is the nurse's understanding of the pathophysiology of cirrhosis? A) Increased oncotic pressure B) Impaired removal of bilirubin C) Impaired conversion of ammonia to urea D) Increased vascular permeability Answer: D Explanation: A) Albumin, which is produced in the liver, is essential for maintenance of the oncotic pressure, thus helping to maintain the vascular system. With liver damage, albumin production stops, resulting in the body fluid leaking out of the vessels into the interstitial spaces and peritoneal cavity, causing edema and ascites (an abnormal collection of fluid in the peritoneal cavity). B) Elevated bilirubin levels leads to jaundice, not cirrhosis. C) Impaired conversion of ammonia to urea may occur in liver damage; however, this is not the pathophysiology of cirrhosis. D) Albumin, which is produced in the liver, is essential for maintenance of the oncotic pressure, thus helping to maintain the vascular system. With liver damage, albumin production stops, resulting in the body fluid leaking out of the vessels into the interstitial spaces and peritoneal cavity, causing edema and ascites (an abnormal collection of fluid in the peritoneal cavity). Page Ref: 1073 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 43.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the liver and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the exocrine pancreatic and hepatobiliary systems to diagnosis and treatment.

5) A client with liver failure is diagnosed with malnutrition. Which vitamin deficiencies does the nurse understand the client is at greatest risk for developing? Select all that apply. A) C B) K C) A D) D E) E Answer: B, C, D, E Explanation: A) Vitamins K, A, D, and E (as well as vitamin B-12) are stored in the liver and may become deficient if the client has impairment of the liver. B) Vitamins K, A, D, and E (as well as vitamin B-12) are stored in the liver and may become deficient if the client has impairment of the liver. C) Vitamins K, A, D, and E (as well as vitamin B-12) are stored in the liver and may become deficient if the client has impairment of the liver. D) Vitamins K, A, D, and E (as well as vitamin B-12) are stored in the liver and may become deficient if the client has impairment of the liver. E) Vitamins K, A, D, and E (as well as vitamin B-12) are stored in the liver and may become deficient if the client has impairment of the liver. Page Ref: 1073 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 43.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the liver and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the exocrine pancreatic and hepatobiliary systems to diagnosis and treatment.

6) A client with liver disease displays alterations in coagulation. Which coagulation factors does the nurse understand may be impaired due to the client's liver dysfunction of clotting factor synthesis? Select all that apply. A) I B) II C) VIII D) VII E) X Answer: A, B, D, E Explanation: A) The liver is responsible for the synthesis of clotting factors I (prothrombin), II (fibrinogen), VII, IX, and X from amino acids. Factor VIII is not synthesized in the liver and is not directly impacted by the impairment of liver clotting factor synthesis. B) The liver is responsible for the synthesis of clotting factors I (prothrombin), II (fibrinogen), VII, IX, and X from amino acids. Factor VIII is not synthesized in the liver and is not directly impacted by the impairment of liver clotting factor synthesis. C) The liver is responsible for the synthesis of clotting factors I (prothrombin), II (fibrinogen), VII, IX, and X from amino acids. Factor VIII is not synthesized in the liver and is not directly impacted by the impairment of liver clotting factor synthesis. D) The liver is responsible for the synthesis of clotting factors I (prothrombin), II (fibrinogen), VII, IX, and X from amino acids. Factor VIII is not synthesized in the liver and is not directly impacted by the impairment of liver clotting factor synthesis. E) The liver is responsible for the synthesis of clotting factors I (prothrombin), II (fibrinogen), VII, IX, and X from amino acids. Factor VIII is not synthesized in the liver and is not directly impacted by the impairment of liver clotting factor synthesis. Page Ref: 1073 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 43.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the liver and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the exocrine pancreatic and hepatobiliary systems to diagnosis and treatment.

7) The nurse cares for a client with chronic alcohol abuse. Which laboratory finding does the nurse recognize as evidence of liver damage? A) Albumin 3.5 g/dL B) ALT 50 unit/L C) ALP 45 unit/L D) AST/SGOT 30 unit/dL Answer: B Explanation: A) Albumin is a component of proteins that makes up more than half of plasma proteins. The normal reference range for adults is 3.5-5 g/dL. B) Alanine aminotransferase (ALT) is an enzyme found primarily in liver cells. An increase in serum ALT levels indicates damage to the liver. The normal reference range for serum ALT for adults is 10-35 unit/L. C) Alkaline phosphatase (ALP) is an enzyme produced in the liver and bone. Increased levels of ALP indicate biliary obstruction or tissue damage and the normal reference range for adults is 42-136 unit/L. D) Aspartate aminotransferase (AST/SGOT) is an enzyme found mainly in the heart muscle and liver. The normal reference range for adults is 8-35 unit/dL. Page Ref: 1074 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 43.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the liver and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the exocrine pancreatic and hepatobiliary systems to diagnosis and treatment.

8) A client with cholelithiasis asks the nurse, "What caused this?" Which factors might the nurse include in the response? Select all that apply. A) Diet B) Culture C) Gender D) Body weight E) Age Answer: A, D Explanation: A) Cholelithiasis, stone formation, is the most common disorder of the gallbladder. Changes in diet, including type of food and fluid consumed and amount of fat and cholesterol, as well as obesity have a direct impact on stone formation in the gallbladder and biliary tract. B) Gallstones may occur in both genders and all cultures. C) Gallstones may occur in both genders and all cultures. D) Cholelithiasis, stone formation, is the most common disorder of the gallbladder. Changes in diet, including type of food and fluid consumed and amount of fat and cholesterol, as well as obesity have a direct impact on stone formation in the gallbladder and biliary tract. E) Young, middle, and older adults are all affected by this condition. Page Ref: 1083 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 43.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the gallbladder and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the exocrine pancreatic and hepatobiliary systems to diagnosis and treatment.

9) A nurse working in oncology notes an overall increase in clients with pancreatic cancer. What does the nurse associate with the overall increase in pancreatic cancer? Select all that apply. A) Multicultural population B) Diabetes mellitus C) Obesity D) Aging population E) Hypercholesterolemia Answer: B, C, D Explanation: A) A multicultural population and hypercholesterolemia are not associated with the overall increase in pancreatic cancer. B) The overall increase in pancreatic cancer rates may be associated with increased rates of diabetes mellitus, obesity, and the aging population. C) The overall increase in pancreatic cancer rates may be associated with increased rates of diabetes mellitus, obesity, and the aging population. D) The overall increase in pancreatic cancer rates may be associated with increased rates of diabetes mellitus, obesity, and the aging population. E) A multicultural population and hypercholesterolemia are not associated with the overall increase in pancreatic cancer. Page Ref: 1091 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 43.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the pancreas and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: VII.1 Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities and populations NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the exocrine pancreatic and hepatobiliary systems to diagnosis and treatment.

10) The nurse cares for a client with liver failure and monitors the client for hepatic encephalopathy. Which findings does the nurse recognize as the earliest signs of hepatic encephalopathy? Select all that apply. A) Restlessness B) Confusion C) Disorientation D) Agitation E) Impaired judgment Answer: A, D, E Explanation: A) Clients with hepatic encephalopathy or portal systemic encephalopathy will show neurologic changes that result from the buildup of toxins and fluid, affecting cognition. The earliest signs of encephalopathy are restlessness, agitation, and impaired judgment. B) Confusion and disorientation are late signs of encephalopathy. C) Confusion and disorientation are late signs of encephalopathy. D) Clients with hepatic encephalopathy or portal systemic encephalopathy will show neurologic changes that result from the buildup of toxins and fluid, affecting cognition. The earliest signs of encephalopathy are restlessness, agitation, and impaired judgment. E) Clients with hepatic encephalopathy or portal systemic encephalopathy will show neurologic changes that result from the buildup of toxins and fluid, affecting cognition. The earliest signs of encephalopathy are restlessness, agitation, and impaired judgment. Page Ref: 1082 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 43.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the liver and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the exocrine pancreatic and hepatobiliary systems to diagnosis and treatment.

11) The nurse cares for a client with portal hypertension who is diagnosed with asterixis. Which assessment finding corresponds with the client's diagnosis of asterixis? A) Muscle tremor and downward flap of the hand B) Flaccid muscles and upward flexion of the hand C) Discoloration of the abdominal skin D) Increased abdominal circumference Answer: A Explanation: A) Asterixis is a muscle tremor that causes the downward flap of the hand when the arm is extended and dorsiflexed at the wrist. B) Asterixis is a muscle tremor that causes the downward flap of the hand when the arm is extended and dorsiflexed at the wrist. Therefore, flaccid muscles and upward flexion of the hand is not correct. C) Discoloration of the abdominal skin and increased abdominal circumference do not describe asterixis. D) Discoloration of the abdominal skin and increased abdominal circumference do not describe asterixis. Page Ref: 1082 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 43.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the liver and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the exocrine pancreatic and hepatobiliary systems to diagnosis and treatment.

12) A client with portal hypertension has bluish veins just under the skin of the abdomen that radiate out across the umbilicus. Which pathophysiological factors does the nurse recognize causes this condition? Select all that apply. A) Elevated bilirubin levels B) Impaired clearance of ammonia C) Increased fluid in the abdomen D) Impaired metabolism of estrogens E) Increased abdominal pressure Answer: C, E Explanation: A) Elevated bilirubin, impaired clearance of ammonia, and impaired metabolism of estrogens may occur with liver impairment; however, these are not pathophysiological factors caused by portal hypertension. B) Elevated bilirubin, impaired clearance of ammonia, and impaired metabolism of estrogens may occur with liver impairment; however, these are not pathophysiological factors caused by portal hypertension. C) Caput medusa is an abnormal assessment finding in the client with portal hypertension. The abdomen has bluish veins just under the skin that radiate out across the umbilicus as a result ofascites and increased abdominal pressure. D) Elevated bilirubin, impaired clearance of ammonia, and impaired metabolism of estrogens may occur with liver impairment; however, these are not pathophysiological factors caused by portal hypertension. E) Caput medusa is an abnormal assessment finding in the client with portal hypertension. The abdomen has bluish veins just under the skin that radiate out across the umbilicus as a result of ascites and increased abdominal pressure. Page Ref: 1082 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 43.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the liver and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the exocrine pancreatic and hepatobiliary systems to diagnosis and treatment.

13) A nurse cares for a client diagnosed with a serous cystadenoma of the pancreas. What statement will the nurse include when teaching the client about the condition? A) "This type of cyst usually causes pain and nausea." B) "This type of cyst is usually surgically removed." C) "This type of cyst is rarely cancerous." D) "This type of cyst may be cancerous." Answer: C Explanation: A) Pancreatic cysts are small, fluid-filled sacs. Most cysts are asymptomatic. B) Solid cysts are usually surgically removed, not serous cystadenomas. C) Pancreatic cysts are small, fluid-filled sacs. Pseudocysts, or false cysts, and serous cystadenomas are more commonly found and are most often noncancerous. D) Pseudocysts, or false cysts, and serous cystadenomas are more commonly found and are most often noncancerous. Page Ref: 1090 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 43.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the pancreas and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the exocrine pancreatic and hepatobiliary systems to diagnosis and treatment.

14) The nurse reviews the health care provider prescriptions for a client diagnosed with acute pancreatitis. Which prescription will the nurse question? A) Oxygen as needed B) Opioid analgesic as needed C) Intravenous colloid infusion D) Clear liquid diet as tolerated Answer: D Explanation: A) The client with acute pancreatitis may require supplemental oxygen to maintain oxygenation. B) The client with acute pancreatitis will most likely require medication for pain relief as this condition can be very painful for the client. C) Intravenous colloid solutions may be infused for treatment and prevention of dehydration, which may occur as a complication to this condition. D) Complete bowel rest and NPO status is required during the acute phase of this condition and a prescription for a clear liquid diet should be questioned by the nurse. Page Ref: 1089 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 43.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the pancreas and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.A.1: Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the exocrine pancreatic and hepatobiliary systems to diagnosis and treatment.

15) A public health nurse is examining the incidence rates of gallbladder cancer in the United States. Which population does the nurse learn is at greatest risk for developing this type of cancer? A) Infants B) Children C) Adults D) Older adults Answer: D Explanation: A) Older adults are at greatest risk for developing gallbladder cancer. Infants, children, and adults are not at greatest risk for developing gallbladder cancer. B) Older adults are at greatest risk for developing gallbladder cancer. Infants, children, and adults are not at greatest risk for developing gallbladder cancer. C) Older adults are at greatest risk for developing gallbladder cancer. Infants, children, and adults are not at greatest risk for developing gallbladder cancer. D) Older adults are at greatest risk for developing gallbladder cancer. Infants, children, and adults are not at greatest risk for developing gallbladder cancer. Page Ref: 1087 Cognitive Level: Remembering Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 43.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the gallbladder and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the exocrine pancreatic and hepatobiliary systems to diagnosis and treatment.

16) The nurse cares for a client with liver failure and impaired bilirubin clearance. What does the nurse know is true regarding bilirubin? A) It is the waste product of red blood cell destruction. B) It is the by-product of protein metabolism. C) It is produced in the small bile ducts. D) It is produced in the hepatic duct. Answer: A Explanation: A) Bilirubin is the waste product of red blood cell destruction. B) Ammonia is the by-product of protein metabolism. C) Bile is produced in the small bile ducts. D) Bilirubin is not produced in the hepatic duct. Page Ref: 1073 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 43.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the liver and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the exocrine pancreatic and hepatobiliary systems to diagnosis and treatment.

17) A nurse cares for a client with alcoholic hepatitis. Which early manifestations of liver impairment does the nurse recognize on assessment? Select all that apply. A) Indigestion B) Jaundice C) Diffuse abdominal pain D) Ascites E) Bleeding impairment Answer: A, C Explanation: A) Early manifestations of liver impairment may be vague and include indigestion and diffuse abdominal pain. B) Jaundice, ascites, and bleeding impairments are all late manifestations of liver impairment. C) Early manifestations of liver impairment may be vague and include indigestion and diffuse abdominal pain. D) Jaundice, ascites, and bleeding impairments are all late manifestations of liver impairment. E) Jaundice, ascites, and bleeding impairments are all late manifestations of liver impairment. Page Ref: 1076 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 43.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the liver and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.A.1: Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the exocrine pancreatic and hepatobiliary systems to diagnosis and treatment.

18) The nurse researcher is examining the factors that lead to liver cancer. What does the nurse recognize begins the process of cellular transformation in liver cancer? A) Autoimmunity B) Allergic reaction C) Infection D) Inflammation Answer: D Explanation: A) An allergic reaction, infection, and autoimmunity do not begin the process of cellular transformation in liver cancer. B) An allergic reaction, infection, and autoimmunity do not begin the process of cellular transformation in liver cancer. C) An allergic reaction, infection, and autoimmunity do not begin the process of cellular transformation in liver cancer. D) Inflammation, as a result of an immune response due to irritation of the hepatic tissue, begins the process of cellular transformation in liver cancer. Page Ref: 1077 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 43.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the liver and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the exocrine pancreatic and hepatobiliary systems to diagnosis and treatment.

19) A client with liver failure is diagnosed with cirrhosis. What is the nurse's understanding of the primary dysfunction related to this condition? A) Fatty deposits lead to thrombi and obstructed blood flow. B) Fatty deposits lead to impaired metabolism and malnutrition. C) Fibrosis leads to constriction and increased vessel pressures. D) Fibrosis leads to impaired absorption of electrolytes and acid-base dysfunction. Answer: C Explanation: A) Cirrhosis is more serious than fatty liver. Fatty liver causes fatty deposits in the liver leading to impaired metabolism of liver function. However, in cirrhosis, fatty deposits are replaced with scar tissue, which leads to constriction and hardening of the hepatic vessels and increased vessel pressures (portal hypertension). Fatty deposits in the liver do not lead to thrombi. Although fibrosis impairs hepatic metabolism, it does not directly impair absorption of electrolytes. B) Cirrhosis is more serious than fatty liver. Fatty liver causes fatty deposits in the liver leading to impaired metabolism of liver function. However, in cirrhosis, fatty deposits are replaced with scar tissue, which leads to constriction and hardening of the hepatic vessels and increased vessel pressures (portal hypertension). Fatty deposits in the liver do not lead to thrombi. Although fibrosis impairs hepatic metabolism, it does not directly impair absorption of electrolytes. C) Cirrhosis is more serious than fatty liver. Fatty liver causes fatty deposits in the liver leading to impaired metabolism of liver function. However, in cirrhosis, fatty deposits are replaced with scar tissue, which leads to constriction and hardening of the hepatic vessels and increased vessel pressures (portal hypertension). Fatty deposits in the liver do not lead to thrombi. Although fibrosis impairs hepatic metabolism, it does not directly impair absorption of electrolytes. D) Cirrhosis is more serious than fatty liver. Fatty liver causes fatty deposits in the liver leading to impaired metabolism of liver function. However, in cirrhosis, fatty deposits are replaced with scar tissue, which leads to constriction and hardening of the hepatic vessels and increased vessel pressures (portal hypertension). Fatty deposits in the liver do not lead to thrombi. Although fibrosis impairs hepatic metabolism, it does not directly impair absorption of electrolytes. Page Ref: 1079 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 43.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the liver and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the exocrine pancreatic and hepatobiliary systems to diagnosis and treatment.

20) The nurse is caring for a client with liver cancer whose diagnosis was delayed after months of non-specific complaints. What leads to delayed diagnosis of liver damage? Select all that apply. A) The deeper location of the liver in the abdomen. B) The superficial location of the liver in the abdomen. C) The regenerative properties of the liver. D) The vascular nature of the liver. E) The size of the liver. Answer: A, C, D Explanation: A) The vascular and regenerative abilities of the liver, as well as its deep location in the abdominal cavity, tend to delay diagnosis of liver damage. B) The vascular and regenerative abilities of the liver, as well as its deep location in the abdominal cavity, tend to delay diagnosis of liver damage. C) The vascular and regenerative abilities of the liver, as well as its deep location in the abdominal cavity, tend to delay diagnosis of liver damage. D) The vascular and regenerative abilities of the liver, as well as its deep location in the abdominal cavity, tend to delay diagnosis of liver damage. E) The vascular and regenerative abilities of the liver, as well as its deep location in the abdominal cavity, tend to delay diagnosis of liver damage. The size of the liver is not a factor. Page Ref: 1079 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 43.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the liver and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the exocrine pancreatic and hepatobiliary systems to diagnosis and treatment.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 44 Liver Failure 1) When planning care for a patient with liver disease, the nurse keeps in mind that the leading cause of chronic liver disease is: A) alcoholism. B) hepatitis C. C) environmental toxins. D) hepatotoxic drugs. Answer: A Explanation: A) Excessive consumption of alcohol is the major cause of chronic liver disease around the world. Alcohol-related liver failure is considered the third most preventable cause of death in the United States alone. Exposure to a particular virus (hepatitis C) is another leading cause of liver disease across the globe. B) Excessive consumption of alcohol is the major cause of chronic liver disease around the world. Alcohol-related liver failure is considered the third most preventable cause of death in the United States alone. Exposure to a particular virus (hepatitis C) is another leading cause of liver disease across the globe. C) Excessive consumption of alcohol is the major cause of chronic liver disease around the world. Alcohol-related liver failure is considered the third most preventable cause of death in the United States alone. Exposure to a particular virus (hepatitis C) is another leading cause of liver disease across the globe. D) Excessive consumption of alcohol is the major cause of chronic liver disease around the world. Alcohol-related liver failure is considered the third most preventable cause of death in the United States alone. Exposure to a particular virus (hepatitis C) is another leading cause of liver disease across the globe. Page Ref: 1097 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 44.1 Define liver failure, including populations most at risk and key pathologic concepts related to failure. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of liver failure.

2) When assessing the liver of a patient, in which quadrant should the nurse percuss? A) Upper left quadrant B) Upper right quadrant C) Lower right quadrant D) Lower left quadrant Answer: B Explanation: A) The liver is the largest solid organ in the body and is located in the right upper quadrant of the abdomen. B) The liver is the largest solid organ in the body and is located in the right upper quadrant of the abdomen. C) The liver is the largest solid organ in the body and is located in the right upper quadrant of the abdomen. D) The liver is the largest solid organ in the body and is located in the right upper quadrant of the abdomen. Page Ref: 1098 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 44.2 Outline the normal function of the liver. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of liver failure.

3) When planning care for a patient with esophageal varices, which action would be a priority for the nurse? A) Discussing the importance of Alcoholics Anonymous meetings B) Assessing for signs and symptoms of hemorrhage C) Teaching the patient signs of bleeding to report D) Encouraging rest periods to reduce fatigue Answer: B Explanation: A) Although all these actions are appropriate for a patient with esophageal varices, acute bleeding from ruptured esophageal varices is a clinical emergency and requires immediate intervention as significant blood loss leading to shock may occur. Once the bleeding is under control, the nurse should encourage the alcoholic patient stop drinking, teach the patient signs and symptoms of bleeding that require immediate medical attention, and encourage rest periods to reduce fatigue. B) Although all these actions are appropriate for a patient with esophageal varices, acute bleeding from ruptured esophageal varices is a clinical emergency and requires immediate intervention as significant blood loss leading to shock may occur. Once the bleeding is under control, the nurse should encourage the alcoholic patient stop drinking, teach the patient signs and symptoms of bleeding that require immediate medical attention, and encourage rest periods to reduce fatigue. C) Although all these actions are appropriate for a patient with esophageal varices, acute bleeding from ruptured esophageal varices is a clinical emergency and requires immediate intervention as significant blood loss leading to shock may occur. Once the bleeding is under control, the nurse should encourage the alcoholic patient stop drinking, teach the patient signs and symptoms of bleeding that require immediate medical attention, and encourage rest periods to reduce fatigue. D) Although all these actions are appropriate for a patient with esophageal varices, acute bleeding from ruptured esophageal varices is a clinical emergency and requires immediate intervention as significant blood loss leading to shock may occur. Once the bleeding is under control, the nurse should encourage the alcoholic patient stop drinking, teach the patient signs and symptoms of bleeding that require immediate medical attention, and encourage rest periods to reduce fatigue. Page Ref: 1100 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 44.3 Differentiate underlying pathogenesis of liver failure and common complications in the context of approaches to treatment and diagnosis across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of liver failure to diagnosis and treatment.

4) To prevent complications in the patient with ascites, who is receiving daily furosemide and spironolactone, the nurse should implement which intervention? A) Restrict sodium. B) Restrict fluids. C) Monitor weights. D) Monitor electrolyte and creatinine levels. Answer: D Explanation: A) Sodium may be restricted, but this will not prevent complications of diuretic therapy. B) Fluids may be restricted, but this will not prevent complications of diuretic therapy. C) Weights should be monitored during diuretic treatment, but this will not prevent complications of diuretic therapy. D) A common treatment approach to ascites involves the use of diuretics. The most common oral diuretic regimen is single morning doses of both spironolactone and furosemide. The use of both diuretics helps to minimize the hyperkalemia associated with spironolactone. Electrolytes (sodium and potassium) and creatinine levels should be monitored during diuretic treatment. Page Ref: 1100 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Implementation | Learning Outcome: 44.3 Differentiate underlying pathogenesis of liver failure and common complications in the context of approaches to treatment and diagnosis across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of liver failure to diagnosis and treatment.

5) Which intravenous solution should the nurse prepare to infuse in the patient with ascites who has had 5.5 liters of fluid removed during paracentesis? A) 25% albumin B) 10% dextrose C) 0.45% normal saline D) Lactated Ringer's Answer: A Explanation: A) Patients from whom more than 5 liters of ascites fluid is drained should receive intravenous 25% albumin at an amount equivalent to 8 g/L fluid removed. B) Patients from whom more than 5 liters of ascites fluid is drained should receive intravenous 25% albumin at an amount equivalent to 8 g/L fluid removed. C) Patients from whom more than 5 liters of ascites fluid is drained should receive intravenous 25% albumin at an amount equivalent to 8 g/L fluid removed. D) Patients from whom more than 5 liters of ascites fluid is drained should receive intravenous 25% albumin at an amount equivalent to 8 g/L fluid removed. Page Ref: 1100 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Implementation | Learning Outcome: 44.3 Differentiate underlying pathogenesis of liver failure and common complications in the context of approaches to treatment and diagnosis across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of liver failure to diagnosis and treatment.

6) The nurse would expect to assess which finding in the patient with type I hepatorenal syndrome? A) Previous diagnosis of renal disease B) Recent ingestion of a nephrotoxic drug C) Ascites D) Serum creatinine level of 1.5 mg/dL Answer: C Explanation: A) In the clinical presentation of hepatorenal syndrome, serum creatinine is elevated without other evidence of underlying renal disease, shock, or nephrotoxic drugs. B) In the clinical presentation of hepatorenal syndrome, serum creatinine is elevated without other evidence of underlying renal disease, shock, or nephrotoxic drugs. C) Hepatorenal syndrome, which is defined as functional renal failure, develops as a result of portal hypertension and the associated systemic circulatory changes. It develops almost exclusively in patients with ascites. D) Type 1 hepatorenal syndrome develops as a result of the significant reduction of circulating volume associated with excessive splanchnic arterial vasodilation and decreased cardiac output. It is a rapidly progressing condition in which the serum creatinine level increases over 2.5 mg/dL within 2 weeks. Page Ref: 1101 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 44.3 Differentiate underlying pathogenesis of liver failure and common complications in the context of approaches to treatment and diagnosis across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of liver failure.

7) Which finding should the nurse expect when assessing a patient with severe portopulmonary syndrome? A) An S4 heart sound (fourth heart sound) B) A murmur of mitral regurgitation C) An accentuated S2 (second heart sound) D) A murmur of pulmonic stenosis Answer: C Explanation: A) Patients with portopulmonary syndrome may exhibit a hyperdynamic precordium, an accentuated second heart sound, or a systolic murmur caused by tricuspid regurgitation. Jugular vein distention, peripheral edema, ascites, and an S3 may be found in patients with severe portopulmonary syndrome. B) Patients with portopulmonary syndrome may exhibit a hyperdynamic precordium, an accentuated second heart sound, or a systolic murmur caused by tricuspid regurgitation. Jugular vein distention, peripheral edema, ascites, and an S3 may be found in patients with severe portopulmonary syndrome. C) Patients with portopulmonary syndrome may exhibit a hyperdynamic precordium, an accentuated second heart sound, or a systolic murmur caused by tricuspid regurgitation. Jugular vein distention, peripheral edema, ascites, and an S3 may be found in patients with severe portopulmonary syndrome. D) Patients with portopulmonary syndrome may exhibit a hyperdynamic precordium, an accentuated second heart sound, or a systolic murmur caused by tricuspid regurgitation. Jugular vein distention, peripheral edema, ascites, and an S3 may be found in patients with severe portopulmonary syndrome. Page Ref: 1102 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 44.3 Differentiate underlying pathogenesis of liver failure and common complications in the context of approaches to treatment and diagnosis across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of liver failure.

8) The nurse would expect a patient with a diagnosis of portopulmonary syndrome to exhibit: A) mean pulmonary artery pressure greater than or equal to 25 mmHg. B) pulmonary vascular resistance less than 240 dyne/s/cm-5. C) pulmonary capillary wedge pressure 25 mmHg or more. D) transpulmonary gradient less than 12 mmHg. Answer: A Explanation: A) Diagnostic criteria for portopulmonary syndrome include the following: portal hypertension, mean pulmonary artery pressure greater than or equal to 25 mmHg, pulmonary vascular resistance greater than 240 dyne/s/cm-5, pulmonary capillary wedge pressure 15 mmHg or less, and transpulmonary gradient greater than 12 mmHg. B) Diagnostic criteria for portopulmonary syndrome include the following: portal hypertension, mean pulmonary artery pressure greater than or equal to 25 mmHg, pulmonary vascular resistance greater than 240 dyne/s/cm-5, pulmonary capillary wedge pressure 15 mmHg or less, and transpulmonary gradient greater than 12 mmHg. C) Diagnostic criteria for portopulmonary syndrome include the following: portal hypertension, mean pulmonary artery pressure greater than or equal to 25 mmHg, pulmonary vascular resistance greater than 240 dyne/s/cm-5, pulmonary capillary wedge pressure 15 mmHg or less, and transpulmonary gradient greater than 12 mmHg. D) Diagnostic criteria for portopulmonary syndrome include the following: portal hypertension, mean pulmonary artery pressure greater than or equal to 25 mmHg, pulmonary vascular resistance greater than 240 dyne/s/cm-5, pulmonary capillary wedge pressure 15 mmHg or less, and transpulmonary gradient greater than 12 mmHg. Page Ref: 1102 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 44.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders causing liver failure and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of liver failure to diagnosis and treatment.

9) The nurse suspects an elevated bilirubin level in a patient who exhibits which findings? A) Pale itchy skin B) Icterus with green-colored stools C) Yellow skin and pruritus D) Xanthomas and pale urine Answer: C Explanation: A) Yellowing of the skin and icterus are the most common signs of jaundice. As bilirubin levels increase, urine may become darker in color (tea colored), and stools become lighter in color (clay colored). Pruritus is a common symptom associated with hyperbilirubinemia as a result of deposition of bile acids in peripheral tissues, including the skin. Xanthomas, which are lipid deposits in the skin typically seen around the eyes, may also be seen in some cholestatic disorders. B) Yellowing of the skin and icterus are the most common signs of jaundice. As bilirubin levels increase, urine may become darker in color (tea colored), and stools become lighter in color (clay colored). Pruritus is a common symptom associated with hyperbilirubinemia as a result of deposition of bile acids in peripheral tissues, including the skin. Xanthomas, which are lipid deposits in the skin typically seen around the eyes, may also be seen in some cholestatic disorders. C) Yellowing of the skin and icterus are the most common signs of jaundice. As bilirubin levels increase, urine may become darker in color (tea colored), and stools become lighter in color (clay colored). Pruritus is a common symptom associated with hyperbilirubinemia as a result of deposition of bile acids in peripheral tissues, including the skin. Xanthomas, which are lipid deposits in the skin typically seen around the eyes, may also be seen in some cholestatic disorders. D) Yellowing of the skin and icterus are the most common signs of jaundice. As bilirubin levels increase, urine may become darker in color (tea colored), and stools become lighter in color (clay colored). Pruritus is a common symptom associated with hyperbilirubinemia as a result of deposition of bile acids in peripheral tissues, including the skin. Xanthomas, which are lipid deposits in the skin typically seen around the eyes, may also be seen in some cholestatic disorders. Page Ref: 1103 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 44.3 Differentiate underlying pathogenesis of liver failure and common complications in the context of approaches to treatment and diagnosis across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of liver failure.

10) The nurse is assessing a patient suspected of having hepatitis A. To elicit information about the likely mode of transmission, which question would be most appropriate for the nurse to ask? A) "Have you had a blood transfusion?" B) "Do you share needles?" C) "Are you sexually active?" D) "Have you recently eaten shellfish?" Answer: D Explanation: A) Hepatitis A is more common in the setting of substandard hygiene and sanitation. Outbreaks commonly occur in institutional settings, such as schools, or where overcrowding is prevalent. Hepatitis A may also be spread by eating contaminated shellfish such as oysters, mussels, or clams that are raw or undercooked or via infected workers in the food industry. B) Hepatitis A is more common in the setting of substandard hygiene and sanitation. Outbreaks commonly occur in institutional settings, such as schools, or where overcrowding is prevalent. Hepatitis A may also be spread by eating contaminated shellfish such as oysters, mussels, or clams that are raw or undercooked or via infected workers in the food industry. C) Hepatitis A is more common in the setting of substandard hygiene and sanitation. Outbreaks commonly occur in institutional settings, such as schools, or where overcrowding is prevalent. Hepatitis A may also be spread by eating contaminated shellfish such as oysters, mussels, or clams that are raw or undercooked or via infected workers in the food industry. D) Hepatitis A is more common in the setting of substandard hygiene and sanitation. Outbreaks commonly occur in institutional settings, such as schools, or where overcrowding is prevalent. Hepatitis A may also be spread by eating contaminated shellfish such as oysters, mussels, or clams that are raw or undercooked or via infected workers in the food industry. Page Ref: 1104 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 44.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders causing liver failure and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: 44.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders causing liver failure and approaches to diagnosis and treatment of these conditions across the lifespan. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of liver failure.

11) Which statement by a patient indicates to the nurse that more teaching is needed about the phases of HBV infection? A) "Chronic infection is the immune tolerant phase." B) "In the immune active phase I will be HBsAg positive." C) "I will be HBcAb positive in all phases." D) "I will develop HBeAb in the inactive phase." Answer: A Explanation: A) HBV infection is classified into three phases: immune tolerant, immune active, and inactive. The immune tolerant phase occurs as a result of vertical transmission from a mother who is HBsAg and HBeAg positive to her infant in the perinatal period. In the immune active phase, also referred to as chronic HBV, the patient is HBsAg positive and may be either HBeAg positive or HbeAg negative. HBeAg positive patients typically have elevated ALT levels and HBV DNA levels greater than 20,000 Iu/mL. HBeAg-negative patients usually have lower ALT and HBV DNA levels. The inactive phase is characterized by loss of HBeAg and development of HBeAb with normal ALT levels and HBV DNA less than 2000 IU/mL. HBcAb remains positive in all phases. B) HBV infection is classified into three phases: immune tolerant, immune active, and inactive. The immune tolerant phase occurs as a result of vertical transmission from a mother who is HBsAg and HBeAg positive to her infant in the perinatal period. In the immune active phase, also referred to as chronic HBV, the patient is HBsAg positive and may be either HBeAg positive or HbeAg negative. HBe Ag positive patients typically have elevated ALT levels and HBV DNA levels greater than 20,000 Iu/mL. HBeAg-negative patients usually have lower ALT and HBV DNA levels. The inactive phase is characterized by loss of HBeAg and development of HBeAb with normal ALT levels and HBV DNA less than 2000 IU/mL. HBcAb remains positive in all phases. C) HBV infection is classified into three phases: immune tolerant, immune active, and inactive. The immune tolerant phase occurs as a result of vertical transmission from a mother who is HBsAg and HBeAg positive to her infant in the perinatal period. In the immune active phase, also referred to as chronic HBV, the patient is HBsAg positive and may be either HBeAg positive or HbeAg negative. HBe Ag positive patients typically have elevated ALT levels and HBV DNA levels greater than 20,000 Iu/mL. HBeAg-negative patients usually have lower ALT and HBV DNA levels. The inactive phase is characterized by loss of HBeAg and development of HBeAb with normal ALT levels and HBV DNA less than 2000 IU/mL. HBcAb remains positive in all phases. D) HBV infection is classified into three phases: immune tolerant, immune active, and inactive. The immune tolerant phase occurs as a result of vertical transmission from a mother who is HBsAg and HBeAg positive to her infant in the perinatal period. In the immune active phase, also referred to as chronic HBV, the patient is HBsAg positive and may be either HBeAg positive or HbeAg negative. HBeAg positive patients typically have elevated ALT levels and HBV DNA levels greater than 20,000 Iu/mL. HBeAg-negative patients usually have lower ALT and HBV DNA levels. The inactive phase is characterized by loss of HBeAg and development of HBeAb with normal ALT levels and HBV DNA less than 2000 IU/mL. HBcAb remains positive in all phases. Page Ref: 1104 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation 11

Standards: Nursing Process: Evaluation | Learning Outcome: 44.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders causing liver failure and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of liver failure. 12) Which of the following concepts should the nurse keep in mind when preparing a plan of care for a patient with hepatitis C virus (HCV) infection? A) The initial infection is always highly symptomatic. B) Most HCV infections become chronic. C) Antibodies to HCV are protective. D) There is only one genotype of HCV infection in the United States. Answer: B Explanation: A) Acute infection with HCV is often asymptomatic. B) Most HCV infections become chronic (75-80%). C) Unfortunately, the antibodies are not protective and do not indicate eradication of the virus. D) Seven major genotypes exist. However, genotypes 1a and 1b are the most common in the United States followed by genotypes 2 and 3. Page Ref: 1104-1105 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 44.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders causing liver failure and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of liver failure.

13) Which concept should the nurse keep in mind when planning care for a patient with hepatitis D (HDV)? A) The patient also has hepatitis C. B) The HDV virus is cleared when the HBV virus is cleared. C) Coinfection with HAV and HBV reduces the risk of cirrhosis. D) Coinfection with HCV and HDV lowers HCV vital titers. Answer: B Explanation: A) Hepatitis D occurs only in people who have the HBV infection. HDV is a small RNA virus that uses HBsAg for transmission and packaging. Simultaneous acquisition of HDV and HBV is associated with more severe acute hepatitis and death as well as an increased likelihood of progression to cirrhosis. People who clear the HBV virus also simultaneously clear the HDV virus. In HDV/HBV coinfection, HBV viral titers are often low as the HDV virus suppresses replication of HBV. B) Hepatitis D occurs only in people who have the HBV infection. HDV is a small RNA virus that uses HBsAg for transmission and packaging. Simultaneous acquisition of HDV and HBV is associated with more severe acute hepatitis and death as well as an increased likelihood of progression to cirrhosis. People who clear the HBV virus also simultaneously clear the HDV virus. In HDV/HBV coinfection, HBV viral titers are often low as the HDV virus suppresses replication of HBV. C) Hepatitis D occurs only in people who have the HBV infection. HDV is a small RNA virus that uses HBsAg for transmission and packaging. Simultaneous acquisition of HDV and HBV is associated with more severe acute hepatitis and death as well as an increased likelihood of progression to cirrhosis. People who clear the HBV virus also simultaneously clear the HDV virus. In HDV/HBV coinfection, HBV viral titers are often low as the HDV virus suppresses replication of HBV. D) Hepatitis D occurs only in people who have the HBV infection. HDV is a small RNA virus that uses HBsAg for transmission and packaging. Simultaneous acquisition of HDV and HBV is associated with more severe acute hepatitis and death as well as an increased likelihood of progression to cirrhosis. People who clear the HBV virus also simultaneously clear the HDV virus. In HDV/HBV coinfection, HBV viral titers are often low as the HDV virus suppresses replication of HBV. Page Ref: 1105 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 44.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders causing liver failure and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of liver failure to diagnosis and treatment.

14) Which of the following should the nurse include when preparing a community program on hepatitis E? A) Adolescents are at lowest risk for HEV. B) Mortality is high for pregnant women with HEV. C) HEV is transmitted through the parenteral route. D) The incubation for HEV is 8 to 12 weeks. Answer: B Explanation: A) Transmission is fecal-oral, and waterborne outbreaks are common. The waterborne form of HEV typically affects adolescents and young adults. B) The mortality rate is high for pregnant women with HEV, possibly owing to the hormonal and immunologic changes associated with pregnancy. C) Transmission of HEV is fecal-oral, and waterborne outbreaks are common. D) The incubation period is 3-8 weeks, after which symptoms and elevated ALT may develop. Page Ref: 1105 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 44.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders causing liver failure and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of liver failure.

15) Which patient statement is typical of data collected on patients during the prodromal stage of hepatitis? A) "I am tired, have a low grade fever, and just don't feel right." B) "I have gained 5 pounds over the last two weeks." C) "My stools are clay-colored." D) "I have left-sided abdominal pain and nausea." Answer: A Explanation: A) The prodromal phase typically begins about 2 weeks after the initial exposure and continues until the development of jaundice. Symptoms in the prodromal phase are often vague and nonspecific and may be seen in many different types of viral illness. They may include fatigue, malaise, nausea, vomiting, low grade fever, cough, and anorexia. Weight loss may occur during this phase. B) The prodromal phase typically begins about 2 weeks after the initial exposure and continues until the development of jaundice. Symptoms in the prodromal phase are often vague and nonspecific and may be seen in many different types of viral illness. They may include fatigue, malaise, nausea, vomiting, low grade fever, cough, and anorexia. Weight loss may occur during this phase. C) In the icteric phase, jaundice is associated with darker urine (tea or cola colored) and lighter stools (clay colored), as the bilirubin is no longer excreted through the bile ducts to the intestines. D) In the icteric phase, the liver is enlarged and may be tender. Page Ref: 1105 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 44.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders causing liver failure and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of liver failure.

16) What finding would the nurse expect to assess in a patient in the prodromal phase of hepatitis? A) Decreased PT B) Decreased liver transaminases C) Elevated serum bilirubin D) Decreased INR Answer: C Explanation: A) In the icteric phase, serum bilirubin rises and may be between 5 and 10 mg/dL. The liver transaminases may be markedly elevated, in the hundreds or even the thousands. PT/INR may also be prolonged. B) In the icteric phase, serum bilirubin rises and may be between 5 and 10 mg/dL. The liver transaminases may be markedly elevated, in the hundreds or even the thousands. PT/INR may also be prolonged. C) In the icteric phase, serum bilirubin rises and may be between 5 and 10 mg/dL. The liver transaminases may be markedly elevated, in the hundreds or even the thousands. PT/INR may also be prolonged. D) In the icteric phase, serum bilirubin rises and may be between 5 and 10 mg/dL. The liver transaminases may be markedly elevated, in the hundreds or even the thousands. PT/INR may also be prolonged. Page Ref: 1105 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 44.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders causing liver failure and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of liver failure.

17) Which finding indicates to the nurse that a patient with hepatitis B has a resolved infection? A) Presence of HBsAG B) Presence of HBcAg IgM C) Presence of HBsAG for more than 6 months D) Loss of HBsAG and development of HBsAb Answer: D Explanation: A) Acute infection is characterized by the presence of HBsAg and HBcAg IgM. The presence of HBsAg for more than 6 months indicates a chronic infection. Loss of HBsAg and development of HBsAb indicates resolved infection. B) Acute infection is characterized by the presence of HBsAg and HBcAg IgM. The presence of HBsAg for more than 6 months indicates a chronic infection. Loss of HBsAg and development of HBsAb indicates resolved infection. C) Acute infection is characterized by the presence of HBsAg and HBcAg IgM. The presence of HBsAg for more than 6 months indicates a chronic infection. Loss of HBsAg and development of HBsAb indicates resolved infection. D) Acute infection is characterized by the presence of HBsAg and HBcAg IgM. The presence of HBsAg for more than 6 months indicates a chronic infection. Loss of HBsAg and development of HBsAb indicates resolved infection. Page Ref: 1106 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 44.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders causing liver failure and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of liver failure.

18) Which physical finding should the nurse expect to assess in a patient with alcoholic liver disease? A) Dyslipidemia B) Insulin resistance C) Palmar erythema D) Hyperglycemia Answer: C Explanation: A) Manifestations of metabolic syndrome, such as obesity, diabetes, or dyslipidemia, may be present in the patient with nonalcoholic fatty liver disease. B) Metabolic syndrome and insulin resistance are important components associated with the development of nonalcoholic steatohepatitis. C) Physical examination findings for patients with alcoholic hepatitis may include ascites, jaundice, hepatic encephalopathy, splenomegaly, hepatomegaly, spider angiomata, and palmar erythema. D) Insulin resistance is the key abnormality associated with obesity-related nonalcoholic fatty liver disease. The fatty liver becomes insulin resistant and overproduces glucose, very lowdensity lipoprotein, C-reactive protein, and interleukin-6, leading to hyperglycemia, dyslipidemia, and hyperinsulinemia, which are components of metabolic syndrome. Page Ref: 1107-1108 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of liver failure. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of liver failure.

19) When taking a health history from a patient with acute liver failure, the nurse most likely expects to find: A) recent use of high doses of acetaminophen. B) infection with hepatitis B. C) high consumption of alcoholic beverages. D) exposure to toxins. Answer: A Explanation: A) The leading cause of acute liver failure is drugs, accounting for about 60% of the cases. Acetaminophen, the most common cause of drug-induced acute liver failure, is responsible for approximately 80% of these cases. Other causes of acute liver failure include viruses, toxins, and an autoimmune response. Before the 1990s, however, hepatitis B was the leading cause of acute liver failure. B) The leading cause of acute liver failure is drugs, accounting for about 60% of the cases. Acetaminophen, the most common cause of drug-induced acute liver failure, is responsible for approximately 80% of these cases. Other causes of acute liver failure include viruses, toxins, and an autoimmune response. Before the 1990s, however, hepatitis B was the leading cause of acute liver failure. C) The leading cause of acute liver failure is drugs, accounting for about 60% of the cases. Acetaminophen, the most common cause of drug-induced acute liver failure, is responsible for approximately 80% of these cases. Other causes of acute liver failure include viruses, toxins, and an autoimmune response. Before the 1990s, however, hepatitis B was the leading cause of acute liver failure. D) The leading cause of acute liver failure is drugs, accounting for about 60% of the cases. Acetaminophen, the most common cause of drug-induced acute liver failure, is responsible for approximately 80% of these cases. Other causes of acute liver failure include viruses, toxins, and an autoimmune response. Before the 1990s, however, hepatitis B was the leading cause of acute liver failure. Page Ref: 1110 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 44.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders causing liver failure and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of liver failure.

20) Which nursing intervention should be included in the care plan for a patient with acute liver failure with encephalopathy? A) Have the patient lie flat in bed. B) Perform frequent neurological checks. C) Initiate a fluid restriction. D) Administer lactulose. Answer: B Explanation: A) In acute liver failure the head of the bed is elevated to minimize the risk of aspiration in the setting of altered mental status. B) In acute liver failure, frequent neurologic checks are necessary to monitor for additional changes in mental status. C) In acute liver failure, dehydration is common, and volume resuscitation is initiated. D) The use of lactulose for treatment of hepatic encephalopathy in acute liver failure has not been shown to be effective and may negatively impact surgical interventions related to possible colonic distention. Page Ref: 1110 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 44.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders causing liver failure and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of liver failure to diagnosis and treatment.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 45 Disorders of Kidney and Urinary Tract Function 1) The nurse examines a newborn male and notes the urethral opening on the dorsal surface of the penis. Which condition does the nurse suspect? A) Hypospadias B) Epispadias C) Cryptorchidism D) Hydrocele Answer: B Explanation: A) Hypospadias is when the urethral meatus forms on the ventral (underneath) surface of the penis. B) Epispadias is a congenital abnormality in which the urethral meatus forms on the dorsal (upper) surface of the penis. C) Cryptorchidism is failure of the testicles to descend into the scrotum. D) Hydrocele is excess fluid in the scrotal sac, which is commonly found in newborn males and usually subsides within the first few months to one year of life. Page Ref: 1117 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 45.1 Describe the role of the kidneys, and discuss concepts related to kidney and urinary tract function. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of kidney and urinary tract structure and function to diagnosis and treatment.

2) A client is diagnosed with primary glomerulonephritis. Which conditions does the nurse recognize that are classified as primary glomerulonephritis? Select all that apply. A) Minimal change disease B) Crescentic glomerulonephritis C) Membranous glomerulonephritis D) Lupus nephritis E) Postinfectious glomerulonephritis Answer: A, B, C Explanation: A) Primary glomerulonephritis is limited to the kidneys and includes minimal change disease, membranous glomerulonephritis, crescentic glomerulonephritis, focal segmental glomerulosclerosis, immunoglobulin A nephropathy, membranoproliferative glomerulonephritis. B) Primary glomerulonephritis is limited to the kidneys and includes minimal change disease, membranous glomerulonephritis, crescentic glomerulonephritis, focal segmental glomerulosclerosis, immunoglobulin A nephropathy, membranoproliferative glomerulonephritis. C) Primary glomerulonephritis is limited to the kidneys and includes minimal change disease, membranous glomerulonephritis, crescentic glomerulonephritis, focal segmental glomerulosclerosis, immunoglobulin A nephropathy, membranoproliferative glomerulonephritis. D) Lupus nephritis and postinfectious glomerulonephritis are secondary glomerulonephritis, which result from another systemic condition. E) Lupus nephritis and postinfectious glomerulonephritis are secondary glomerulonephritis, which result from another systemic condition. Page Ref: 1118 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 45.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of glomerular disorders and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of kidney and urinary tract structure and function to diagnosis and treatment.

3) The nurse cares for a client with a glomerular disorder. Which typical assessment findings does the nurse anticipate in the client? Select all that apply. A) Proteinuria B) Hypertension C) Hematuria D) Oliguria E) Edema Answer: A, C, E Explanation: A) Glomerular disorders impact the glomeruli and capillaries and are characterized by proteinuria, hematuria, and edema. B) While hypertension and oliguria (decreased urine output) may occur in glomerular disorders, these are not typical characteristics of glomerular disorders. C) Glomerular disorders impact the glomeruli and capillaries and are characterized by proteinuria, hematuria, and edema. D) While hypertension and oliguria (decreased urine output) may occur in glomerular disorders, these are not typical characteristics of glomerular disorders. E) Glomerular disorders impact the glomeruli and capillaries and are characterized by proteinuria, hematuria, and edema. Page Ref: 1118 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 45.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of glomerular disorders and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of kidney and urinary tract structure and function to diagnosis and treatment.

4) The nurse cares for a client with diabetes recently diagnosed with diabetic nephropathy. Which findings does the nurse recognize are the result of the client's diagnosis of diabetic nephropathy? Select all that apply. A) Leukocytosis B) Glucosuria C) Hyperfiltration D) Proteinuria E) Chronic kidney disease Answer: C, D, E Explanation: A) Leukocytosis, elevated white blood cell count, does not result from diabetic nephropathy. B) Glucosuria, glucose present in the urine, may result from diabetes; however, this is not the result from diabetic nephropathy. C) Diabetic nephropathy results in eventual hyperfiltration, proteinuria, and chronic kidney disease. Leukocytosis, elevated white blood cell count, does not result from diabetic nephropathy. Glucosuria, glucose present in the urine, may result from diabetes; however, this is not the result from diabetic nephropathy. D) Diabetic nephropathy results in eventual hyperfiltration, proteinuria, and chronic kidney disease. E) Diabetic nephropathy results in eventual hyperfiltration, proteinuria, and chronic kidney disease. Page Ref: 1122 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 45.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of diabetic nephropathy and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of kidney and urinary tract structure and function to diagnosis and treatment.

5) The nurse examines the urinalysis results of a client suspected of having nephritis. Which finding will the nurse expect if the client has a glomerular injury? A) Hematuria B) Glucosuria C) Ketonuria D) Albuminuria Answer: D Explanation: A) Hematuria is blood in the urine and is not typically present with glomerular injury. B) With glomerular injury, albuminuria is present. This finding results from glomerular injury when the glomerular capillaries are not able to filter out macromolecules, such as albumin in the glomerulus. Hematuria is blood in the urine and is not typically present with glomerular injury. Ketonuria is the present of ketones in the urine and occurs when the body breaks down cells for energy. Ketonuria is not a typical finding in glomerular injury. C) Ketonuria is the present of ketones in the urine and occurs when the body breaks down cells for energy. Ketonuria is not a typical finding in glomerular injury. D) With glomerular injury, albuminuria is present. This finding results from glomerular injury when the glomerular capillaries are not able to filter out macromolecules, such as albumin in the glomerulus. Page Ref: 1122 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 45.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of diabetic nephropathy and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of kidney and urinary tract structure and function to diagnosis and treatment.

6) An older adult client with type 2 diabetes and hypertension asks the nurse, "What should my blood pressure goal be?" How should the nurse respond? A) "Less than 190/88 mmHg." B) "Less than 150/90 mmHg." C) "Less than 140/88 mmHg." D) "Less than 130/90 mmHg." Answer: B Explanation: A) Older adults with hypertension should not have hypertension aggressively treated for risk of dizziness and falling. The goal of the older adult with hypertension should be less than 150/90 mmHg. B) Older adults with hypertension should not have hypertension aggressively treated for risk of dizziness and falling. The goal of the older adult with hypertension should be less than 150/90 mmHg. C) Older adults with hypertension should not have hypertension aggressively treated for risk of dizziness and falling. The goal of the older adult with hypertension should be less than 150/90 mmHg. D) Older adults with hypertension should not have hypertension aggressively treated for risk of dizziness and falling. The goal of the older adult with hypertension should be less than 150/90 mmHg. Page Ref: 1123 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 45.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of diabetic nephropathy and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of kidney and urinary tract structure and function to diagnosis and treatment.

7) A client with diabetes and hypertension is placed on lisinopril for treatment of hypertension. Which laboratory results does the nurse recognize may result from the client's medications? Select all that apply. A) K+ 2.8 mEq/L B) K+ 5.5 mEq/L C) Na+ 128 mEq/L D) Cl- 120 mEq/L E) Creatinine 2.2 mg/dL Answer: A, E Explanation: A) Lisinopril is an ACE inhibitor. This type of medication is prescribed to lower the client's blood pressure in individuals with hypertension. However, hypokalemia (decreased potassium) and elevated creatinine may occur after beginning therapy with this medication. A potassium level of 2.8 mEq/L represents hypokalemia (normal potassium level is 3.5-5 mEq/L). An elevated creatinine level of 2.2 mg/dL may also occur with this medication (normal creatinine is approximately 0.6-1.2 mg/dL). B) Lisinopril is an ACE inhibitor. This type of medication is prescribed to lower the client's blood pressure in individuals with hypertension. However, hypokalemia (decreased potassium) and elevated creatinine may occur after beginning therapy with this medication. A potassium level of 2.8 mEq/L represents hypokalemia (normal potassium level is 3.5-5 mEq/L). An elevated creatinine level of 2.2 mg/dL may also occur with this medication (normal creatinine is approximately 0.6-1.2 mg/dL). C) Lisinopril is an ACE inhibitor. This type of medication is prescribed to lower the client's blood pressure in individuals with hypertension. However, hypokalemia (decreased potassium) and elevated creatinine may occur after beginning therapy with this medication. A potassium level of 2.8 mEq/L represents hypokalemia (normal potassium level is 3.5-5 mEq/L). An elevated creatinine level of 2.2 mg/dL may also occur with this medication (normal creatinine is approximately 0.6-1.2 mg/dL). D) Lisinopril is an ACE inhibitor. This type of medication is prescribed to lower the client's blood pressure in individuals with hypertension. However, hypokalemia (decreased potassium) and elevated creatinine may occur after beginning therapy with this medication. A potassium level of 2.8 mEq/L represents hypokalemia (normal potassium level is 3.5-5 mEq/L). An elevated creatinine level of 2.2 mg/dL may also occur with this medication (normal creatinine is approximately 0.6-1.2 mg/dL). E) Lisinopril is an ACE inhibitor. This type of medication is prescribed to lower the client's blood pressure in individuals with hypertension. However, hypokalemia (decreased potassium) and elevated creatinine may occur after beginning therapy with this medication. A potassium level of 2.8 mEq/L represents hypokalemia (normal potassium level is 3.5-5 mEq/L). An elevated creatinine level of 2.2 mg/dL may also occur with this medication (normal creatinine is approximately 0.6-1.2 mg/dL). Page Ref: 1123 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies

Standards: Nursing Process: Evaluation | Learning Outcome: 45.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of diabetic nephropathy and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of kidney and urinary tract structure and function to diagnosis and treatment. 8) The nurse is caring for a client with end-stage renal disease (ESRD) on hemodialysis. Which factor does the nurse recognize is the leading cause of this disease? A) Diabetes B) Hypertension C) Heredity D) Autoimmune disease Answer: A Explanation: A) Diabetes is the leading cause of ESRD and diabetes is second. Heredity and autoimmune disease are factors that may lead to ESRD; however, these are not the leading cause of ESRD. B) Diabetes is the leading cause of ESRD and diabetes is second. Heredity and autoimmune disease are factors that may lead to ESRD; however, these are not the leading cause of ESRD. C) Diabetes is the leading cause of ESRD and diabetes is second. Heredity and autoimmune disease are factors that may lead to ESRD; however, these are not the leading cause of ESRD. D) Diabetes is the leading cause of ESRD and diabetes is second. Heredity and autoimmune disease are factors that may lead to ESRD; however, these are not the leading cause of ESRD. Page Ref: 1123 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 45.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of diabetic nephropathy and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: VII.1 Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities and populations NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of kidney and urinary tract structure and function to diagnosis and treatment.

9) The nurse cares for four clients with cystitis. Which client represents a complicated cystitis case? A) Middle-age adult female who has hypertension. B) Young adult female who is pregnant. C) Older adult female who has impaired mobility. D) Older adult female who lives in a skilled nursing facility. Answer: B Explanation: A) Pregnant women, those with abnormal urinary tract anatomy, immunosuppressed individuals, males, recent invasive procedures performed on the urethra, or infections of unknown etiology all represent complicated cystitis. B) Pregnant women, those with abnormal urinary tract anatomy, immunosuppressed individuals, males, recent invasive procedures performed on the urethra, or infections of unknown etiology all represent complicated cystitis. C) Pregnant women, those with abnormal urinary tract anatomy, immunosuppressed individuals, males, recent invasive procedures performed on the urethra, or infections of unknown etiology all represent complicated cystitis. D) Pregnant women, those with abnormal urinary tract anatomy, immunosuppressed individuals, males, recent invasive procedures performed on the urethra, or infections of unknown etiology all represent complicated cystitis. Page Ref: 1125 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 45.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of urinary tract infections and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: VII.1 Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities and populations NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of kidney and urinary tract structure and function to diagnosis and treatment.

10) A nurse manager plans training for staff nurses on early recognition of urinary tract infections (UTIs) in older adults. What will the nurse say is a frequent manifesting symptom of UTI in the older adult? A) Fever B) Abdominal pain C) Confusion D) Dysuria Answer: C Explanation: A) Abdominal pain, fever, and dysuria (pain with urination) may not occur in the older adult. B) Abdominal pain, fever, and dysuria (pain with urination) may not occur in the older adult. C) Confusion is often the manifesting symptom of UTI in the older adult. D) Abdominal pain, fever, and dysuria (pain with urination) may not occur in the older adult. Page Ref: 1125 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 45.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of urinary tract infections and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: II.B.11. Solicit input from other team members to improve individual, as well as team, performance | AACN Essential Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of kidney and urinary tract structure and function to diagnosis and treatment.

11) The nurse cares for a client with chronic pyelonephritis. What is the nurse's understanding of the most frequent cause of this condition? A) Vesicoureteral reflux B) Papillary necrosis C) Nephrolithiasis D) Tubulointerstitial injury Answer: A Explanation: A) Vesicoureteral reflux (VUR) is the most common cause of chronic pyelonephritis. VUR is the abnormal backflow of urine from the bladder to the kidney, which can lead to renal scarring, tubulointerstitial injury, and end-stage renal disease (ESRD). B) Papillary necrosis and nephrolithiasis (kidney stones) may lead to chronic pyelonephritis; however, these are not the most frequent cause of this condition. C) Papillary necrosis and nephrolithiasis (kidney stones) may lead to chronic pyelonephritis; however, these are not the most frequent cause of this condition. D) Vesicoureteral reflux (VUR) is the most common cause of chronic pyelonephritis. VUR is the abnormal backflow of urine from the bladder to the kidney, which can lead to renal scarring, tubulointerstitial injury, and end-stage renal disease (ESRD). Page Ref: 1126 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 45.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of urinary tract infections and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of kidney and urinary tract structure and function to diagnosis and treatment.

12) A client is admitted to a medical unit with the primary diagnosis of acute pyelonephritis. Which assessment findings does the nurse anticipate? Select all that apply. A) Headache B) Fever C) Chills D) Abdominal pain E) Costovertebral angle pain Answer: B, C, E Explanation: A) Abdominal pain and headache are not universal symptoms of acute pyelonephritis. B) Individuals with acute pyelonephritis often present with fever, chills, and costovertebral angle pain. C) Individuals with acute pyelonephritis often present with fever, chills, and costovertebral angle pain. D) Abdominal pain and headache are not universal symptoms of acute pyelonephritis. E) Individuals with acute pyelonephritis often present with fever, chills, and costovertebral angle pain. Page Ref: 1127 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 45.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of urinary tract infections and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of kidney and urinary tract structure and function to diagnosis and treatment.

13) A client is suspected of having renal cell carcinoma (RCC). Which manifestation will the nurse likely assess? Select all that apply. A) Hematuria B) Dysuria C) Abdominal mass D) Weight loss E) Urinary frequency Answer: A, C, D Explanation: A) Manifestations of RCC include hematuria, abdominal mass, weight loss, and dull or achy pain. Some clients may be asymptomatic and many times the symptoms are vague and difficult to diagnose. These factors make it difficult for the health care provider to diagnosis RCC and many times delayed diagnosis occurs. B) Dysuria and urinary frequency are common in UTI but not in RCC. C) Manifestations of RCC include hematuria, abdominal mass, weight loss, and dull or achy pain. Some clients may be asymptomatic and many times the symptoms are vague and difficult to diagnose. These factors make it difficult for the health care provider to diagnosis RCC and many times delayed diagnosis occurs. D) Manifestations of RCC include hematuria, abdominal mass, weight loss, and dull or achy pain. Some clients may be asymptomatic and many times the symptoms are vague and difficult to diagnose. These factors make it difficult for the health care provider to diagnosis RCC and many times delayed diagnosis occurs. E) Dysuria and urinary frequency are common in UTI but not in RCC. Page Ref: 1129 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 45.8 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of benign tumors and malignancies of the kidney and bladder and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of kidney and urinary tract structure and function to diagnosis and treatment.

14) A client is diagnosed with renal papillary adenoma. Which characteristic of this condition does the nurse recognize is true? A) It is difficult to differentiate from a malignancy. B) It is associated with tuberous sclerosis. C) It is very aggressive and often deadly. D) It is a hereditary disease of the proximal tubule. Answer: D Explanation: A) Oncocytoma is difficult to differentiate from a malignancy. B) Angiomyolipoma is associated with tuberous sclerosis. C) Renal papillary adenoma is a benign tumor of the kidney that is a hereditary condition of the proximal tubule. D) Renal papillary adenoma is a benign tumor of the kidney that is a hereditary condition of the proximal tubule. Page Ref: 1129 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 45.8 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of benign tumors and malignancies of the kidney and bladder and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of kidney and urinary tract structure and function to diagnosis and treatment.

15) The community health nurse is providing education to a group of adults on prevention of bladder cancer. Which modifiable risk factor will the nurse identify as the most important in the prevention of bladder cancer? A) Obesity B) Smoking C) Hyperlipidemia D) Sedentary lifestyle Answer: B Explanation: A) While all answer choices represent modifiable risk factors for cardiac disease and general health, smoking and exposure to toxic chemicals are the most important modifiable risk factors in the development of bladder cancer. Smoking has been shown to be the greatest contributor to this disease and education on the prevention of bladder cancer must stress the importance of smoking cessation. B) While all answer choices represent modifiable risk factors for cardiac disease and general health, smoking and exposure to toxic chemicals are the most important modifiable risk factors in the development of bladder cancer. Smoking has been shown to be the greatest contributor to this disease and education on the prevention of bladder cancer must stress the importance of smoking cessation. C) While all answer choices represent modifiable risk factors for cardiac disease and general health, smoking and exposure to toxic chemicals are the most important modifiable risk factors in the development of bladder cancer. Smoking has been shown to be the greatest contributor to this disease and education on the prevention of bladder cancer must stress the importance of smoking cessation. D) While all answer choices represent modifiable risk factors for cardiac disease and general health, smoking and exposure to toxic chemicals are the most important modifiable risk factors in the development of bladder cancer. Smoking has been shown to be the greatest contributor to this disease and education on the prevention of bladder cancer must stress the importance of smoking cessation. Page Ref: 1129 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 45.8 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of benign tumors and malignancies of the kidney and bladder and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of kidney and urinary tract structure and function to diagnosis and treatment.

16) The nurse cares for a client with a renal neoplasm. What location of the body does the nurse recognize is the most likely origin of this disease? A) Renal cortex B) Renal pelvis C) Renal medulla D) Renal fascia Answer: A Explanation: A) Approximately 85% of all renal neoplasms arise from the renal cortex. B) Approximately 85% of all renal neoplasms arise from the renal cortex. Although the pelvis, medulla, and fascia are all components of the kidney, these are not the most likely origination of renal neoplasms. C) Approximately 85% of all renal neoplasms arise from the renal cortex. Although the pelvis, medulla, and fascia are all components of the kidney, these are not the most likely origination of renal neoplasms. D) Approximately 85% of all renal neoplasms arise from the renal cortex. Although the pelvis, medulla, and fascia are all components of the kidney, these are not the most likely origination of renal neoplasms. Page Ref: 1129 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 45.8 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of benign tumors and malignancies of the kidney and bladder and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of kidney and urinary tract structure and function to diagnosis and treatment.

17) The nurse is caring for an older adult who reports recent urinary incontinence. What is the nurse's understanding about urinary incontinence in the older adult? A) It is not a normal outcome of aging. B) It is the expected result of muscle atrophy. C) It generally occurs at night only. D) It most commonly occurs with position changes. Answer: A Explanation: A) Urinary incontinence is not a normal outcome of aging nor is it expected from muscle atrophy. Incontinence in the older adult should be assessed. Incontinence may occur at any time during the day and only postural incontinence occurs with position changes. B) Urinary incontinence is not a normal outcome of aging nor is it expected from muscle atrophy. Incontinence in the older adult should be assessed. Incontinence may occur at any time during the day and only postural incontinence only occurs with position changes. C) Urinary incontinence is not a normal outcome of aging nor is it expected from muscle atrophy. Incontinence in the older adult should be assessed. Incontinence may occur at any time during the day and only postural incontinence only occurs with position changes. D) Urinary incontinence is not a normal outcome of aging nor is it expected from muscle atrophy. Incontinence in the older adult should be assessed. Incontinence may occur at any time during the day and only postural incontinence only occurs with position changes. Page Ref: 1128 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 45.7 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of urinary incontinence and approaches to diagnosis and treatment of this condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of kidney and urinary tract structure and function to diagnosis and treatment.

18) The nurse cares for a client with tuberous sclerosis. In addition to renal impairment, which findings does the nurse expect in this client? Select all that apply. A) Early-onset gout B) Skin tumors C) Cognitive impairment D) Visual impairment E) Seizures Answer: B, C, E Explanation: A) Early-onset gout is associated with medullary cystic kidney/autosomal dominant interstitial kidney disease, not tuberous sclerosis. B) Tuberous sclerosis is an inherited renal disease that also causes skin tumors, cognitive impairment, and seizures. C) Tuberous sclerosis is an inherited renal disease that also causes skin tumors, cognitive impairment, and seizures. D) Visual impairment may occur with Alport syndrome, not tuberous sclerosis. E) Tuberous sclerosis is an inherited renal disease that also causes skin tumors, cognitive impairment, and seizures. Page Ref: 1116 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 45.1 Describe the role of the kidneys, and discuss concepts related to kidney and urinary tract function. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of kidney and urinary tract structure and function to diagnosis and treatment.

19) The nurse works on a pediatric renal unit and cares for several clients with renal disorders. Which glomerular disorder does the nurse recognize as the most common primary glomerular disorder in children? A) Autosomal dominant polycystic kidney disease B) Autosomal recessive polycystic kidney disease C) Idiopathic nephrotic syndrome D) Hemolytic uremic syndrome Answer: C Explanation: A) Autosomal dominant polycystic kidney disease usually manifests in adults. B) Autosomal recessive polycystic kidney disease is the leading cause of CKD in children younger than 12; however, it is not the most common primary glomerular disorder in children. C) The most common primary glomerular disorder in children is idiopathic nephrotic syndrome. D) Hemolytic uremic syndrome is one of the main causes of AKI in children; however, it is not the most common primary glomerular disorder in children. Page Ref: 1121 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 45.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of glomerular disorders and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of kidney and urinary tract structure and function to diagnosis and treatment.

20) The nurse cares for a client with postinfectious glomerulonephritis (PIGN). Which infection does the nurse recognize as most commonly causing this condition? A) Group A beta-hemolytic streptococcus B) Beta-hemolytic E. coli C) Alpha-hemolytic streptococcus D) Cocciodiodes immitis Answer: A Explanation: A) Group A beta-hemolytic streptococcus most commonly causes postinfectious glomerulonephritis (PIGN). B) Beta-hemolytic E. coli and alpha-hemolytic streptococcus are bacterial pathogens; however, these are not the most common causes of PIGN. C) Beta-hemolytic E. coli and alpha-hemolytic streptococcus are bacterial pathogens; however, these are not the most common causes of PIGN. D) Cocciodiodes immitis is a fungal pathogen and is not the most common cause of PIGN. Page Ref: 1121 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 45.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of glomerular disorders and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of kidney and urinary tract structure and function to diagnosis and treatment.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 46 Acute Kidney Injury and Chronic Kidney Disease 1) How should the nurse respond when a patient asks how he could have chronic kidney disease (CKD) when he has not had symptoms of the disease? A) "Symptoms of CKD are often vague." B) "CKD comes on suddenly." C) "Your current urinary tract infection may have caused your CKD." D) "You must have had symptoms that you did not report." Answer: A Explanation: A) Chronic kidney disease is often vague and asymptomatic early in the disease process and is the result of long-term damage to the kidney from diseases such as untreated hypertension or diabetes mellitus or medications and other drugs. Acute kidney injury can progress to chronic kidney disease. B) Chronic kidney disease is often vague and asymptomatic early in the disease process and is the result of long-term damage to the kidney from diseases such as untreated hypertension or diabetes mellitus or medications and other drugs. Acute kidney injury can progress to chronic kidney disease. C) Chronic kidney disease is often vague and asymptomatic early in the disease process and is the result of long-term damage to the kidney from diseases such as untreated hypertension or diabetes mellitus or medications and other drugs. Acute kidney injury can progress to chronic kidney disease. D) Chronic kidney disease is often vague and asymptomatic early in the disease process and is the result of long-term damage to the kidney from diseases such as untreated hypertension or diabetes mellitus or medications and other drugs. Acute kidney injury can progress to chronic kidney disease. Page Ref: 1136 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 46.1 Describe the role of the kidneys, and discuss concepts related to acute kidney injury and chronic kidney disease. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of acute kidney injury and end-stage kidney disease.

2) Which findings would the nurse utilize to identify the level of acute kidney injury in a patient? A) Blood urea nitrogen levels B) Ratio of fluid intake to fluid output C) Blood pressure readings D) Serum creatinine levels and urinary output Answer: D Explanation: A) The RIFLE, AKIN, and KDIGO staging systems utilize the current kidney function indices of serum creatinine levels and urinary output to identify the level of injury or failure. The accumulation of serum creatinine signifies an excess of nitrogenous waste products, and urinary output reflects the ability of the kidney to remove waste products and maintain fluid balance. B) The RIFLE, AKIN, and KDIGO staging systems utilize the current kidney function indices of serum creatinine levels and urinary output to identify the level of injury or failure. The accumulation of serum creatinine signifies an excess of nitrogenous waste products, and urinary output reflects the ability of the kidney to remove waste products and maintain fluid balance. C) The RIFLE, AKIN, and KDIGO staging systems utilize the current kidney function indices of serum creatinine levels and urinary output to identify the level of injury or failure. The accumulation of serum creatinine signifies an excess of nitrogenous waste products, and urinary output reflects the ability of the kidney to remove waste products and maintain fluid balance. D) The RIFLE, AKIN, and KDIGO staging systems utilize the current kidney function indices of serum creatinine levels and urinary output to identify the level of injury or failure. The accumulation of serum creatinine signifies an excess of nitrogenous waste products, and urinary output reflects the ability of the kidney to remove waste products and maintain fluid balance. Page Ref: 1137 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 46.2 Differentiate the causes, underlying pathogenesis, and clinical manifestations of acute kidney injury and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of acute kidney injury and end-stage kidney disease.

3) When the nurse is assessing the glomerular filtration rate (GFR) of a patient, which method is more accurate when the patient's GFR is normal or mildly decreased? A) Cockcroft-Gault equation B) Modification of Diet in Renal Disease C) Chronic Kidney Disease-Epidemiology Collaboration D) RIFLE Answer: C Explanation: A) Cockcroft-Gault equation, which preceded the Modification of Diet in Renal Disease (MDRD) equation, may overestimate creatinine clearance. The MDRD equation is the equation that many laboratories still utilize when reporting GFR as part of the basic metabolic panel, but in 2009, the National Kidney Foundation recommended the Chronic Kidney DiseaseEpidemiology Collaboration (CKD-EPI) equation to estimate the GFR. The CKD-EPI is preferred for better prediction of CKD risk and is more accurate when the GFR is normal or only mildly decreased. B) Cockcroft-Gault equation, which preceded the Modification of Diet in Renal Disease (MDRD) equation, may overestimate creatinine clearance. The MDRD equation is the equation that many laboratories still utilize when reporting GFR as part of the basic metabolic panel, but in 2009, the National Kidney Foundation recommended the Chronic Kidney DiseaseEpidemiology Collaboration (CKD-EPI) equation to estimate the GFR. The CKD-EPI is preferred for better prediction of CKD risk and is more accurate when the GFR is normal or only mildly decreased. C) Cockcroft-Gault equation, which preceded the Modification of Diet in Renal Disease (MDRD) equation, may overestimate creatinine clearance. The MDRD equation is the equation that many laboratories still utilize when reporting GFR as part of the basic metabolic panel, but in 2009, the National Kidney Foundation recommended the Chronic Kidney DiseaseEpidemiology Collaboration (CKD-EPI) equation to estimate the GFR. The CKD-EPI is preferred for better prediction of CKD risk and is more accurate when the GFR is normal or only mildly decreased. D) RIFLE does not estimate GFR. Rather, because of the continuum of kidney damage that can occur in AKI and the lack of consensus on a definition, in 2004 the Acute Dialysis Quality Initiative Group developed the Risk, Injury, Failure, Loss, End-Stage Renal Disease (RIFLE) criteria to standardize the diagnosis and treatment of AKI. RIFLE stands for risk, injury, failure, loss, and ESRD. Page Ref: 1137 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 46.2 Differentiate the causes, underlying pathogenesis, and clinical manifestations of acute kidney injury and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of acute kidney injury and end-stage kidney disease. 3

4) When assessing acute kidney injury in the pediatric population using the pRIFLE criteria, the nurse observes which parameters? A) Serum creatinine levels B) Changes in glomerular filtration rate C) Blood urea nitrogen levels D) Urinary output Answer: B Explanation: A) A modified version of the RIFLE criteria for pediatric patients, known as pRIFLE, takes into account GFR changes rather than changes in creatinine. B) A modified version of the RIFLE criteria for pediatric patients, known as pRIFLE, takes into account GFR changes rather than changes in creatinine. C) A modified version of the RIFLE criteria for pediatric patients, known as pRIFLE, takes into account GFR changes rather than changes in creatinine. D) A modified version of the RIFLE criteria for pediatric patients, known as pRIFLE, takes into account GFR changes rather than changes in creatinine. Page Ref: 1138 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 46.2 Differentiate the causes, underlying pathogenesis, and clinical manifestations of acute kidney injury and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of acute kidney injury and end-stage kidney disease.

5) When planning care for a patient with heart failure, the nurse keeps in mind that this condition may lead to: A) prerenal AKI. B) intrinsic AKI. C) postrenal AKI. D) glomerulonephritis. Answer: A Explanation: A) Prerenal AKI occurs for two primary reasons: reduced blood flow to the kidney due to intravascular volume depletion from nausea, vomiting, diarrhea, or aggressive diuresis and reduced effective arterial blood volume from shock, related to heart failure, hypovolemia, or sepsis. B) Prerenal AKI occurs for two primary reasons: reduced blood flow to the kidney due to intravascular volume depletion from nausea, vomiting, diarrhea, or aggressive diuresis and reduced effective arterial blood volume from shock, related to heart failure, hypovolemia, or sepsis. C) Prerenal AKI occurs for two primary reasons: reduced blood flow to the kidney due to intravascular volume depletion from nausea, vomiting, diarrhea, or aggressive diuresis and reduced effective arterial blood volume from shock, related to heart failure, hypovolemia, or sepsis. D) Intrinsic AKI results from several causes and include vasculitis, acute glomerulonephritis, sepsis, ischemia, and nephrotoxin exposure. Page Ref: 1139-1140 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 46.2 Differentiate the causes, underlying pathogenesis, and clinical manifestations of acute kidney injury and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of acute kidney injury and end-stage kidney disease.

6) The nurse should expect to assess which laboratory value in the patient with prerenal acute kidney disease? A) Low urine sodium concentration B) High fractional excretion of sodium C) High fractional excretion of urea D) Low urine osmolality Answer: A Explanation: A) Classic clinical features of prerenal AKI include low urine sodium concentration (620 mmol/L), fractional excretion of sodium (FeNa) (61,), and fractional excretion of urea (FeUr) (635,) as well as high urine osmolality and specific gravity (1.030). B) Classic clinical features of prerenal AKI include low urine sodium concentration (620 mmol/L), fractional excretion of sodium (FeNa) (61,), and fractional excretion of urea (FeUr) (635,) as well as high urine osmolality and specific gravity (1.030). C) Classic clinical features of prerenal AKI include low urine sodium concentration (620 mmol/L), fractional excretion of sodium (FeNa) (61,), and fractional excretion of urea (FeUr) (635,) as well as high urine osmolality and specific gravity (1.030). D) Classic clinical features of prerenal AKI include low urine sodium concentration (620 mmol/L), fractional excretion of sodium (FeNa) (61,), and fractional excretion of urea (FeUr) (635,) as well as high urine osmolality and specific gravity (1.030). Page Ref: 1140 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 46.2 Differentiate the causes, underlying pathogenesis, and clinical manifestations of acute kidney injury and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of acute kidney injury and end-stage kidney disease.

7) Which intervention should be included in the nursing plan of care for a patient with prerenal acute kidney injury? A) Provide intravenous fluids. B) Administer antihypertensive medication. C) Limit fluid intake. D) Prepare for dialysis. Answer: A Explanation: A) In prerenal AKI, any significant drop in blood pressure from the individual's baseline should be managed aggressively to avoid prerenal injury. Fluid resuscitation is the most common treatment in resolving prerenal AKI. Overdiuresis of heart failure and provision of heart failure medications for individuals with volume depletion can initiate prerenal AKI. B) In prerenal AKI, any significant drop in blood pressure from the individual's baseline should be managed aggressively to avoid prerenal injury. Fluid resuscitation is the most common treatment in resolving prerenal AKI. Overdiuresis of heart failure and provision of heart failure medications for individuals with volume depletion can initiate prerenal AKI. C) In prerenal AKI, any significant drop in blood pressure from the individual's baseline should be managed aggressively to avoid prerenal injury. Fluid resuscitation is the most common treatment in resolving prerenal AKI. Overdiuresis of heart failure and provision of heart failure medications for individuals with volume depletion can initiate prerenal AKI. D) In prerenal AKI, any significant drop in blood pressure from the individual's baseline should be managed aggressively to avoid prerenal injury. Fluid resuscitation is the most common treatment in resolving prerenal AKI. Overdiuresis of heart failure and provision of heart failure medications for individuals with volume depletion can initiate prerenal AKI. Page Ref: 1140 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 46.2 Differentiate the causes, underlying pathogenesis, and clinical manifestations of acute kidney injury and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of acute kidney injury and endstage kidney disease to diagnosis and treatment.

8) Which concept should the nurse keep in mind when developing a plan of care for the patient with intrinsic acute kidney injury (AKI)? A) This condition is potentially and easily reversible. B) This condition in not reversible. C) This condition may not result in prompt recovery. D) This condition is caused by chronic kidney disease. Answer: C Explanation: A) Intrinsic kidney injury is different from prerenal and postrenal AKI in that it does not necessarily result in prompt recovery of renal function. B) Intrinsic kidney injury is different from prerenal and postrenal AKI in that it does not necessarily result in prompt recovery of renal function. C) Intrinsic kidney injury is different from prerenal and postrenal AKI in that it does not necessarily result in prompt recovery of renal function. D) Intrinsic kidney injury is different from prerenal and postrenal AKI in that it does not necessarily result in prompt recovery of renal function. Page Ref: 1140 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 46.2 Differentiate the causes, underlying pathogenesis, and clinical manifestations of acute kidney injury and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of acute kidney injury and endstage kidney disease to diagnosis and treatment.

9) The nurse assessing a patient with acute interstitial nephritis is most likely to note which findings? A) Lymphocytopenia B) Leukocytosis C) Neutropenia D) Eosinophilia Answer: D Explanation: A) Acute interstitial nephritis usually presents with rash, fever, and eosinophilia. Urinary findings in acute interstitial nephritis include sterile pyuria, white blood cell casts, nonnephrotic-range proteinuria, hematuria, and eosinophiluria. B) Acute interstitial nephritis usually presents with rash, fever, and eosinophilia. Urinary findings in acute interstitial nephritis include sterile pyuria, white blood cell casts, nonnephroticrange proteinuria, hematuria, and eosinophiluria. C) Acute interstitial nephritis usually presents with rash, fever, and eosinophilia. Urinary findings in acute interstitial nephritis include sterile pyuria, white blood cell casts, nonnephroticrange proteinuria, hematuria, and eosinophiluria. D) Acute interstitial nephritis usually presents with rash, fever, and eosinophilia. Urinary findings in acute interstitial nephritis include sterile pyuria, white blood cell casts, nonnephroticrange proteinuria, hematuria, and eosinophiluria. Page Ref: 1142 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 46.2 Differentiate the causes, underlying pathogenesis, and clinical manifestations of acute kidney injury and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of kidney and urinary tract structure and function.

10) Which finding should the nurse expect when assessing the patient with acute kidney injury? A) Peripheral neuropathy B) Enlarged kidney C) Normal hemoglobin D) Bone pain Answer: C Explanation: A) In acute kidney injury, findings include a normal hemoglobin, normal kidney size, and no evidence of renal osteodystrophy or peripheral neuropathy. B) In acute kidney injury, findings include a normal hemoglobin, normal kidney size, and no evidence of renal osteodystrophy or peripheral neuropathy. C) In acute kidney injury, findings include a normal hemoglobin, normal kidney size, and no evidence of renal osteodystrophy or peripheral neuropathy. D) In acute kidney injury, findings include a normal hemoglobin, normal kidney size, and no evidence of renal osteodystrophy or peripheral neuropathy. Page Ref: 1142 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 46.2 Differentiate the causes, underlying pathogenesis, and clinical manifestations of acute kidney injury and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of acute kidney injury and end-stage kidney disease.

11) While admitting a patient with acute kidney injury, the patient reports to the nurse that he has had no urinary output during the last 24 hours. Which of the following would the nurse record in the medical record? A) The patient is anuric. B) The patient is oliguric. C) The patient is nonoliguric. D) The patient has a normal GFR. Answer: A Explanation: A) Terms describing reductions in urine output include anuric (no urine output), oliguric (urine output less than 400 milliliters in 24 hours), or nonoliguric (urine output greater than 400 milliliters in 24 hours). B) Terms describing reductions in urine output include anuric (no urine output), oliguric (urine output less than 400 milliliters in 24 hours), or nonoliguric (urine output greater than 400 milliliters in 24 hours). C) Terms describing reductions in urine output include anuric (no urine output), oliguric (urine output less than 400 milliliters in 24 hours), or nonoliguric (urine output greater than 400 milliliters in 24 hours). D) Terms describing reductions in urine output include anuric (no urine output), oliguric (urine output less than 400 milliliters in 24 hours), or nonoliguric (urine output greater than 400 milliliters in 24 hours). Page Ref: 1142 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 46.2 Differentiate the causes, underlying pathogenesis, and clinical manifestations of acute kidney injury and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Effective Communication MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of acute kidney injury and end-stage kidney disease.

12) The urinalysis of a patient with acute interstitial nephritis is likely to have which characteristics? A) Hematuria with red blood cell casts, dysmorphic red blood cells, proteinuria B) Leukocyturia with leukocyte casts or urinary eosinophils C) Renal tubular epithelial cells and muddy brown casts D) Few cells with little or no casts or proteinuria Answer: B Explanation: A) The of a patient with acute glomerulonephritis is likely to show hematuria with red blood cell casts, dysmorphic red blood cells, and proteinuria. B) The of a patient with acute interstitial nephritis is likely to show leukocyturia with leukocyte casts or urinary eosinophils. C) The of a patient with acute tubular necrosis is likely to show renal tubular epithelial cells and muddy brown casts. D) The of a patient with prerenal disease or urinary tract obstruction is likely to show few cells with little or no casts or proteinuria. Page Ref: 1143 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 46.2 Differentiate the causes, underlying pathogenesis, and clinical manifestations of acute kidney injury and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of acute kidney injury and end-stage kidney disease.

13) The nurse is performing risk assessments for chronic kidney disease (CKD) at a community health fair. Which concept should guide the assessments? A) African Americans have a higher incidence of CKD than Caucasians. B) Caucasians have a higher incidence of CKD than Native Americans. C) Non-Hispanics have a higher incidence of CKD than Hispanics. D) African Americans progress more slowly to end-stage renal disease than the general population. Answer: A Explanation: A) African Americans and Native Americans have a higher incidence of CKD than Caucasians, and Hispanics also have a higher incidence than non-Hispanics. Compared to European Americans, African Americans are 4-5 times more likely to develop ESRD independent of socioeconomic status. African Americans, compared to the general population, also progress more rapidly to ESRD with consideration for age-associated progression. B) African Americans and Native Americans have a higher incidence of CKD than Caucasians, and Hispanics also have a higher incidence than non-Hispanics. Compared to European Americans, African Americans are 4-5 times more likely to develop ESRD independent of socioeconomic status. African Americans, compared to the general population, also progress more rapidly to ESRD with consideration for age-associated progression. C) African Americans and Native Americans have a higher incidence of CKD than Caucasians, and Hispanics also have a higher incidence than non-Hispanics. Compared to European Americans, African Americans are 4-5 times more likely to develop ESRD independent of socioeconomic status. African Americans, compared to the general population, also progress more rapidly to ESRD with consideration for age-associated progression. D) African Americans and Native Americans have a higher incidence of CKD than Caucasians, and Hispanics also have a higher incidence than non-Hispanics. Compared to European Americans, African Americans are 4-5 times more likely to develop ESRD independent of socioeconomic status. African Americans, compared to the general population, also progress more rapidly to ESRD with consideration for age-associated progression. Page Ref: 1144 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 46.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of chronic kidney disease and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of acute kidney injury and end-stage kidney disease.

14) Which response by a patient with chronic kidney disease indicates to the nurse that more teaching about the disease is needed? A) "CKD can cause me to have a high blood count." B) "CKD can progress quickly to ESRD." C) "Bone fractures may occur." D) "I need to modify my risk factors for cardiovascular disease." Answer: A Explanation: A) Outcomes of CKD include complications of decreased kidney function, which include anemia, uremia, derangements of bone and mineral metabolism, cardiovascular disease (CVD), and the potential to progress to ESRD. Cardiovascular disease is the leading cause of death for people with CKD. B) Chronic kidney disease can progress to ESRD rapidly, over a few months, or slowly over many years with the deterioration related to the cause. C) Outcomes of CKD include complications of decreased kidney function, which include anemia, uremia, derangements of bone and mineral metabolism, cardiovascular disease (CVD), and the potential to progress to ESRD. Cardiovascular disease is the leading cause of death for people with CKD. D) Increasing evidence suggests that some of the adverse outcomes can be delayed by early prevention and treatment of CKD. Management of CVD risk factors reduces the risk of progression. Page Ref: 1145 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 46.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of chronic kidney disease and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of acute kidney injury and endstage kidney disease to diagnosis and treatment.

15) Which laboratory value alerts the nurse that a patient is in stage 3 of chronic kidney disease (CKD)? A) GFR > 90 mL/min/1.73m2 B) GFR 60-89 mL/min/1.73m2 C) GFR 30-59 mL/min/1.73m2 D) GFR 15-29 mL/min/1.73m2 Answer: C Explanation: A) Stage 1 of CKD is characterized by kidney damage with normal or elevated GFR > 90 mL/min/1.73m2. B) Stage 2 of CKD is characterized by kidney damage with a GFR of 60-89 mL/min/1.73m2. C) Stage 3 of CKD is characterized by a GFR of 30-59 mL/min/1.73m2. D) Stage 4 of CKD is characterized by a GFR of 15-29 mL/min/1.73m2. Page Ref: 1145 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 46.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of chronic kidney disease and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of acute kidney injury and end-stage kidney disease.

16) When assessing a patient for modifiable risk factors for chronic kidney disease, the nurse should ask which question? A) "What is your age?" B) "Do you use NSAIDs?" C) "Were you born prematurely?" D) "Do you have a family history of kidney disease?" Answer: B Explanation: A) Nonmodifiable risk factors for CKD include age, premature birth, heredity, and ethnicity. B) Modifiable risk factors include hypertension, hyperglycemia, dyslipidemia, obesity, excessive protein and sodium intake, and exposure to nephrotoxic agents such as radiocontrast dyes. The GFR should be monitored in people who are administered nephrotoxic medications such as NSAIDs and calcineurin inhibitors. C) Nonmodifiable risk factors for CKD include age, premature birth, heredity, and ethnicity. D) Nonmodifiable risk factors for CKD include age, premature birth, heredity, and ethnicity. Page Ref: 1145-1146 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 46.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of chronic kidney disease and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII.1 Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities and populations NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of acute kidney injury and end-stage kidney disease.

17) Which finding would alert the nurse that a patient with diabetes may be in the early stages of developing diabetic nephropathy? A) Albuminuria B) Increased glomerular filtration rate C) Hypotension D) Cardiac disease Answer: A Explanation: A) Moderately increased albuminuria (albumin in the urine) is an early indicator of diabetic nephropathy. Clinically, diabetic nephropathy is characterized by a reduced GFR, hypertension, severely increased albuminuria, and a high risk of CVD. B) Moderately increased albuminuria (albumin in the urine) is an early indicator of diabetic nephropathy. Clinically, diabetic nephropathy is characterized by a reduced GFR, hypertension, severely increased albuminuria, and a high risk of CVD. C) Moderately increased albuminuria (albumin in the urine) is an early indicator of diabetic nephropathy. Clinically, diabetic nephropathy is characterized by a reduced GFR, hypertension, severely increased albuminuria, and a high risk of CVD. D) Moderately increased albuminuria (albumin in the urine) is an early indicator of diabetic nephropathy. Clinically, diabetic nephropathy is characterized by a reduced GFR, hypertension, severely increased albuminuria, and a high risk of CVD. Page Ref: 1146 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 46.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of chronic kidney disease and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of acute kidney injury and end-stage kidney disease.

18) Which assessment data is the nurse likely to observe in a patient with chronic kidney disease? A) Serum creatinine of 0.7 mg/dL B) BUN:creatinine ratio of 10:1 C) Serum phosphorous of 3.1 mg/dL D) Parathyroid hormone of 62 pg/mL Answer: D Explanation: A) Serum creatinine becomes elevated with kidney damage; useful in calculating GFR. Normal is 0.6-1.2 mg/dL in males and 0.5-1.1 mg/dL in females. B) The BUN:creatinine ratio is normally around 10:1. C) Serum phosphorus becomes elevated as GFR declines; diseased kidneys are unable to excrete excess phosphorus. Normal phosphorus is 2.5-4.5 mg/dL. D) PTH becomes elevated in response to increasing phosphorus and decreasing calcium. Normal PTH is 10-55 pg/mL. Page Ref: 1151 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 46.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of chronic kidney disease and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of acute kidney injury and end-stage kidney disease.

19) Which physician order should the nurse question on a patient with hyperkalemia secondary to chronic kidney disease? A) Renal replacement therapy B) Administration of a potassium-sparing diuretic C) Discontinuing ACE inhibitors D) Administering potassium binders Answer: B Explanation: A) Treatment of hyperkalemia in the patient with chronic kidney disease may include renal replacement therapy, reduced used of potassium-sparing diuretics, discontinue ACE inhibitors, and use of potassium binders (cation exchange resin, patiromer). B) Treatment of hyperkalemia in the patient with chronic kidney disease may include renal replacement therapy, reduced used of potassium-sparing diuretics, discontinue ACE inhibitors, and use of potassium binders (cation exchange resin, patiromer). C) Treatment of hyperkalemia in the patient with chronic kidney disease may include renal replacement therapy, reduced used of potassium-sparing diuretics, discontinue ACE inhibitors, and use of potassium binders (cation exchange resin, patiromer). D) Treatment of hyperkalemia in the patient with chronic kidney disease may include renal replacement therapy, reduced used of potassium-sparing diuretics, discontinue ACE inhibitors, and use of potassium binders (cation exchange resin, patiromer). Page Ref: 1153 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Implementation | Learning Outcome: 46.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of chronic kidney disease and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of acute kidney injury and endstage kidney disease to diagnosis and treatment.

20) The nursing plan of care for a patient with stage 4 chronic kidney disease (CKD) includes: A) controlling blood pressure and diabetes. B) treating hyperphosphatemia. C) cardiovascular risk reduction. D) preparation for renal replacement therapy. Answer: D Explanation: A) Interventions appropriate for stage 2 CKD includes controlling blood pressure and diabetes. B) Interventions appropriate for stage 3 CKD includes treating complications, such as hyperphosphatemia. C) Interventions appropriate for stage 1 CKD includes reducing the risk of cardiovascular disease. D) Interventions appropriate for stage 4 CKD includes preparation for renal replacement therapy. Page Ref: 1153 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 46.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of chronic kidney disease and approaches to diagnosis and treatment of the condition across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of acute kidney injury and endstage kidney disease to diagnosis and treatment.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 47 Disorders of the Female Reproductive System 1) What response should the nurse give to the parents who are concerned about milk secretion from their male newborn's breasts? A) "I will alert the doctor because this may indicate a serious problem." B) "This is normal and should go away soon." C) "This should only occur in female babies." D) "This will last for about a year." Answer: B Explanation: A) Neonatal galactorrhea is caused by elevated levels of estrogen in the intrapartum period resulting in breast engorgement and lactation. Also known as "witch's milk," this issue usually clears on its own in the neonatal period. There is no reason to notify the doctor. B) Neonatal galactorrhea is caused by elevated levels of estrogen in the intrapartum period resulting in breast engorgement and lactation. Also known as "witch's milk," this issue usually clears on its own in the neonatal period. C) Neonatal galactorrhea is caused by elevated levels of estrogen in the intrapartum period resulting in breast engorgement and lactation. Also known as "witch's milk," this issue usually clears on its own in the neonatal period. There is no reason to notify the doctor. D) Neonatal galactorrhea is caused by elevated levels of estrogen in the intrapartum period resulting in breast engorgement and lactation. Also known as "witch's milk," this issue usually clears on its own in the neonatal period. There is no reason to notify the doctor. Page Ref: 1166 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 47.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the female breasts and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of disorders of the female reproductive system.

2) The nurse would expect to observe which findings in a breastfeeding woman with mastitis? A) Dimpling of the skin, erythema, and inverted nipple B) Red, scaly rash and warm, hard mass C) Tenderness, warmth, and erythema D) Tenderness, inverted nipple, and red, scaly rash Answer: C Explanation: A) Clinical manifestations of mastitis include local tenderness, swelling, warmth, and erythema in one breast with a consistent or intermittent burning sensation during breastfeeding. Flulike symptoms of fever 101°F (38.3°C) or greater, chills, malaise, body aches, headache, and loss of appetite may also be experienced. B) Clinical manifestations of mastitis include local tenderness, swelling, warmth, and erythema in one breast with a consistent or intermittent burning sensation during breastfeeding. Flulike symptoms of fever 101°F (38.3°C) or greater, chills, malaise, body aches, headache, and loss of appetite may also be experienced. C) Clinical manifestations of mastitis include local tenderness, swelling, warmth, and erythema in one breast with a consistent or intermittent burning sensation during breastfeeding. Flulike symptoms of fever 101°F (38.3°C) or greater, chills, malaise, body aches, headache, and loss of appetite may also be experienced. D) Clinical manifestations of mastitis include local tenderness, swelling, warmth, and erythema in one breast with a consistent or intermittent burning sensation during breastfeeding. Flulike symptoms of fever 101°F (38.3°C) or greater, chills, malaise, body aches, headache, and loss of appetite may also be experienced. Page Ref: 1167 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 47.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the female breasts and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of the female reproductive system.

3) Which statement by a breastfeeding woman with mastitis alerts the nurse to a potential problem? A) "I am favoring my unaffected breast when I breastfeed." B) "I should continue to breastfeed because the infection won't spread to my baby." C) "I will try different positions for breastfeeding." D) "I need to drink a lot of water." Answer: A Explanation: A) Drainage of milk from the affected breast is encouraged through continuing breastfeeding or pumping to relieve engorgement and to maintain the mother's milk supply. B) Mastitis will not spread to an infant; nor does breastfeeding in the presence of mastitis pose a risk to the infant. C) Treatment of mastitis includes improving breastfeeding technique with the help of a lactation specialist, specifically to improve position and latching. D) Adequate rest, a healthy diet, and good hydration are all important for mastitis management. Page Ref: 1167 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Evaluation | Learning Outcome: 47.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the female breasts and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the female reproductive system to diagnosis and treatment.

4) The nurse is preparing a woman with a breast lump for diagnostic testing. Which of the following is not part of the triple assessment for diagnosis of breast cancer? A) Clinical examination B) Mammogram C) Needle biopsy D) Magnetic resonance imaging Answer: D Explanation: A) Practitioners use the triple assessment for diagnosis of breast cancer. This method includes clinical examination, imaging of the breast using mammogram and/or ultrasound, and biopsy with a needle biopsy for examination of cells and tissue. B) Practitioners use the triple assessment for diagnosis of breast cancer. This method includes clinical examination, imaging of the breast using mammogram and/or ultrasound, and biopsy with a needle biopsy for examination of cells and tissue. C) Practitioners use the triple assessment for diagnosis of breast cancer. This method includes clinical examination, imaging of the breast using mammogram and/or ultrasound, and biopsy with a needle biopsy for examination of cells and tissue. D) Magnetic resonance imaging is not part of the triple assessment for diagnosis breast cancer. Page Ref: 1168 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 47.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the female breasts and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the female reproductive system to diagnosis and treatment.

5) Which patient statement is typical of data collected on patients who have primary dysmenorrhea? A) "Oral contraceptives have not helped my menstrual pain." B) "I have heavy and irregular menstrual flow." C) "Pain during menstruation began when I was 22 years old." D) "I have always had pain during menstruation." Answer: D Explanation: A) Secondary dysmenorrhea affects patients in their second and third decades of life. The patients may have had normal pain-free menstrual cycles until this point. Clinically, they present with heavy flow or irregular bleeding, painful intercourse, vaginal discharge, and poor response to pain medication or oral contraceptives. B) Secondary dysmenorrhea affects patients in their second and third decades of life. The patients may have had normal pain-free menstrual cycles until this point. Clinically, they present with heavy flow or irregular bleeding, painful intercourse, vaginal discharge, and poor response to pain medication or oral contraceptives. C) Secondary dysmenorrhea affects patients in their second and third decades of life. The patients may have had normal pain-free menstrual cycles until this point. Clinically, they present with heavy flow or irregular bleeding, painful intercourse, vaginal discharge, and poor response to pain medication or oral contraceptives. D) Patients with primary dysmenorrhea will present with symptoms that begin about 6 months after menarche. Page Ref: 1169 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 47.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of menstruation and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of the female reproductive system.

6) A woman describes her bleeding during menstruation as abnormally heavy. The nurse explains that this condition is called: A) menorrhagia. B) metrorrhagia. C) menometrorrhagia. D) dysmenorrhea. Answer: A Explanation: A) Menorrhagia is abnormally heavy bleeding. B) Metrorrhagia is irregular and frequent bouts of bleeding that are noncycle related. C) Menometrorrhagia is excessive bleeding over a prolonged period of time at irregular intervals. D) Dysmenorrhea is painful menstruation. Page Ref: 1171 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 47.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of menstruation and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of the female reproductive system.

7) Which of the following descriptions of symptoms would alert the nurse to a diagnosis of premenstrual syndrome? A) Symptoms are present for 5 days before menstruation begins, symptoms end within 2 days after menstrual cycle starts B) Symptoms are present for 5 days before menstruation begins, symptoms are present for at least three consecutive menstrual cycles C) Symptoms are present for 2 days before menstruation begins, symptoms are present for at least six consecutive menstrual cycles D) Symptoms are present for 2 days before menstruation begins, symptoms end within 4 days after menstrual cycle starts Answer: B Explanation: A) To diagnose premenstrual syndrome, a pattern of symptoms must be confirmed. Symptoms must be present for 5 days before the menstrual period begins and should persist for at least three consecutive menstrual cycles. Symptoms must clearly interfere with normal activities of life and end within 4 days after the menstrual cycle begins. B) To diagnose premenstrual syndrome, a pattern of symptoms must be confirmed. Symptoms must be present for 5 days before the menstrual period begins and should persist for at least three consecutive menstrual cycles. Symptoms must clearly interfere with normal activities of life and end within 4 days after the menstrual cycle begins. C) To diagnose premenstrual syndrome, a pattern of symptoms must be confirmed. Symptoms must be present for 5 days before the menstrual period begins and should persist for at least three consecutive menstrual cycles. Symptoms must clearly interfere with normal activities of life and end within 4 days after the menstrual cycle begins. D) To diagnose premenstrual syndrome, a pattern of symptoms must be confirmed. Symptoms must be present for 5 days before the menstrual period begins and should persist for at least three consecutive menstrual cycles. Symptoms must clearly interfere with normal activities of life and end within 4 days after the menstrual cycle begins. Page Ref: 1172 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 47.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of menstruation and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of the female reproductive system.

8) Which findings would the nurse expect when assessing a woman with polycystic ovary syndrome? A) Acanthosis nigricans and small ovaries B) Hirsutism and acne C) Hypotension and linea nigra D) Enlarged ovaries and lack of body hair Answer: B Explanation: A) On examination, findings in women with polycystic ovary syndrome may include virilizing signs (excess facial hair, acne), acanthosis nigricans (dark, velvety discoloration in body folds and creases often linked to diabetes), enlarged ovaries, and hypertension. B) On examination, findings in women with polycystic ovary syndrome may include virilizing signs (excess facial hair, acne), acanthosis nigricans (dark, velvety discoloration in body folds and creases often linked to diabetes), enlarged ovaries, and hypertension. C) On examination, findings in women with polycystic ovary syndrome may include virilizing signs (excess facial hair, acne), acanthosis nigricans (dark, velvety discoloration in body folds and creases often linked to diabetes), enlarged ovaries, and hypertension. Linea nigra is the dark vertical line on the abdomen of pregnant women. D) On examination, findings in women with polycystic ovary syndrome may include virilizing signs (excess facial hair, acne), acanthosis nigricans (dark, velvety discoloration in body folds and creases often linked to diabetes), enlarged ovaries, and hypertension. Page Ref: 1173 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 47.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the ovaries and fallopian tubes and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of the female reproductive system.

9) A woman, who has just been diagnosed with stage II endometriosis, asks the nurse what the diagnosis means. The nurse explains that in stage II endometriosis: A) there is minimal invasion of endometrial tissue. B) there is deeper implantation of into the endometrial tissue. C) there are many deep implants into the tissue with involvement of the ovaries and some adhesions. D) there are many deep implants, involvement of the ovaries, and deep adhesions in the rectum. Answer: B Explanation: A) Stage I involves minimal invasion of the endometrial tissue. B) Stage II involves deeper implantation into the endometrial tissue. C) Stage III is moderate and involves many deep implants into the tissue with endometriomas on one or both of the ovaries as well as some adhesions. D) Stage IV, the most severe stage of endometriosis, involves many deep implants with large endometriomas on one or both ovaries as well as deep adhesions that can grow into the rectum on the backside of the uterus. Page Ref: 1177 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 47.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the uterus and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the female reproductive system to diagnosis and treatment.

10) The nurse is teaching a community program about endometrial cancer. Which risk factors does the nurse include? A) Obesity B) Multiparity C) Late onset menarche D) Low-fat diet Answer: A Explanation: A) Risk factors for endometrial cancer include obesity, diabetes, a high-fat diet, increased exposure to hormones such as estrogen, early onset of menarche, a history of anovulation, infertility, and nulliparity (never having given birth or carried a pregnancy). B) Risk factors for endometrial cancer include obesity, diabetes, a high-fat diet, increased exposure to hormones such as estrogen, early onset of menarche, a history of anovulation, infertility, and nulliparity (never having given birth or carried a pregnancy). C) Risk factors for endometrial cancer include obesity, diabetes, a high-fat diet, increased exposure to hormones such as estrogen, early onset of menarche, a history of anovulation, infertility, and nulliparity (never having given birth or carried a pregnancy). D) Risk factors for endometrial cancer include obesity, diabetes, a high-fat diet, increased exposure to hormones such as estrogen, early onset of menarche, a history of anovulation, infertility, and nulliparity (never having given birth or carried a pregnancy). Page Ref: 1177-1178 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 47.5 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the uterus and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of disorders of the female reproductive system.

11) Which of the following should the nurse include in the teaching plan for a patient with cervicitis? A) This condition is never caused by a sexually transmitted infection. B) Sexual partners do not need to be tested for sexually transmitted diseases. C) The infection is confined to the cervix. D) Chlamydia is a common cause of cervicitis. Answer: D Explanation: A) The most common cause of infectious cervicitis is chlamydia or gonorrhea. It can also be related to trichomoniasis or genital herpes. Noninfectious cervicitis may result from trauma to the cervix, radiation treatments, systemic inflammation, and malignancy. B) Because of the relationship between cervicitis and STIs, all patients with cervicitis and their partners should be tested for STIs. C) Because the cervix is connected to the uterus, all patients should also be tested for PID because the infection can migrate toward the uterus and ovaries. D) The most common cause of infectious cervicitis is chlamydia or gonorrhea. It can also be related to trichomoniasis or genital herpes. Noninfectious cervicitis may result from trauma to the cervix, radiation treatments, systemic inflammation, and malignancy. Page Ref: 1178 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 47.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the cervix, vagina, and vulva and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the female reproductive system to diagnosis and treatment.

12) Which of the following statements made by a patient with cervical cancer indicates to the nurse that more teaching is needed? A) "This cancer is caused by HPV." B) "Multiple sexual partners increased my risk for HPV." C) "HPV does not increase my risk for HIV." D) "HPV places me at risk for other sexually transmitted infections." Answer: C Explanation: A) Cervical cancer occurs only in women who have had an HPV virus. B) The risk factors for contracting HPV are initiation of sexual contact at a young age, multiple sex partners, and a history of STIs. C) Positive cases of HPV place a woman at risk for HIV and other sexually transmitted diseases. D) Positive cases of HPV place a woman at risk for HIV and other sexually transmitted diseases. Page Ref: 1180 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Evaluation | Learning Outcome: 47.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the cervix, vagina, and vulva and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of disorders of the female reproductive system.

13) Which recommendation should the nurse at a women's center on a college campus give to women during a health and wellness presentation? A) HPV vaccination is recommended for most college-age women. B) Women should undergo Pap smear testing beginning at age 16. C) Women should begin Pap smear testing within 5 years of beginning sexual activity. D) HPV vaccination is only indicated before age 21. Answer: A Explanation: A) An HPV vaccination is now available for women 9-26 years of age. B) All women should undergo Pap smear testing beginning at age 21 or within 3 years of initiating sexual activity. C) All women should undergo Pap smear testing beginning at age 21 or within 3 years of initiating sexual activity. D) An HPV vaccination is now available for women 9-26 years of age. Page Ref: 1180 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 47.6 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the cervix, vagina, and vulva and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of disorders of the female reproductive system.

14) Which statement by a 34-year-old woman, who has been trying to get pregnant, indicates to the nurse that more teaching is needed? A) "My husband may also contribute to my infertility." B) "I have infertility because I have had unprotected sex for at least a year without conceiving." C) "I have infertility because I have been trying to get pregnant for 6 months. " D) "Cervical stenosis can contribute to my infertility." Answer: C Explanation: A) It should be noted that men can also have or contribute to infertility issues. When a couple is having difficulty conceiving, men are tested early in the process of infertility evaluation. B) An infertility assessment is usually initiated after 1 year of regular unprotected intercourse in women under age 35 and after 6 months of unprotected intercourse in women age 35 and older. C) An infertility assessment is usually initiated after 1 year of regular unprotected intercourse in women under age 35 and after 6 months of unprotected intercourse in women age 35 and older. D) The etiology of female infertility is multifactorial and can arise from various parts of the reproductive system, including cervical stenosis. Page Ref: 1182 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Evaluation | Learning Outcome: 47.8 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of female fertility and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of disorders of the female reproductive system.

15) Which response should the nurse give when a woman shares that she has never had an orgasm? A) "Some women never have an orgasm." B) "It is not necessary for you to have an orgasm in order to be healthy." C) "Tell me more about this." D) "This problem does not involve your sexual partner." Answer: C Explanation: A) This is dismissive of the patient's concern and may prevent the woman seeking evaluation and care. B) This is dismissive of the patient's concern and may prevent the woman seeking evaluation and care. C) This open-ended question lets the woman know that the nurse is open to hearing more about the problem. D) Psychotherapy and counseling for the woman and her partner may help with primary orgasmic disorder, particularly if it is associated with abuse. Page Ref: 1184 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity Standards: Nursing Process: Implementation | Learning Outcome: 47.9 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of sexual dysfunction and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.A.9 Discuss principles of effective communication | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Effective Communication MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the female reproductive system to diagnosis and treatment.

16) Which of the following laboratory values would the nurse anticipate might occur in a patient with galactorrhea? A) Decreased TSH levels B) Elevated estradiol levels C) Elevated serum gonadotropin levels D) Elevated prolactin levels Answer: D Explanation: A) Primary hypothyroidism as a cause of galactorrhea is ruled out by an elevated serum level of TSH. B) Serum gonadotropin and estradiol levels are either low or in the normal range in women with hyperprolactinemia. C) Serum gonadotropin and estradiol levels are either low or in the normal range in women with hyperprolactinemia. D) Elevated levels of prolactin, typically greater than five times the normal range, indicate a prolactin-secreting pituitary tumor. Page Ref: 1166 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 47.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the female breasts and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of disorders of the female reproductive system.

17) The nurse is participating in a community health fair and is teaching risk factors for breast cancer. Which statement is the nurse most likely to make? A) "Menopause after age 55 increases the risk of breast cancer." B) "Overuse of alcohol does not increase the risk of breast cancer." C) "Menarche after age 15 increases the risk of breast cancer." D) "A first- or second-degree relative with breast cancer before age of 50 increases the risk of breast cancer." Answer: A Explanation: A) Menarche before age 12 and menopause after age 55 both increase the risk for breast cancer. B) Environmental risks for breast cancer include smoking, overuse of alcohol, and exposure to radiation. C) Menarche before age 12 and menopause after age 55 both increase the risk for breast cancer. D) Having a first-degree relative who had breast cancer under the age of 50 increases the risk of breast cancer. Page Ref: 1167 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 47.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the female breasts and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of disorders of the female reproductive system.

18) Which statement by a woman with breast cancer indicates that more teaching about treatment is needed? A) "Staging the cancer helps guide treatment." B) "Because my friend didn't have chemotherapy after lumpectomy, I am not expecting chemotherapy either." C) "Because I have the BRCA1 gene, I am considering having both breasts removed." D) "Hormone therapy won't work because my cancer doesn't have hormone receptors." Answer: B Explanation: A) Staging of the cancer is done by using the TNM system, which involves measuring the size of the primary tumor (T), determining how many nodes (N) are involved locally and regionally from the breast, and whether there is metastasis (M) in any other areas of the body. This staging helps guide treatment of breast cancer. B) Treatment for cancer is individual and depends on many factors, including staging of the tumor, whether the woman has reached menopause, assessment of her hormone receptor status to guide the medication regimen, her baseline health status, and the risk for recurrence (including the patient's BRCA1 or BRCA2 status). C) Women who are BRCA1 and BRCA2 positive have a high risk for breast cancer in the other breast. D) If no receptors are present, hormone therapy would not be effective, and another treatment is chosen. Page Ref: 1168 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 47.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the female breasts and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the female reproductive system to diagnosis and treatment.

19) Which of the following information should the nurse not include in a women's breast health program? A) Breast tissue changes throughout the menstrual cycle. B) Nonproliferative benign breast disease raises the risk of breast cancer. C) Many women develop benign breast disease during their lifetime. D) One in eight women in the United States will be diagnosed with breast cancer. Answer: B Explanation: A) Breast tissue can change throughout the month in conjunction with a woman's menstrual cycle and hormonal changes, causing the breast tissue to feel larger and more painful than it would during the rest of the month. B) Nonproliferative BBD involves no increase in cellular production and does not carry an increased risk of subsequent cancer. C) It is estimated that 50% of women will develop some form of BBD in their lifetime; it generally starts in the second decade of life and tends to peak after menopause. D) It is estimated that one in eight women in the United States will have a diagnosis of breast cancer in their lifetime. Page Ref: 1165 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 47.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the female breasts and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of disorders of the female reproductive system.

20) Which of the following statements by a woman with a follicular ovarian cyst indicates that more teaching is needed? A) "What is the prognosis for this type of cancer?" B) "The cyst formed during a surge of FSH and a drop in LH before ovulation." C) "My CA-125 test was negative so it is likely my cyst is benign." D) "Because my cyst is small, I will need to follow up in a few months to see if it has grown." Answer: A Explanation: A) Follicular ovarian cysts are not cancerous. Follicular cysts form during the follicular phase of the cycle. These cysts form when the ovum fails to be released. Often, there is a surge of FSH and a lower level of LH before ovulation occurs, causing cyst formation. B) Follicular cysts form during the follicular phase of the cycle. These cysts form when the ovum fails to be released. Often, there is a surge of FSH and a lower level of LH before ovulation occurs, causing cyst formation. C) Laboratory testing to rule out ovarian cancer is done by using the CA-125 tests. D) Asymptomatic patients who have cysts that are smaller than 5 cm in diameter can be followed up with ultrasound after 4 months to determine whether there is any change in the size of the cysts. Page Ref: 1174 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Evaluation | Learning Outcome: 47.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the ovaries and fallopian tubes and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the female reproductive system to diagnosis and treatment.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 48 Disorders of the Male Reproductive System 1) Which findings would the nurse expect in a patient diagnosed with chronic prostatitis? A) Fever, chills, and dysuria B) Chronic symptoms of prostatitis, recurrent urinary tract infection, epididymitis C) Chronic pelvic pain, painful ejaculation, blood-tinged urine, and scrotal pain D) Inflamed prostate, but no genitourinary tract symptoms Answer: C Explanation: A) Acute bacterial prostatitis causes symptoms of fever, chills, arthralgia, low back pain, pelvic pain, abdominal pain, perineal fullness, dysuria (painful urination), urinary frequency and urgency usually at night, painful ejaculation, foul-smelling urine, urinary obstruction, blood-tinged urine, and/or semen-tinged urine. B) Chronic bacterial prostatitis is a chronic bacterial infection of the prostate that occurs with or without symptoms of prostatitis, often with recurrent UTIs caused by the same bacterial strain, associated with episodes of urethritis, epididymitis, or acute prostatitis. C) The symptoms of chronic prostatitis include painful ejaculation; dysuria; blood-tinged urine; blood-tinged semen; and pain in the perineal, suprapubic, coccygeal, rectal, urethral, testicular, and scrotal areas. D) In asymptomatic inflammatory prostatitis there is prostate inflammation without genitourinary tract symptoms. Page Ref: 1194-1195 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 48.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the prostate and approaches to diagnosis and treatment of these conditions. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of male reproductive disorders.

2) When looking at the medical record of a patient with prostatitis, the nurse would expect the digital rectal examination to reveal: A) a hard, enlarged nontender prostate. B) a firm prostate with nodules. C) an enlarged, boggy, tender prostate. D) a firm prostate protruding into rectum. Answer: C Explanation: A) Diagnosis of prostatitis includes a digital rectal examination (DRE), during which the clinician palpates the prostate through the rectum. An enlarged, boggy, tender prostate is an expected finding. B) Diagnosis of prostatitis includes a digital rectal examination (DRE), during which the clinician palpates the prostate through the rectum. An enlarged, boggy, tender prostate is an expected finding. C) Diagnosis of prostatitis includes a digital rectal examination (DRE), during which the clinician palpates the prostate through the rectum. An enlarged, boggy, tender prostate is an expected finding. D) Diagnosis of prostatitis includes a digital rectal examination (DRE), during which the clinician palpates the prostate through the rectum. An enlarged, boggy, tender prostate is an expected finding. Page Ref: 1195 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 48.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the prostate and approaches to diagnosis and treatment of these conditions. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of male reproductive disorders.

3) Which statement by a patient indicates that he needs more teaching about prostate-specific antigen (PSA) levels? A) "Infection can increase my PSA level." B) "PSA levels can't distinguish between cancer and benign prostatic hyperplasia." C) "An elevated PSA would be an indication for further testing." D) "An elevated PSA level means I have prostate cancer." Answer: D Explanation: A) While PSA levels are elevated in prostate cancer, infection can also increase PSA levels. B) Because infection may increase PSA levels, PSA levels cannot be used to distinguish between cancer and benign prostatic hyperplasia. C) Because PSA levels cannot be used to distinguish between cancer and benign prostatic hyperplasia, further testing would be needed. D) Because infection may increase PSA levels, PSA levels cannot be used to distinguish between cancer and benign prostatic hyperplasia. Page Ref: 1196 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 48.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the prostate and approaches to diagnosis and treatment of these conditions. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the male reproductive systems to diagnosis and treatment.

4) When assessing a patient with benign prostatic hyperplasia, which would the nurse consider a late finding? A) Difficulty starting a flow of urine B) A weak stream of urine C) Nocturia D) Urinary incontinence Answer: D Explanation: A) These are all findings in benign prostatic hyperplasia, but as the bladder becomes more sensitive to the retention of urine, incontinence may result. B) These are all findings in benign prostatic hyperplasia, but as the bladder becomes more sensitive to the retention of urine, incontinence may result. C) These are all findings in benign prostatic hyperplasia, but as the bladder becomes more sensitive to the retention of urine, incontinence may result. D) These are all findings in benign prostatic hyperplasia, but as the bladder becomes more sensitive to the retention of urine, incontinence may result. Page Ref: 1195 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 48.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the prostate and approaches to diagnosis and treatment of these conditions. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of male reproductive disorders.

5) Which of the follow statements made by a patient with benign prostatic hyperplasia indicates that he needs more instruction about active surveillance treatment? A) "I need to get a digital rectal exam every year." B) "I should not take tranquilizers." C) "I should drink plenty of fluids in the evening." D) "I should avoid over-the-counter decongestants." Answer: C Explanation: A) The least invasive treatment for BPH is watchful waiting, or active surveillance. This approach is used for patients who have minimal symptoms and minimal enlargement of the prostate. Patients who opt for watchful waiting receive yearly examinations with evaluation using DRE. B) During this period of active surveillance, the patient should avoid tranquilizers and over-thecounter medications that contain decongestants, as these medications can worsen obstructive symptoms. C) During this period of active surveillance, the patient should avoid excess fluids in the evening to decrease the chances of nocturia. D) During this period of active surveillance, the patient should avoid tranquilizers and over-thecounter medications that contain decongestants, as these medications can worsen obstructive symptoms. Page Ref: 1196 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Evaluation | Learning Outcome: 48.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the prostate and approaches to diagnosis and treatment of these conditions. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the male reproductive systems to diagnosis and treatment.

6) Which instruction should the nurse give the patient with benign prostatic hyperplasia being treated with an alpha blocker? A) "This drug works by relaxing the smooth muscles of the prostate." B) "Symptoms should start to improve in 48 to 72 hours." C) "Notify the doctor if you experience a slow heart rate." D) "This drug may make you hyperaroused or excitable." Answer: A Explanation: A) Alpha blockers act on the alpha receptors in the prostate, causing the smooth muscles of the prostate to relax. Relaxation of these muscles decreases constriction of the urethra. B) It may take 2 weeks to 4 months to notice symptom improvement when starting an alpha blocker. C) Adverse effects of alpha blockers include headache, nasal congestion, dizziness, drowsiness, postural hypotension, reflex tachycardia, and retrograde or delayed ejaculation. D) Adverse effects of alpha blockers include headache, nasal congestion, dizziness, drowsiness, postural hypotension, reflex tachycardia, and retrograde or delayed ejaculation. Page Ref: 1196 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Implementation | Learning Outcome: 48.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the prostate and approaches to diagnosis and treatment of these conditions. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the male reproductive systems to diagnosis and treatment.

7) When conducting a community program about prostate cancer screening, which of the following digital rectal examination (DRE) screening schedules does the nurse recommend? A) All men should have an annual DRE by age 60. B) African American men should begin annual DRE screening at age 45. C) Men with a first-degree relative with prostate cancer should start DRE screening at age 50. D) Men with more than one first-degree relative with prostate cancer should begin DRE screening at age 45. Answer: B Explanation: A) The American Cancer Society recommends that men have a DRE annually beginning at the age of 50. B) The American Cancer Society recommendations change to age 45 for African American men and those with a first-degree relative with prostate cancer and to age 40 for those with more than one first-degree relative with prostate cancer. C) The American Cancer Society recommendations change to age 45 for African American men and those with a first-degree relative with prostate cancer and to age 40 for those with more than one first-degree relative with prostate cancer. D) The American Cancer Society recommendations change to age 45 for African American men and those with a first-degree relative with prostate cancer and to age 40 for those with more than one first-degree relative with prostate cancer. Page Ref: 1197 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 48.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the prostate and approaches to diagnosis and treatment of these conditions. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of disorders of the male reproductive system.

8) Which information does the nurse give the patient when he asks what his grade 1 score on his prostate biopsy using the Gleason Scoring System means? A) The tissue sample was poorly differentiated cancer, with a good prognosis. B) The tissue sample was well differentiated, with a poor chance of cure. C) The tissue sample was well differentiated, with a good chance of cure. D) The tissue sample was poorly differentiated cancer, with a poor prognosis. Answer: C Explanation: A) This Gleason Scoring System differentiates the diagnosis of prostate cancer into five different grades. In grade 1, the tissue is well differentiated, and the patient is most likely to have a good prognosis with the greatest chance of a cure. A grade 5 classification would be a poorly differentiated cancer with a poor prognosis. B) This Gleason Scoring System differentiates the diagnosis of prostate cancer into five different grades. In grade 1, the tissue is well differentiated, and the patient is most likely to have a good prognosis with the greatest chance of a cure. A grade 5 classification would be a poorly differentiated cancer with a poor prognosis. C) This Gleason Scoring System differentiates the diagnosis of prostate cancer into five different grades. In grade 1, the tissue is well differentiated, and the patient is most likely to have a good prognosis with the greatest chance of a cure. A grade 5 classification would be a poorly differentiated cancer with a poor prognosis. D) This Gleason Scoring System differentiates the diagnosis of prostate cancer into five different grades. In grade 1, the tissue is well differentiated, and the patient is most likely to have a good prognosis with the greatest chance of a cure. A grade 5 classification would be a poorly differentiated cancer with a poor prognosis. Page Ref: 1197 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 48.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the prostate and approaches to diagnosis and treatment of these conditions. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the male reproductive systems to diagnosis and treatment.

9) Which information should the nurse give to parents who are concerned about the newborn's hydrocele? A) "Your baby will need surgery to correct this before his first birthday." B) "Typically, no treatment is needed as the fluid goes away on its own within the first year of life." C) "Keep the testicles elevated when the baby is lying down." D) "Scrotal massage can help to hasten the fluid resorption." Answer: B Explanation: A) Hydroceles are common in newborns. They usually disappear in the first year of life without any treatment. B) Hydroceles are common in newborns. They usually disappear in the first year of life without any treatment. C) Hydroceles are common in newborns. They usually disappear in the first year of life without any treatment. D) Hydroceles are common in newborns. They usually disappear in the first year of life without any treatment. Page Ref: 1198 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 48.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the testicles and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the male reproductive systems to diagnosis and treatment.

10) Which of the following findings would the nurse anticipate prompted a patient with epididymitis to seek care? A) Burning on urination B) Fever, nausea, and vomiting C) Pain and swelling for several days D) Foul-smelling urine Answer: C Explanation: A) Burning on urination may signal a urinary tract infection. B) Signs and symptoms of orchitis usually develop suddenly and include swelling in one or both testicles, pain, tenderness, fever, nausea, and vomiting. C) Symptoms of acute epididymitis include pain and swelling over several days. D) Symptoms of acute bacterial prostatitis include fever, chills, arthralgia, low back pain, pelvic pain, abdominal pain, perineal fullness, dysuria (painful urination), urinary frequency and urgency usually at night, painful ejaculation, foul-smelling urine, urinary obstruction, bloodtinged urine, and/or semen-tinged urine. Page Ref: 1195, 1198 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 48.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the testicles and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of male reproductive disorders.

11) Which is a priority intervention if the nurse suspects testicular torsion in a male patient? A) Instruct the patient to wear an athletic strap to support the scrotum. B) Apply cold packs to the scrotum. C) Notify the physician immediately. D) Place the patient in a supine position with the legs elevated. Answer: C Explanation: A) Testicular torsion occurs when the spermatic cord structures twist within the testicle, causing loss of blood supply to the ipsilateral testis. Testicular torsion is a medical emergency. To salvage the testicle, surgical repair must happen within 6 hours of the onset of symptoms. If surgical treatment is delayed, the patient may have decreased fertility or require an orchiectomy (removed of the testicle). B) Testicular torsion occurs when the spermatic cord structures twist within the testicle, causing loss of blood supply to the ipsilateral testis. Testicular torsion is a medical emergency. To salvage the testicle, surgical repair must happen within 6 hours of the onset of symptoms. If surgical treatment is delayed, the patient may have decreased fertility or require an orchiectomy (removed of the testicle). C) Testicular torsion occurs when the spermatic cord structures twist within the testicle, causing loss of blood supply to the ipsilateral testis. Testicular torsion is a medical emergency. To salvage the testicle, surgical repair must happen within 6 hours of the onset of symptoms. If surgical treatment is delayed, the patient may have decreased fertility or require an orchiectomy (removed of the testicle). D) Testicular torsion occurs when the spermatic cord structures twist within the testicle, causing loss of blood supply to the ipsilateral testis. Testicular torsion is a medical emergency. To salvage the testicle, surgical repair must happen within 6 hours of the onset of symptoms. If surgical treatment is delayed, the patient may have decreased fertility or require an orchiectomy (removed of the testicle). Page Ref: 1198-1199 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 48.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the testicles and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: VII. 10. Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and prevention of illness, injury, disability and premature death NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the male reproductive systems to diagnosis and treatment.

12) When performing health screenings on a college campus, which factor should the university health nurse keep in mind as increasing the risk of testicular cancer in men? A) History of measles B) African American race C) Family history of prostate cancer D) Cryptorchidism Answer: D Explanation: A) There are certain risk factors associated with testicular cancer, including having had mumps, low weight at birth, trauma to the testes, a family history of testicular cancer, cryptorchidism (the absence of one or both testes from the scrotum, also referred to as undescended testes), age, congenital abnormalities, and white ethnicity. B) There are certain risk factors associated with testicular cancer, including having had mumps, low weight at birth, trauma to the testes, a family history of testicular cancer, cryptorchidism (the absence of one or both testes from the scrotum, also referred to as undescended testes), age, congenital abnormalities, and white ethnicity. C) There are certain risk factors associated with testicular cancer, including having had mumps, low weight at birth, trauma to the testes, a family history of testicular cancer, cryptorchidism (the absence of one or both testes from the scrotum, also referred to as undescended testes), age, congenital abnormalities, and white ethnicity. D) Males with cryptorchidism may have a 10-40% increased chance of getting testicular cancer. Page Ref: 1199-1200 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Assessment | Learning Outcome: 48.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the testicles and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII.2. Conduct a health history, including environmental exposure and a family history that recognizes genetic risks, to identify current and future health problems NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of disorders of the male reproductive system.

13) Which tumor markers would the nurse anticipate being tested in a 22-year-old man with a testicular mass? A) Alpha-fetoprotein, human chorionic gonadotropin, lactate dehydrogenase B) BRCA1, BRCA2, alpha-fetoprotein C) CA-125, human chorionic gonadotropin, lactate dehydrogenase D) Carcinoembryonic antigen, immunoglobulins, alpha-fetoprotein Answer: A Explanation: A) Tumor markers are essential indicators of testicular cancer. These tumor markers include alpha-fetoprotein, human chorionic gonadotropin, and lactate dehydrogenase. The blood tests are important in diagnosing and monitoring testicular cancer. These serum markers may detect testicular cancer even before a small tumor is evident. B) Tumor markers are essential indicators of testicular cancer. These tumor markers include alpha-fetoprotein, human chorionic gonadotropin, and lactate dehydrogenase. The blood tests are important in diagnosing and monitoring testicular cancer. These serum markers may detect testicular cancer even before a small tumor is evident. C) Tumor markers are essential indicators of testicular cancer. These tumor markers include alpha-fetoprotein, human chorionic gonadotropin, and lactate dehydrogenase. The blood tests are important in diagnosing and monitoring testicular cancer. These serum markers may detect testicular cancer even before a small tumor is evident. D) Tumor markers are essential indicators of testicular cancer. These tumor markers include alpha-fetoprotein, human chorionic gonadotropin, and lactate dehydrogenase. The blood tests are important in diagnosing and monitoring testicular cancer. These serum markers may detect testicular cancer even before a small tumor is evident. Page Ref: 1200 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 48.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the testicles and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the male reproductive systems to diagnosis and treatment.

14) Which statement by a parent of a newborn with hypospadias indicates an understanding of instructions given by the nurse? A) "Circumcision should not be done now." B) "We will have the baby circumcised before we leave the hospital." C) "The condition will be surgically repaired before we leave the hospital." D) "The condition will be repaired at 3 months of age." Answer: A Explanation: A) Hypospadias can be surgically repaired, usually when the child is between 6 months and 2 years of age. Boys with this condition should not be circumcised at birth. B) Hypospadias can be surgically repaired, usually when the child is between 6 months and 2 years of age. Boys with this condition should not be circumcised at birth. C) Hypospadias can be surgically repaired, usually when the child is between 6 months and 2 years of age. Boys with this condition should not be circumcised at birth. D) Hypospadias can be surgically repaired, usually when the child is between 6 months and 2 years of age. Boys with this condition should not be circumcised at birth. Page Ref: 1200-1201 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Evaluation | Learning Outcome: 48.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the penis and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the male reproductive systems to diagnosis and treatment.

15) Which of the following is a priority action when the nurse observes paraphimosis in an elderly man? A) Place the patient on bedrest and assess in two hours. B) Administer an analgesic for pain. C) Notify the physician immediately. D) Teach the patient how to care for his foreskin. Answer: C Explanation: A) Paraphimosis is a medical emergency–failure to resolve the problem can lead to necrosis and gangrene of the glans penis. The goal is to reduce the foreskin to its naturally occurring position over the glans penis. The nurse should not wait two hours to reassess the patient but should call the physician immediately. B) While the patient may be in pain, the first step is to notify the physician immediately. Paraphimosis is a medical emergency–failure to resolve the problem can lead to necrosis and gangrene of the glans penis. C) Paraphimosis is a medical emergency–failure to resolve the problem can lead to necrosis and gangrene of the glans penis. The goal is to reduce the foreskin to its naturally occurring position over the glans penis. The nurse should call the physician immediately. D) While teaching the patient to replace the foreskin after cleaning is important, it is not a priority action. Page Ref: 1201 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 48.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the penis and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the male reproductive systems to diagnosis and treatment.

16) Which finding is the patient with Peyronie disease most likely to report? A) Inability to retract foreskin of penis B) A painful, bent erection C) Urinary meatus on the underside of the penis D) Inability to attain an erection Answer: B Explanation: A) Phimosis is a condition in which the foreskin cannot be retracted over the glans penis. B) In Peyronie disease, the presence of a hard, fibrous plaque causes the penis to bend, which in turn causes painful, bent erections. C) Hypospadias is an abnormality of the location of the male urethral meatus. The meatus develops on the ventral (underneath) of the penis and can be anywhere from the glans to the perineum. D) Erectile dysfunction is the inability to attain or maintain an erection sufficient to permit mutually satisfactory sexual intercourse with a partner. Page Ref: 1201-1202 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 48.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the penis and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of male reproductive disorders.

17) Which concept should the nurse keep in mind when preparing a care plan for a patient with prostate cancer? A) Prostate cancer is a fast-growing cancer. B) Prostate cancer occurs predominantly in middle-age men. C) Men with localized prostate cancer often die of other causes. D) Prostate cancer is easy to diagnose early. Answer: C Explanation: A) Prostate cancer is a slow-growing cancer. B) Prostate cancer is often considered a cancer of older men. The median age of men diagnosed with prostate cancer is 69 years. C) Many patients, particularly those who have cancer that is localized, die of other diseases without ever knowing that they had prostate cancer. D) Prostate cancer is a slow-growing cancer. It remains difficult to diagnose, as there are no extraordinary warning signs. Page Ref: 1196 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 48.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the prostate and approaches to diagnosis and treatment of these conditions. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of disorders of the male reproductive system.

18) Which information should the nurse include in the teaching plan for a male patient with varicocele? A) Varicocele is an enlarged varicose vein in the leg. B) This condition can cause low sperm production. C) Sperm quality is not affected. D) Varicoceles are painful. Answer: B Explanation: A) A varicocele is an enlargement of the veins in the scrotum, similar to varicose veins in the legs. B) A varicocele can cause low sperm production and decreased sperm quality, both of which are factors in infertility. C) A varicocele can cause low sperm production and decreased sperm quality, both of which are factors in infertility. D) Most varicoceles develop slowly over time and cause few, if any, symptoms. Page Ref: 1198 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 48.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the testicles and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of disorders of the male reproductive systems to diagnosis and treatment.

19) What instruction should the nurse give to a patient who has been cured of testicular cancer? A) "You no longer need to do testicular self-exam of the remaining testicle." B) "You should continue to do testicular self-exam of the remaining testicle." C) "Your risk of breast cancer is increased." D) "Your risk of prostate cancer is increased." Answer: B Explanation: A) Males who have been cured of testicular cancer have a 2% cumulative risk of developing testicular cancer in the other testicle during the 15 years after the initial diagnosis. B) Males who have been cured of testicular cancer have a 2% cumulative risk of developing testicular cancer in the other testicle during the 15 years after the initial diagnosis. C) Having testicular cancer does not increase the risk of breast cancer. D) Having testicular cancer does not increase the risk of prostate cancer. Page Ref: 1200 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 48.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the testicles and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of disorders of the male reproductive system.

20) When teaching a community health program about benign prostatic hyperplasia (BPH), which information should the nurse include? A) Half of all men experience BPH by age 50. B) African American men develop BPH symptoms earlier than Caucasian men. C) Asian men develop symptoms of BPH earlier than Caucasian men. D) Latino men develop BPH symptoms later than Caucasian men. Answer: B Explanation: A) BPH is considered a normal part of aging; it is noted in 50% of men by age 60. B) Racial background may play a role in BPH. Black and Hispanic or Latino men develop symptoms earlier than Caucasian men, and Asian men develop symptoms later than Caucasian men. C) Racial background may play a role in BPH. Black and Hispanic or Latino men develop symptoms earlier than Caucasian men, and Asian men develop symptoms later than Caucasian men. D) Racial background may play a role in BPH. Black and Hispanic or Latino men develop symptoms earlier than Caucasian men, and Asian men develop symptoms later than Caucasian men. Page Ref: 1195 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 48.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders of the prostate and approaches to diagnosis and treatment of these conditions. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of disorders of the male reproductive system.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 49 Sexually Transmitted Infections 1) Which concept should the nurse utilize when planning care for individuals with a sexually transmitted infection (STI)? A) Females experience more cases of gonorrhea than males. B) Males have higher rates of human papilloma virus and syphilis than females. C) STIs can only be transmitted through sexual contact. D) Individuals with higher socioeconomic status are more at risk for STIs. Answer: A Explanation: A) There are some gender differences in that females experience more cases of gonorrhea while males have higher rates of chlamydia and syphilis. B) There are some gender differences in that females experience more cases of gonorrhea while males have higher rates of chlamydia and syphilis. C) Although most STIs are acquired through sexual contact with an infected individual, some STIs can be passed from mother to infant during childbirth, through sharing of needles for injecting drugs, and through blood transfusion. D) Risk factors include low socioeconomic status, low levels of education, use of substances such as alcohol and drugs, multiple sex partners, and the exchange of sex for money or services. Page Ref: 1207 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 49.1 Discuss the epidemiology and prevalence of sexually transmitted infections and concepts related to sexually transmitted infections. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of sexually transmitted infections.

2) When counseling a sexually active 22-year-old, which recommendation should the nurse give to prevent sexually transmitted infections? A) Abstain from sex. B) Get vaccinated against hepatitis B and HPV. C) Use birth control. D) Ask sex partners if they have an STI. Answer: B Explanation: A) This patient is already sexually active, so advising her to abstain from sexual activity is not helpful and can be construed by the patient as judgmental. B) The patient can prevent hepatitis B and HPV by getting vaccinated. C) Recommending the use of birth control, in general, will not reduce the risk of being infected with a sexually transmitted infection (STI). The nurse should specifically recommend the use of condoms to prevent STIs. D) Asking sex partners is not a reliable form of prevention. Many sex partners may be asymptomatic and not know they have an STI. Page Ref: 1208 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Implementation | Learning Outcome: 49.1 Discuss the epidemiology and prevalence of sexually transmitted infections and concepts related to sexually transmitted infections. | QSEN Competencies: I.A.9 Discuss principles of effective communication | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of sexually transmitted infections.

3) When preparing a program for college women on human papillomavirus (HPV), which concept should the nurse keep in mind? A) The time from HPV infection to diagnosis of cervical cancer is 5 years. B) HPV prevalence peaks in women following menopause. C) HPV incidence has been steadily increasing in women in their 30s and 40s. D) HPV is most common in women in their early 20s Answer: D Explanation: A) The typical interval between infection of the HPV and a diagnosis of malignant cancer cells is 10-20 years, which is often about 40 years of age. B) HPV infection in women is most common in their early 20s. After 20 years of age, the prevalence of HPV has a steady decline. Recently, a second peak of prevalence has been occurring in postmenopausal women. C) HPV infection in women is most common in their early 20s. After 20 years of age, the prevalence of HPV has a steady decline. Recently, a second peak of prevalence has been occurring in postmenopausal women. D) HPV infection in women is most common in their early 20s. After 20 years of age, the prevalence of HPV has a steady decline. Recently, a second peak of prevalence has been occurring in postmenopausal women. Page Ref: 1209 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 49.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of viral STIs and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of sexually transmitted infections.

4) Which test does the nurse anticipate a 40-year-old woman will undergo to screen for cervical dysplasia? A) Digene HPV Test B) Hybrid Capture 2 C) Papanicolaou test D) DNA testing Answer: C Explanation: A) HPV infections are detected through polymerase chain reaction testing or DNA testing. DNA tests detect only high-risk HPV types. Current testing with the Digene HPV Test or Hybrid Capture 2 has a sensitivity of approximately 90% for high-risk HPV types. These tests detect HPV infection and not cervical cancer. B) HPV infections are detected through polymerase chain reaction testing or DNA testing. DNA tests detect only high-risk HPV types. Current testing with the Digene HPV Test or Hybrid Capture 2 has a sensitivity of approximately 90% for high-risk HPV types. These tests detect HPV infection and not cervical cancer. C) The Papanicolaou test (commonly known as the Pap smear) is the gold standard of primary screening for cervical dysplasia. D) HPV infections are detected through polymerase chain reaction testing or DNA testing. DNA tests detect only high-risk HPV types. Current testing with the Digene HPV Test or Hybrid Capture 2 has a sensitivity of approximately 90% for high-risk HPV types. These tests detect HPV infection and not cervical cancer. Page Ref: 1210 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 49.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of viral STIs and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of sexually transmitted infections to diagnosis and treatment.

5) Which instruction does the nurse give to a patient prescribed 0.5% podophyllotoxin solution for genital warts? A) Apply to warts twice a day for 3 days, repeat each week for up to 4 weeks B) Take orally twice a day for 3 days, repeat each week for up to 4 weeks C) Apply to warts twice a day for 4 weeks D) Take orally twice a day for 4 weeks Answer: A Explanation: A) Patients with genital warts may be prescribed 0.5% podophyllotoxin solution or gel to apply topically to the lesions twice a day for 3 consecutive days, followed by 4 days without treatment. This regimen is repeated up to 4 weeks. B) Patients with genital warts may be prescribed 0.5% podophyllotoxin solution or gel to apply topically to the lesions twice a day for 3 consecutive days, followed by 4 days without treatment. This regimen is repeated up to 4 weeks. C) Patients with genital warts may be prescribed 0.5% podophyllotoxin solution or gel to apply topically to the lesions twice a day for 3 consecutive days, followed by 4 days without treatment. This regimen is repeated up to 4 weeks. D) Patients with genital warts may be prescribed 0.5% podophyllotoxin solution or gel to apply topically to the lesions twice a day for 3 consecutive days, followed by 4 days without treatment. This regimen is repeated up to 4 weeks. Page Ref: 1210 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Implementation | Learning Outcome: 49.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of viral STIs and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of sexually transmitted infections to diagnosis and treatment.

6) Following Centers for Disease Control and Prevention guidelines, which recommendation does the school nurse make to parents of middle-school children? A) All males and females should begin the three-dose HPV vaccine between 12 and 14 years of age. B) All females should begin the three-dose HPV vaccine between 12 and 14 years of age. C) All males and females should begin the three-dose HPV vaccine between 10 and 12 years of age. D) All males should begin the three-dose HPV vaccine at age 9. Answer: C Explanation: A) The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices currently recommends that all males and females be vaccinated with the three-dose HPV vaccine starting at age 10-12 years. B) The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices currently recommends that all males and females be vaccinated with the three-dose HPV vaccine starting at age 10-12 years. C) The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices currently recommends that all males and females be vaccinated with the three-dose HPV vaccine starting at age 10-12 years. D) The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices currently recommends that all males and females be vaccinated with the three-dose HPV vaccine starting at age 10-12 years. Page Ref: 1210 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 49.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of viral STIs and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of sexually transmitted infections.

7) Which of the following concepts should the nurse use to guide community health programming on herpes simplex virus (HSV)? A) HSV-1 and HSV-2 are only transmitted when symptoms are present. B) Only HSV-2 is transmitted through contact with bodily fluids. C) HSV-1 is most commonly associated with cold sores around the mouth. D) One out of three individuals between 14 and 49 years of age have been exposed to HSV. Answer: C Explanation: A) Transmission of both HSV-1 and HSV-2 can occur even while the infected individual is asymptomatic. B) Both HSV-1 and HSV-2 are transmitted by direct contact with the bodily fluids of an infected individual. C) There are two forms of herpes simplex virus (HSV): HSV-1 and HSV-2. HSV-1 is more commonly associated with infections around the mouth, typically manifesting as cold sores. D) It is estimated that one out of every six individuals between 14 and 49 years of age in the United States has been exposed to HSV. Page Ref: 1210-1211 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 49.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of viral STIs and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of sexually transmitted infections.

8) When assessing a male patient, which assessment findings suggest that the patient has HSV2? A) Painful vesicles on the glans of shaft of the penis. B) Purulent urethral discharge. C) Dysuria and yellow urethral drainage. D) Sores around the mouth. Answer: A Explanation: A) Genital manifestations of HSV include small vesicles located in the genital area that are often accompanied by pain. For males, lesions typically manifest on the glans or shaft of the penis. B) Genital manifestations of HSV include small vesicles located in the genital area that are often accompanied by pain. For males, lesions typically manifest on the glans or shaft of the penis. Dysuria and urethral discharge are not findings in HSV-2. C) Genital manifestations of HSV include small vesicles located in the genital area that are often accompanied by pain. For males, lesions typically manifest on the glans or shaft of the penis. Dysuria and urethral discharge are not findings in HSV-2. D) Genital manifestations of HSV include small vesicles located in the genital area that are often accompanied by pain. For males, lesions typically manifest on the glans or shaft of the penis. HSV-1 is more commonly associated with cold sores around the mouth. Page Ref: 1211 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 49.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of viral STIs and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of sexually transmitted infections.

9) When providing care to a female patient with chlamydia, the nurse also anticipates treating the patient for which other disease? A) HSV-2 B) HPV C) Syphilis D) Gonorrhea Answer: D Explanation: A) Chlamydia is the most common bacterial STI in the United States and is often found in combination with gonorrhea. B) Chlamydia is the most common bacterial STI in the United States and is often found in combination with gonorrhea. C) Chlamydia is the most common bacterial STI in the United States and is often found in combination with gonorrhea. D) Chlamydia is the most common bacterial STI in the United States and is often found in combination with gonorrhea. Page Ref: 1211 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 49.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of bacterial STIs and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of sexually transmitted infections.

10) How should the university health center nurse respond when a 20-year-old sexually active female asks why she is being screened for chlamydia because she does not have symptoms? A) "Chlamydia may be asymptomatic and can lead to infertility if untreated." B) "Chlamydia is easier to treat in the early stages of infection." C) "Chlamydia infection increases the risk of getting all other STIs." D) "Chlamydia only occurs in women." Answer: A Explanation: A) The prevalence of chlamydia is believed to be significantly underestimated, as most infections are asymptomatic. This can lead to delay in seeking treatment and may result in complications such as infertility and ectopic pregnancy. B) Chlamydia is a treatable infection. C) Chlamydia is often found in combination with gonorrhea but is not associated with otherSTIs. D) In men, chlamydia is often asymptomatic as well and can lead to the development of a form of arthritis. Page Ref: 1211-1212 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 49.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of bacterial STIs and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of sexually transmitted infections to diagnosis and treatment.

11) Which statement by a woman being treated for chlamydia indicates that more teaching is needed? A) "I will take doxycycline for 1 week." B) "I will take a single dose of azithromycin." C) "I don't need to tell my sex partner that I have this infection." D) "I can resume sexual activity once I begin taking the antibiotics." Answer: C Explanation: A) The primary means of treatment for chlamydia is providing a single dose of azithromycin or doxycycline for 1 week. B) The primary means of treatment for chlamydia is providing a single dose of azithromycin or doxycycline for 1 week. C) Because the infection is spread through sexual contact, the sex partner needs to be treated so that the woman is not reinfected and so the partner does not infect others. D) Sexual activity should not be resumed until treatment has been completed. Therefore, if the woman is taking doxycycline for a week, sexual activity should not resume until the course of antibiotics is complete. Page Ref: 1212 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Evaluation | Learning Outcome: 49.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of bacterial STIs and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of sexually transmitted infections to diagnosis and treatment.

12) A 27-year-old sexually active female patient is being seen in the clinic with a purulent vaginal discharge, dysuria, and a sore throat. These findings suggest to the nurse that the patient has: A) chlamydia. B) HSV-2. C) gonorrhea. D) pediculosis pubis. Answer: C Explanation: A) Females with gonorrhea exhibit dysuria, purulent vaginal discharge, and pain during intercourse. Gonococcal infection can extend to the eye and the pharynx. Pharyngitis may be asymptomatic or can manifest with lymphadenopathy. Ocular manifestations generally present with unilateral purulent discharge. B) Females with gonorrhea exhibit dysuria, purulent vaginal discharge, and pain during intercourse. Gonococcal infection can extend to the eye and the pharynx. Pharyngitis may be asymptomatic or can manifest with lymphadenopathy. Ocular manifestations generally present with unilateral purulent discharge. C) Females with gonorrhea exhibit dysuria, purulent vaginal discharge, and pain during intercourse. Gonococcal infection can extend to the eye and the pharynx. Pharyngitis may be asymptomatic or can manifest with lymphadenopathy. Ocular manifestations generally present with unilateral purulent discharge. D) Females with gonorrhea exhibit dysuria, purulent vaginal discharge, and pain during intercourse. Gonococcal infection can extend to the eye and the pharynx. Pharyngitis may be asymptomatic or can manifest with lymphadenopathy. Ocular manifestations generally present with unilateral purulent discharge. Page Ref: 1212 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 49.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of bacterial STIs and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of sexually transmitted infections.

13) Which findings would the nurse expect in a patient with secondary syphilis? A) Genital chancres B) Lymphadenopathy, fever, and rash on the soles of the feet C) Asymptomatic D) Stroke meningitis, hearing loss Answer: B Explanation: A) Primary syphilis is associated with the development of a lesion, or chancre. B) Manifestations that are common in secondary syphilis include alopecia, fever, arthralgia, lymphadenopathy, and rash. The rash is most likely to be on the soles of the feet or palms of the hands. C) Latent syphilis reflects a period of asymptomatic infection. The manifestations of the primary and secondary stage have resolved. D) Tertiary syphilis reflects the accumulation of damage to the arterial lining and nervous system. Cardiovascular manifestations are generally related to damage to the lining of the ascending aorta that may result in development of an aneurysm. Neurologically, meningitis may occur and reflects not only the presence of infection but also damage to the arterial lining. Confusion, vision disturbance, and hearing loss are not uncommon. Page Ref: 1213 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 49.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of bacterial STIs and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of sexually transmitted infections.

14) Which manifestation would the nurse expect in a female patient with trichomoniasis? A) A discharge with a sweet odor B) Discharge with pH great than 5 C) Small white dots on the pubic hair D) Genital chancres Answer: B Explanation: A) Acute trichomoniasis infections involve all or some of the following symptoms: vulvar itching, burning, soreness, swelling, and redness; white, grayish-green, or yellow discharge that sometimes has a frothy characteristic; musty or fishy smelling odor of the discharge; pH of discharge greater than 5; a "strawberry cervix" pelvic exam (named for the cervical petechiae and friability of the cervix); dyspareunia; dysuria; and sometimes postcoital bleeding and lower abdominal pain. B) Acute trichomoniasis infections involve all or some of the following symptoms: vulvar itching, burning, soreness, swelling, and redness; white, grayish-green, or yellow discharge that sometimes has a frothy characteristic; musty or fishy smelling odor of the discharge; pH of discharge greater than 5; a "strawberry cervix" pelvic exam (named for the cervical petechiae and friability of the cervix); dyspareunia; dysuria; and sometimes postcoital bleeding and lower abdominal pain. C) Acute trichomoniasis infections involve all or some of the following symptoms: vulvar itching, burning, soreness, swelling, and redness; white, grayish-green, or yellow discharge that sometimes has a frothy characteristic; musty or fishy smelling odor of the discharge; pH of discharge greater than 5; a "strawberry cervix" pelvic exam (named for the cervical petechiae and friability of the cervix); dyspareunia; dysuria; and sometimes postcoital bleeding and lower abdominal pain. D) Acute trichomoniasis infections involve all or some of the following symptoms: vulvar itching, burning, soreness, swelling, and redness; white, grayish-green, or yellow discharge that sometimes has a frothy characteristic; musty or fishy smelling odor of the discharge; pH of discharge greater than 5; a "strawberry cervix" pelvic exam (named for the cervical petechiae and friability of the cervix); dyspareunia; dysuria; and sometimes postcoital bleeding and lower abdominal pain. Page Ref: 1214 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 49.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of parasitic STIs and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of sexually transmitted infections.

15) Which statement by a patient indicates to the nurse that more teaching is needed about pubic lice? A) "Wearing a condom can protect me from pubic lice." B) "I cannot contract pubic lice from a toilet seat." C) "Lice need a warm human host to survive." D) "Lice have difficulty moving along a flat, smooth surface." Answer: A Explanation: A) Individuals who practice safe sex with condoms are not safe from infestation with pubic lice, as condoms do not stop the spread of the parasite. B) Lice cannot be spread by a toilet seat, as is a common myth, as they cannot live for a long time without a warm human host body, and they have trouble moving along flat, smooth surfaces because of their anatomy. C) Lice cannot be spread by a toilet seat, as is a common myth, as they cannot live for a long time without a warm human host body, and they have trouble moving along flat, smooth surfaces because of their anatomy. D) Lice cannot be spread by a toilet seat, as is a common myth, as they cannot live for a long time without a warm human host body, and they have trouble moving along flat, smooth surfaces because of their anatomy. Page Ref: 1215 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Evaluation | Learning Outcome: 49.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of parasitic STIs and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of sexually transmitted infections.

16) Which instruction should the nurse give to a patient with pediculosis pubis? A) "Use an over-the-counter lotion with permethrin." B) "Apply a second treatment of permethrin 7 days after the first treatment." C) "Wash all linens and towels in cold water." D) "Place items that cannot be washed in a garbage bag for one week." Answer: A Explanation: A) Pediculosis pubis can be treated with over-the-counter permethrin (usually 1%) lotion. B) Permethrin is highly effective against live lice; however, it will not penetrate unhatched nits. A second treatment with permethrin is recommended roughly 9 days after the first treatment to kill any newly hatched nits to prevent another life cycle. Delaying or omitting this second treatment can lead to the new lice laying more nits, which will contribute to reinfestation. C) Towels, clothing, and even bedding from the patient's environment used within 2-3 days before treatment should be machine-washed in water of at least 130 degrees Fahrenheit and dried on the hot setting in a dryer to kill the remaining lice and nits. D) Any items that cannot be washed need to be disposed of or placed in a garbage bag for a period of no less than 2 weeks. This will kill the remaining lice and nits within the soiled cloth. Page Ref: 1215 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 49.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of parasitic STIs and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of sexually transmitted infections to diagnosis and treatment.

17) The nurse on a medical mission trip to a developing part of the world should keep which facts about HPV in mind when assessing and treating women? A) Most women in developing parts of the world do not receive Papanicolaou testing. B) About half the cases of cervical cancer occur in the developing world. C) A vaccine is available against all types of HPV. D) Worldwide, about 200,000 women are diagnosed with cervical cancer each year. Answer: A Explanation: A) The most pressing need for HPV vaccination is in the developing world, where most women never receive Papanicolaou testing and cervical cancer is a major cause of death. B) Approximately 80% of cases of cervical cancer occur in the developing world. C) A vaccine that is effective against the four or five most common high-risk HPV types could prevent 80-90% of cervical cancers worldwide. D) Globally, 529,000 women are diagnosed with cervical cancer every year, and 275,000 deaths are attributed to cervical cancer. Page Ref: 1210 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 49.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of viral STIs and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: VII.5 Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan. NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the pathophysiology of sexually transmitted infections to diagnosis and treatment.

18) When planning care for a patient with HSV, which concept should the nurse keep in mind? A) HSV can be cured. B) Preventing transmission of HSV is key to treatment. C) The goal of treatment is to eradicate the virus. D) Antiviral therapy has been shown to prevent transmission of HSV. Answer: B Explanation: A) There is no cure for HSV. B) The most effective means of treating HSV is preventing transmission. C) Current therapeutic approaches are designed to shorten the periods of exacerbation and symptomatology and to lessen the severity of these episodes. D) Antiviral therapies are the mainstay of pharmacologic treatment; some evidence supports the use of such agents to prevent viral transmission. Research in this area is still needed, and antivirals should not be counted on at this point in time to reduce transmission. Page Ref: 1211 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 49.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of viral STIs and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Identify risk factors that may lead to the development of sexually transmitted infections.

19) When assessing the newborn born to a woman with a chlamydial infection, the nurse should be alert for: A) genital discharge. B) conjunctivitis. C) foul-smelling urine. D) pharyngitis. Answer: B Explanation: A) There is a high rate of maternal transmission of chlamydia to the infant during birth. It may result in conjunctivitis or pneumonia in the infant. B) There is a high rate of maternal transmission of chlamydia to the infant during birth. It may result in conjunctivitis or pneumonia in the infant. C) There is a high rate of maternal transmission of chlamydia to the infant during birth. It may result in conjunctivitis or pneumonia in the infant. D) There is a high rate of maternal transmission of chlamydia to the infant during birth. It may result in conjunctivitis or pneumonia in the infant. Page Ref: 1211 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Assessment | Learning Outcome: 49.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of bacterial STIs and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of sexually transmitted infections.

20) When planning a community program on sexually transmitted infections, which concept should guide the nurse's teaching plan for syphilis? A) Syphilis progresses through three stages without treatment. B) The incubation period for syphilis is two weeks. C) Spirochetes can penetrate the central nervous system causing damage. D) Syphilis is a self-limiting infection. Answer: C Explanation: A) Without appropriate intervention, syphilis will progress through four stages: primary, secondary, latent, and tertiary. B) After infection, the spirochetes rapidly disseminate systemically, traveling through the blood and lymphatic systems. The incubation period averages approximately 3 weeks and can range from 10 to 90 days. C) After infection, the spirochetes rapidly disseminate systemically, traveling through the blood and lymphatic systems. The incubation period averages approximately 3 weeks and can range from 10 to 90 days. During this time, the spirochetes penetrate the central nervous system. D) Without treatment, syphilis causes cardiovascular and neurologic damage, resulting in death. Page Ref: 1213 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance Standards: Nursing Process: Planning | Learning Outcome: 49.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of bacterial STIs and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology, incidence and pathogenesis of sexually transmitted infections.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 50 Mechanisms of Traumatic Injury 1) A nurse in a level III trauma center is preparing her patient for transport to a level I trauma center. How should the nurse describe a level I trauma center to the patient and family? A) Basic trauma services are available, but the center is not involved in community education programs. B) Basic trauma services are available, but 24-hour surgical services may not be available. C) Trauma and specialty surgical services are available; center provides trauma education to staff. D) Trauma and specialty surgical services are available; provides trauma and injury prevention education to community. Answer: D Explanation: A) A level V trauma center is able to provide basic trauma level services but may not have 24-hour coverage for surgical services. A level V trauma center generally is not involved in continuing or community-level educational activities. B) A level IV trauma center is able to provide basic trauma emergency services with around-theclock laboratory services. It may not be able to provide 24-hour coverage of surgical services. C) In a level II trauma center, trauma care is available at all hours with specialty surgical services available. A level II center provides education on trauma and injury prevention to institutional staff and may need to refer patients to a Level I facility after initial stabilization. D) In a level I trauma center, trauma care is available at all hours with specialty surgical services available. A level I trauma center has a system in place for substance abuse screening and intervention. It also provides system leadership and oversight and education to the surrounding community on trauma and injury prevention. Page Ref: 1225 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Implementation | Learning Outcome: 50.2 Outline the team approach to trauma care and the ABCDE approach to trauma care. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology and classifications of traumatic injuries.

2) Which principle should guide the trauma nurse's plan of care for a pregnant woman? A) Pregnant women have a 45% increase in plasma volume. B) Pregnant women can lose up to 50% of blood volume before showing signs of hypovolemia. C) In hypovolemia, the body shunts blood to the pregnant uterus. D) The pregnant women shows signs of shock before the fetus. Answer: A Explanation: A) The physiologic changes in pregnancy may alter how traumatic injuries affect the mother and fetus because pregnant women experience a 45% increase in plasma volume. B) Pregnant women experience a 45% increase in plasma volume. This volume expansion allows for women to lose up to 35% of their blood volume before showing any signs of hypovolemic shock. C) In a hypovolemic state, the body shunts blood to essential organs and away from nonessential organs, including the uterus. D) There can be extensive fetal compromise before the mother shows any signs of shock. Page Ref: 1225 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 50.2 Outline the team approach to trauma care and the ABCDE approach to trauma care. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the risk and care for special populations and across the lifespan as related to traumatic injuries.

3) Which concept should the nurse consider when planning care for an older adult trauma patient? A) Traumatic injuries should be treated independent of comorbid conditions. B) An older adult may be on an anticoagulant for atrial fibrillation or stroke. C) Comorbidities are independent risk factors for mortality in the older adult trauma patient. D) A history of hypertension can prevent shock. Answer: B Explanation: A) Older adults usually have more comorbid conditions that must be treated concurrently with the traumatic injuries, but preexisting comorbidities are not considered independent risk factors for mortality of the geriatric trauma patient. B) Anticoagulants are frequently prescribed to older adults for atrial fibrillation and after cerebral vascular attacks. Treatment with anticoagulants complicates injuries by increasing bleeding time and leading to more blood loss than would occur in a non-anticoagulated patient. C) Older adults usually have more comorbid conditions that must be treated concurrently with the traumatic injuries, but preexisting comorbidities are not considered independent risk factors for mortality of the geriatric trauma patient. D) Being hypertensive at baseline may cause the patient to have "normal" vital signs even in the setting of severe shock. Page Ref: 1226 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 50.2 Outline the team approach to trauma care and the ABCDE approach to trauma care. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the risk and care for special populations and across the lifespan as related to traumatic injuries.

4) When assessing a trauma patient using the ABCDE approach, what does the nurse understand the "E" to represent? A) Establishing an airway B) Checking for hemorrhage C) Exposing and assessing the full body but preventing hypothermia D) Assessing neurological status Answer: C Explanation: A) "A" represents an assessment and opening of the airway. B) "B" represents evaluating for and treating breathing issues. C) "E" represents exposing and assessing the body for injuries while preventing hypothermia. D) "D" represents assessing for disability through a neurological assessment. Page Ref: 1226 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 50.2 Outline the team approach to trauma care and the ABCDE approach to trauma care. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Link the pathophysiology of traumatic injuries to diagnosis and treatment.

5) The nurse, assessing a patient who was in a motor vehicle accident, notes a large purple discoloration of the thigh. The nurse explains to the patient that he has: A) a laceration. B) a contusion. C) an abrasion. D) an acceleration-deceleration injury. Answer: B Explanation: A) When a blunt force injures tissue to the extent that a tearing of the tissue occurs, the injury is called a laceration. B) Contusions occur when blunt force is applied to the tissues causing underlying blood vessels to tear, resulting in ecchymosis or purple discoloration of the skin due to blood seeping into thesubcutaneous tissues. C) Abrasions occur when the superficial layers of the skin are damaged as a result of friction or pressure from being rubbed or scraped along a fixed object. D) Brain injury in children and adults can result from a direct blow to the head (coup injury) or the acceleration-deceleration movement of the brain (contrecoup injury). The inertial forces that result when the head and skull stop moving allow the brain tissue to continue moving within the skull. This results in tearing of nerves, fibers, and blood vessels. Page Ref: 1227-1228 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 50.3 Differentiate the causes, classification, and clinical manifestations of injuries caused by blunt trauma and approaches to diagnosis and treatment of those injuries across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology and classifications of traumatic injuries.

6) The nurse is assessing a dog bite on a child's forearm and notes that the epidermis, dermis, and subcutaneous tissues have been damaged and the wound is bleeding profusely. The nurse classifies the severity of the bite as: A) mild. B) moderate. C) severe. D) life-threatening. Answer: C Explanation: A) A mild bite extends through the epidermis and part of the dermis. B) A moderate bite extends through the epidermis and dermis. C) A severe bite extends through the epidermis, dermis, and subcutaneous tissues, resulting in blood loss. D) This bite is not life-threatening. Page Ref: 1229 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 50.4 Differentiate the causes, classification, and clinical manifestations of injuries caused by penetrating trauma and approaches to diagnosis and treatment of those injuries across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology and classifications of traumatic injuries.

7) The initial plan of care for a patient with a contaminated dog bite wound, with an animal that is available for testing, should include: A) administering a rabies vaccination. B) administering antivenom. C) suturing the wound. D) irrigating and debriding the wound. Answer: D Explanation: A) Immunoglobulin therapy against rabies should be considered if the bite is from a high-risk species and the animal is not available for testing; however, rabies vaccination will not clean a contaminated dog-bite wound. B) Antivenom is not needed with a dog bite. C) If the wound appears clean and there is little risk of contamination, it can be sutured. However, if there is concern about infection or wound contamination, the wound should be left open to close by secondary intention. D) Meticulous irrigation and debridement of any foreign material and saliva must be undertaken to clean the bite injury. Page Ref: 1229 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 50.4 Differentiate the causes, classification, and clinical manifestations of injuries caused by penetrating trauma and approaches to diagnosis and treatment of those injuries across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Link the pathophysiology of traumatic injuries to diagnosis and treatment.

8) The nurse should expect to assess which finding in a patient with a mild reaction to a snake bite of the index finger? A) Scratches or small lacerations on the finger accompanied by localized edema of the finger. B) Scratches or small lacerations on the finger accompanied by edema of the hand. C) Heavy bleeding from the wound and thrombocytopenia. D) Significant edema, hypovolemia, and shock. Answer: A Explanation: A) Mild reactions include scratches or small lacerations from the physical fangs. These reactions are not accompanied by any systemic responses beyond the possibility of minor localized edema caused by the puncture or laceration of the skin. B) Moderate reactions include extension of edema beyond the site of the bite. These reactions are not considered to be life threatening. C) Severe reactions emerge from anaphylactic responses to snake venom or from physiologic receptor blockade. Select venoms can result in coagulopathy, leading to thrombocytopenia and excessive bleeding. Bleeding into tissue and significant edema lead to a reduction in circulatory volume. The lack of adequate circulating volume then contributes to hypotension and possibly shock. Hypotension in combination with hemolysis can then contribute to the development of acute renal failure. D) Severe reactions emerge from anaphylactic responses to snake venom or from physiologic receptor blockade. Select venoms can result in coagulopathy, leading to thrombocytopenia and excessive bleeding. Bleeding into tissue and significant edema lead to a reduction in circulatory volume. The lack of adequate circulating volume then contributes to hypotension and possibly shock. Hypotension in combination with hemolysis can then contribute to the development of acute renal failure. Page Ref: 1229-1230 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 50.4 Differentiate the causes, classification, and clinical manifestations of injuries caused by penetrating trauma and approaches to diagnosis and treatment of those injuries across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Relate the pathogenesis of traumatic injuries to clinical manifestations.

9) The nurse is assessing a patient who was burned lighting a charcoal grill and is in severe pain. The nurse notes blistering red, moist skin. How should the nurse classify this burn? A) Superficial B) Superficial partial thickness C) Deep partial thickness D) Full thickness Answer: B Explanation: A) Superficial injury (formerly known as a first-degree burn) involves damage to the epidermal layer of skin, such as a sunburn. B) Partial thickness burn injuries (formerly known as second-degree burns) are further classified as superficial partial thickness burns or deep partial thickness burns. In superficial partial thickness burns, the epidermis and the papillary dermis are burned. Blistering usually occurs, and the dermis is red and moist with good capillary refill. These burns are very painful. C) Deep partial thickness burns involve damage to the epidermis, papillary dermis, and reticular layer of the dermis. Skin is usually blistered, and the exposed dermis is whitish to yellow, does not blanch, and does not have good capillary refill. There is usually no pain sensation to the area of deep partial thickness burns. D) A full thickness burn (formerly known as a third degree burn) involves injury to epidermal, all the dermal layers and structures, and subcutaneous tissues. Full-thickness burns may even extend into muscle, bone, or organs. The skin is charred, pale, and painless and has a leathery appearance. There is no capillary refill and no blanching. Page Ref: 1232 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 50.5 Differentiate the causes, classification, and clinical manifestations of thermal injuries and approaches to diagnosis and treatment of those injuries across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Relate the pathogenesis of traumatic injuries to clinical manifestations.

10) A patient in the emergency department has sustained burns to the back of the torso and the back of one leg. The nurse calculates that this patient has burns covering what percentage of total body surface area using the Rule of Nines formula? A) 9% B) 18% C) 27% D) 36% Answer: C Explanation: A) The Rule of Nines gives a rough estimate of body surface area (BSA) burned by assigning 9% to each body area. The Rule of Nines for an adult patient is as follows: 9% is assigned to the head (front and back together), 9% for each arm (front and back), 18% for EACH leg (front and back), 18% for front torso, 18% for back torso (includes buttocks), and 1% for genitalia. Therefore, the patient with burns to the torso (18%) and the back of a leg (9%) has burns covering 27% of the body. B) The Rule of Nines gives a rough estimate of body surface area (BSA) burned by assigning 9% to each body area. The Rule of Nines for an adult patient is as follows: 9% is assigned to the head (front and back together), 9% for each arm (front and back), 18% for EACH leg (front and back), 18% for front torso, 18% for back torso (includes buttocks), and 1% for genitalia. Therefore, the patient with burns to the torso (18%) and the back of a leg (9%) has burns covering 27% of the body. C) The Rule of Nines gives a rough estimate of body surface area (BSA) burned by assigning 9% to each body area. The Rule of Nines for an adult patient is as follows: 9% is assigned to the head (front and back together), 9% for each arm (front and back), 18% for EACH leg (front and back), 18% for front torso, 18% for back torso (includes buttocks), and 1% for genitalia. Therefore, the patient with burns to the torso (18%) and the back of a leg (9%) has burns covering 27% of the body. D) The Rule of Nines gives a rough estimate of body surface area (BSA) burned by assigning 9% to each body area. The Rule of Nines for an adult patient is as follows: 9% is assigned to the head (front and back together), 9% for each arm (front and back), 18% for EACH leg (front and back), 18% for front torso, 18% for back torso (includes buttocks), and 1% for genitalia. Therefore, the patient with burns to the torso (18%) and the back of a leg (9%) has burns covering 27% of the body. Page Ref: 1233 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 50.5 Differentiate the causes, classification, and clinical manifestations of thermal injuries and approaches to diagnosis and treatment of those injuries across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology and classifications of traumatic injuries.

11) The nurse is caring for a pediatric patient who has sustained burns to the back of the torso and the back of one leg. The nurse calculates that this child has burns covering what percentage of total body surface area using the Rule of Nines formula? A) 9% B) 18% C) 25% D) 36% Answer: C Explanation: A) The Rule of Nines for a pediatric patient is as follows: 18% is assigned to the head (front and back), 9% for each arm (front and back), 36% for the torso (front and back), 14% for EACH leg (front and back), and 1% for the genitals. Therefore, half the torso (18%) and the back of a leg (7%) is equal to 25% of body surface area. B) The Rule of Nines for a pediatric patient is as follows: 18% is assigned to the head (front and back), 9% for each arm (front and back), 36% for the torso (front and back), 14% for EACH leg (front and back), and 1% for the genitals. Therefore, half the torso (18%) and the back of a leg (7%) is equal to 25% of body surface area. C) The Rule of Nines for a pediatric patient is as follows: 18% is assigned to the head (front and back), 9% for each arm (front and back), 36% for the torso (front and back), 14% for EACH leg (front and back), and 1% for the genitals. Therefore, half the torso (18%) and the back of a leg (7%) is equal to 25% of body surface area. D) The Rule of Nines for a pediatric patient is as follows: 18% is assigned to the head (front and back), 9% for each arm (front and back), 36% for the torso (front and back), 14% for EACH leg (front and back), and 1% for the genitals. Therefore, half the torso (18%) and the back of a leg (7%) is equal to 25% of body surface area. Page Ref: 1233 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 50.5 Differentiate the causes, classification, and clinical manifestations of thermal injuries and approaches to diagnosis and treatment of those injuries across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology and classifications of traumatic injuries.

12) A patient is brought to the emergency department with chemical burns on his skin. The nurse obtains the materials safety data sheet (MDS) on the chemical substance. Which information is not included on the MDS? A) Uses of the chemical B) First aid measures C) Effects on the body D) Precautions needed to protect healthcare workers from exposure Answer: A Explanation: A) When a patient with a chemical burn presents for treatment, a materials safety data sheet (MSDS) should be obtained for information that includes first aid measures, effects on the body, and any special precautions that must be taken to protect staff members from exposure. How the chemical is used is not important to treatment. B) When a patient with a chemical burn presents for treatment, a materials safety data sheet (MSDS) should be obtained for information that includes first aid measures, effects on the body, and any special precautions that must be taken to protect staff members from exposure. C) When a patient with a chemical burn presents for treatment, a materials safety data sheet (MSDS) should be obtained for information that includes first aid measures, effects on the body, and any special precautions that must be taken to protect staff members from exposure. D) When a patient with a chemical burn presents for treatment, a materials safety data sheet (MSDS) should be obtained for information that includes first aid measures, effects on the body, and any special precautions that must be taken to protect staff members from exposure. Page Ref: 1235 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 50.6 Differentiate the causes, classification, and clinical manifestations of chemical burns and approaches to diagnosis and treatment of those injuries across the lifespan. | QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the risk and care for special populations and across the lifespan as related to traumatic injuries.

13) A patient performing home renovations is brought to the emergency department with electrical burns. When assessing the patient, the nurse should recall that: A) bone has a lower resistance than other body tissues. B) electricity bounces off bone toward soft tissues. C) electrical damage follows a straight path through the body. D) most tissues of the body are insulators. Answer: B Explanation: A) Although bone will still conduct current, it has a higher resistance than other tissues in the body. B) Because electricity follows the path of least resistance, the practitioner must consider the path of the electrical injury as it bounces off hard surfaces such as bone toward soft tissues such as arteries, muscles, and organs. C) Damage does not necessarily follow a straight path; however, the damage will follow a path parallel to that of the electricity conducted through the body. D) Materials that enhance the flow of electrical current are called conductors; materials that slow or stop the conduction of electrical current are called insulators. Most of the tissues of the body are conductors, easily allowing the flow of electrical current through body tissues. Page Ref: 1236-1237 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 50.7 Differentiate the causes, classification, and clinical manifestations of electrical injuries and approaches to diagnosis and treatment of those injuries across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Relate the pathogenesis of traumatic injuries to clinical manifestations.

14) A patient is being assessed in the emergency department following a skiing accident in which the patient was found unconscious at the foot of a tree with his left leg at an obtuse angle. Which concept of hypothermia should guide the nurse's assessment and plan of care? A) Shivering increases body temperature and reduces the metabolic demand. B) Hypothermia reduces perfusion to the tissues. C) Hypothermia improves hypoxia. D) Hypothermia stimulates activity of clotting factors. Answer: B Explanation: A) As the patient begins to experience hypothermia, the body responds with shivering, which increases oxygen consumption in skeletal muscle and metabolic demand. The increased metabolic demand in conjunction with decreased volume and perfusion problems leads to issues with acid-base regulation, ultimately resulting in metabolic acidosis. B) Relative hypothermia leads to impaired perfusion, which is compounded by the trauma patient's hypovolemic state. C) Relative hypothermia leads to impaired perfusion, which is compounded by the trauma patient's hypovolemic state. This decrease in perfusion leads to decreased oxygenation and decreased heat production. This leads to worsening hypoxia. D) The body's clotting factors are less active at lower body temperatures, leading to further blood loss. Page Ref: 1223, 1238 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 50.8 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of the lethal triad of trauma and approaches to diagnosis and treatment of those conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the etiology and classifications of traumatic injuries.

15) The nurse is caring for a patient with major blood loss following a motor vehicle accident. Which ratio does the nurse anticipate for replacement of red blood cells, platelets, and fresh frozen plasma? A) A 1:1:1 ratio B) A 1:2:1 ratio C) A 2:1:2 ratio D) A 2:1:1 ratio Answer: A Explanation: A) As packed red blood cells and saline are administered, platelets and coagulation factors are diluted. Current guidelines call for a replacement of red blood cells, platelets, and fresh frozen plasma in a 1:1:1 ratio in an attempt to replace all blood components that are lost as a result of bleeding. B) As packed red blood cells and saline are administered, platelets and coagulation factors are diluted. Current guidelines call for a replacement of red blood cells, platelets, and fresh frozen plasma in a 1:1:1 ratio in an attempt to replace all blood components that are lost as a result of bleeding. C) As packed red blood cells and saline are administered, platelets and coagulation factors are diluted. Current guidelines call for a replacement of red blood cells, platelets, and fresh frozen plasma in a 1:1:1 ratio in an attempt to replace all blood components that are lost as a result of bleeding. D) As packed red blood cells and saline are administered, platelets and coagulation factors are diluted. Current guidelines call for a replacement of red blood cells, platelets, and fresh frozen plasma in a 1:1:1 ratio in an attempt to replace all blood components that are lost as a result of bleeding. Page Ref: 1238 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 50.8 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of the lethal triad of trauma and approaches to diagnosis and treatment of those conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Link the pathophysiology of traumatic injuries to diagnosis and treatment.

16) The trauma committee at a level II trauma center is discussing ways to reduce death during the second peak of the trimodal distribution for trauma deaths. The trauma nurse on the committee suggests which intervention to reduce deaths during this time frame? A) Passing and enforcing helmet laws B) Transporting victims to a trauma center with qualified staff C) Enforcing highway safety D) Recognizing early signs of shock Answer: B Explanation: A) The first peak of trauma deaths is those that occur instantly, at the scene of the injury. An example of this would be death from a massive head injury or penetrating wound to the heart or aorta, which would cause immediate exsanguination. The only way to save these patients is through aggressive prevention strategies such as helmet laws and highway and automobile safety. B) The second peak of trauma deaths occurs in the early minutes and early hours of injury. Most of these deaths occur from major injuries to the head, chest, and abdomen. Deaths during this peak of trauma can be decreased by enforcing a trauma system that accurately identifies these vulnerable patients and quickly transports them to an appropriate trauma center that is staffed with qualified surgeons, nurses, and operating room personnel. C) The first peak of trauma deaths is those that occur instantly, at the scene of the injury. An example of this would be death from a massive head injury or penetrating wound to the heart or aorta, which would cause immediate exsanguination. The only way to save these patients is through aggressive prevention strategies such as helmet laws and highway and automobile safety. D) The third peak of trauma deaths occurs when trauma patients die in the hospital, usually in the intensive care unit. These deaths occur when the organ damage that occurred during the initial injury and the resuscitation phase begins to fulminate or when sepsis develops. Multiple organ failure begins to occur, often resulting in shock and death, usually days or weeks after the initial injury. Aggressive resuscitative care, prompt recognition of early signs of shock and organ ischemia, and early treatment of these injuries are paramount in the ongoing treatment of acutely injured patients. Page Ref: 1238-1239 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 50.9 Describe the trimodal distribution of trauma deaths and the four-step process for trauma prevention. | QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essential Competencies: VII. 10. Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and prevention of illness, injury, disability and premature death NLN Competencies: Teamwork: Function competently within one's own scope of practice as leader or member of the health care team and manage delegation effectively MNL Learning Outcome: LO 1: Examine the etiology and classifications of traumatic injuries.

17) Which of the following should the nurse consider when assessing a pregnant trauma victim? A) Pregnant women often have decreased fluid volume B) Pregnant women often have mild tachycardia C) Pregnant women are often bradycardic D) Pregnant women are often hypertensive Answer: B Explanation: A) The vital signs of pregnant women also differ from those of women who are not pregnant. Because of the additional fluid volume and additional thyroxine, the woman's heart rate may increase by 10-15 beats per minute. B) The vital signs of pregnant women also differ from those of women who are not pregnant. Because of the additional fluid volume and additional thyroxine, the woman's heart rate may increase by 10-15 beats per minute. C) The vital signs of pregnant women also differ from those of women who are not pregnant. Because of the additional fluid volume and additional thyroxine, the woman's heart rate may increase by 10-15 beats per minute. D) Pregnant women usually have normal to low blood pressures due to higher levels of circulating estrogen. Page Ref: 1225 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 50.2 Outline the team approach to trauma care and the ABCDE approach to trauma care. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the risk and care for special populations and across the lifespan as related to traumatic injuries.

18) The nurse is caring for a trauma patient in the emergency department who is 26-weeks pregnant. Which maternal test does the nurse anticipate will be performed to determine if there is fetal blood in the maternal circulation? A) Hematocrit B) Alpha-fetoprotein test C) Amniocentesis D) Kleihauer-Betke test Answer: D Explanation: A) Hematocrit gives an indication of maternal blood loss. B) The alpha-fetoprotein test can be used to screen for neural tube defects in a fetus. C) Amniocentesis is a screening tool for birth defects. D) Direct injury to the uterus or fetus must also be considered. The Kleihauer-Betke test is used to detect fetal blood in circulation. This can be an indication of fetal hemorrhage. Page Ref: 1225 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 50.2 Outline the team approach to trauma care and the ABCDE approach to trauma care. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 4: Consider the risk and care for special populations and across the lifespan as related to traumatic injuries.

19) A 77-kilogram patient with burns to the front of the torso, both arms, and face is being treated in the emergency department. Using the Parkland formula, how much lactated Ringer's solution does the nurse anticipate infusing of the first 8 hours? A) 3,118 mL B) 6,237 mL C) 12,474 mL D) 24,948 mL Answer: B Explanation: A) There are several formulas for estimating initial fluid replacement requirements for the severely burned patient. The Parkland formula: 4 mL x weight in kilograms x % BSA burned = amount of fluid over 24 hours. The formula is used to determine the amount of lactated Ringer's solution that should be infused over the first 24 hours, the first half being infused over the first 8 hours and the second half being infused over the next 16 hours. The nurse calculates that burns cover 40.5% of BSA (18% for front of torso, 9% for each arm [18%], and 4.5% for front of head). Using the equation, the patient should receive 12,474 mL fluid over the first 24 hours. The first half, or 6,237 mL, should be infused over the first 8 hours and the second half being infused over the following 16 hours. B) There are several formulas for estimating initial fluid replacement requirements for the severely burned patient. The Parkland formula: 4 mL x weight in kilograms x % BSA burned = amount of fluid over 24 hours. The formula is used to determine the amount of lactated Ringer's solution that should be infused over the first 24 hours, the first half being infused over the first 8 hours and the second half being infused over the next 16 hours. The nurse calculates that burns cover 40.5% of BSA (18% for front of torso, 9% for each arm [18%], and 4.5% for front of head). Using the equation, the patient should receive 12,474 mL fluid over the first 24 hours. The first half, or 6,237 mL, should be infused over the first 8 hours and the second half being infused over the following 16 hours. C) There are several formulas for estimating initial fluid replacement requirements for the severely burned patient. The Parkland formula: 4 mL x weight in kilograms x % BSA burned = amount of fluid over 24 hours. The formula is used to determine the amount of lactated Ringer's solution that should be infused over the first 24 hours, the first half being infused over the first 8 hours and the second half being infused over the next 16 hours. The nurse calculates that burns cover 40.5% of BSA (18% for front of torso, 9% for each arm [18%], and 4.5% for front of head). Using the equation, the patient should receive 12,474 mL fluid over the first 24 hours. The first half, or 6,237 mL, should be infused over the first 8 hours and the second half being infused over the following 16 hours. D) There are several formulas for estimating initial fluid replacement requirements for the severely burned patient. The Parkland formula: 4 mL x weight in kilograms x % BSA burned = amount of fluid over 24 hours. The formula is used to determine the amount of lactated Ringer's solution that should be infused over the first 24 hours, the first half being infused over the first 8 hours and the second half being infused over the next 16 hours. The nurse calculates that burns cover 40.5% of BSA (18% for front of torso, 9% for each arm [18%], and 4.5% for front of head). Using the equation, the patient should receive 12,474 mL fluid over the first 24 hours. The first half, or 6,237 mL, should be infused over the first 8 hours and the second half being infused over the following 16 hours. Page Ref: 1233 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies 19

Standards: Nursing Process: Planning | Learning Outcome: 50.5 Differentiate the causes, classification, and clinical manifestations of thermal injuries and approaches to diagnosis and treatment of those injuries across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 3: Link the pathophysiology of traumatic injuries to diagnosis and treatment. 20) A patient has burns that are pale and leathery and reports little pain from the burn site. How should the nurse classify this burn? A) Superficial B) Superficial partial thickness C) Deep partial thickness D) Full thickness Answer: D Explanation: A) Superficial injury (formerly known as a first-degree burn) involves damage to the epidermal layer of skin, such as a sunburn. B) Partial thickness burn injuries (formerly known as second-degree burns) are further classified as superficial partial thickness burns or deep partial thickness burns. In superficial partial thickness burns, the epidermis and the papillary dermis are burned. Blistering usually occurs, and the dermis is red and moist with good capillary refill. These burns are very painful. C) Deep partial thickness burns involve damage to the epidermis, papillary dermis, and reticular layer of the dermis. Skin is usually blistered, and the exposed dermis is whitish to yellow, does not blanch, and does not have good capillary refill. There is usually no pain sensation to the area of deep partial thickness burns. D) A full thickness burn (formerly known as a third degree burn) involves injury to epidermal, all the dermal layers and structures, and subcutaneous tissues. Full-thickness burns may even extend into muscle, bone, or organs. The skin is charred, pale, and painless and has a leathery appearance. There is no capillary refill and no blanching. Page Ref: 1232 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 50.5 Differentiate the causes, classification, and clinical manifestations of thermal injuries and approaches to diagnosis and treatment of those injuries across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Relate the pathogenesis of traumatic injuries to clinical manifestations.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 51 The Pathophysiology of Primary and Secondary Traumatic Injury 1) The trauma nurse has arrived at the scene of a large scale industrial accident. When assessing clients who have suffered trauma, the nurse understands that the primary survey begins with the assessment of which areas? Select all that apply. A) Circulation B) Exposure C) Breathing D) Airway E) Disability Answer: A, C, D Explanation: A) The primary survey for trauma assessment includes assessing the airway, breathing, and circulation of the client. B) Disability and exposure are elements of the secondary survey. C) The primary survey for trauma assessment includes assessing the airway, breathing, and circulation of the client. D) The primary survey for trauma assessment includes assessing the airway, breathing, and circulation of the client. E) Disability and exposure are elements of the secondary survey. Page Ref: 1245 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 51.1 Describe the primary survey and application to traumatic injuries in the context of the A (Airway), B (Breathing), C (Circulation), D (Disability), E (Exposure) approach to trauma | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Relate the pathogenesis of traumatic injuries to clinical manifestations.

2) The trauma nurse is assigned to triage clients who have suffered trauma during a natural disaster. The nurse understands that according to the guidelines for field triage of injured patients, step 2 of triage includes which assessment? A) Level of consciousness B) Anatomy of injury C) Mechanism of injury D) Special considerations Answer: B Explanation: A) Assessing level of consciousness is included in step 1 of triage. B) Step 2 of triage, according to the guidelines for field triage of injured patients, includes assessing the anatomy of injury. C) Assessing the mechanism of injury is included in step 3 of triage. D) Assessing for special considerations is included in step 4 of triage. Page Ref: 1246 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 51.1 Describe the primary survey and application to traumatic injuries in the context of the A (Airway), B (Breathing), C (Circulation), D (Disability), E (Exposure) approach to trauma | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Relate the pathogenesis of traumatic injuries to clinical manifestations.

3) The trauma nurse is assessing a client's level of consciousness with the Glasgow coma scale. Which components does the nurse recognize are part of the Glasgow coma scale? Select all that apply. A) Airway clear B) Best verbal response C) Eyes open D) Best pupillary response E) Best motor response Answer: B, C, E Explanation: A) Best pupillary response and airway clear are not included in the Glasgow coma scale. B) The Glasgow coma scale includes best verbal response, eyes open, and best motor response. C) The Glasgow coma scale includes best verbal response, eyes open, and best motor response. D) Best pupillary response and airway clear are not included in the Glasgow coma scale. E) The Glasgow coma scale includes best verbal response, eyes open, and best motor response. Page Ref: 1247 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 51.1 Describe the primary survey and application to traumatic injuries in the context of the A (Airway), B (Breathing), C (Circulation), D (Disability), E (Exposure) approach to trauma | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Relate the pathogenesis of traumatic injuries to clinical manifestations.

4) The trauma nurse has arrived at the scene of a large accident and is preparing to transport clients to a trauma center. Which injury does the nurse immediately identify as requiring priority transport? A) Penetrating injury to the thigh, with visible bleeding B) Open fracture of the arm, with severe pain C) Open fracture of the leg, with visible deformity D) Scalp laceration, unconscious, with normal respirations Answer: D Explanation: A) According to the guidelines for field triage of injured clients, the unconscious client can be immediately identified as requiring transport to a trauma facility. Although the client with a penetrating injury to the thigh and the clients with open fractures also require transport, this would be determined during step 2 of the guidelines for field triage of injured clients. B) According to the guidelines for field triage of injured clients, the unconscious client can be immediately identified as requiring transport to a trauma facility. Although the client with a penetrating injury to the thigh and the clients with open fractures also require transport, this would be determined during step 2 of the guidelines for field triage of injured clients. C) According to the guidelines for field triage of injured clients, the unconscious client can be immediately identified as requiring transport to a trauma facility. Although the client with a penetrating injury to the thigh and the clients with open fractures also require transport, this would be determined during step 2 of the guidelines for field triage of injured clients. D) According to the guidelines for field triage of injured clients, the unconscious client can be immediately identified as requiring transport to a trauma facility. Although the client with a penetrating injury to the thigh and the clients with open fractures also require transport, this would be determined during step 2 of the guidelines for field triage of injured clients. Page Ref: 1246 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 51.1 Describe the primary survey and application to traumatic injuries in the context of the A (Airway), B (Breathing), C (Circulation), D (Disability), E (Exposure) approach to trauma | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Relate the pathogenesis of traumatic injuries to clinical manifestations.

5) The trauma nurse is performing a primary survey on a client who suffered trauma. Which assessment does the nurse determine will take the highest priority during the survey? A) Stability of the cervical spine B) Head and neck for severe bleeding C) Patency of airway D) Ability to breathe Answer: C Explanation: A) The primary purpose for assessing the client's airway during the primary survey is to determine the patency of the airway. While stability of the cervical spine, severe bleeding in the head and neck, and the client's breathing ability are also included in the primary assessment, assessing the client's airway is priority. B) The primary purpose for assessing the client's airway during the primary survey is to determine the patency of the airway. While stability of the cervical spine, severe bleeding in the head and neck, and the client's breathing ability are also included in the primary assessment, assessing the client's airway is priority. C) The primary purpose for assessing the client's airway during the primary survey is to determine the patency of the airway. While stability of the cervical spine, severe bleeding in the head and neck, and the client's breathing ability are also included in the primary assessment, assessing the client's airway is priority. D) The primary purpose for assessing the client's airway during the primary survey is to determine the patency of the airway. While stability of the cervical spine, severe bleeding in the head and neck, and the client's breathing ability are also included in the primary assessment, assessing the client's airway is priority. Page Ref: 1245 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 51.1 Describe the primary survey and application to traumatic injuries in the context of the A (Airway), B (Breathing), C (Circulation), D (Disability), E (Exposure) approach to trauma | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Relate the pathogenesis of traumatic injuries to clinical manifestations.

6) The nurse is assessing an older adult client for trauma following a motor vehicle accident. Which special considerations does the nurse understand must be taken for this client? A) The effects of blood loss may be delayed. B) Age-related changes in cognition may increase the risk of delirium. C) A narrowed tolerance for a change in blood volume may occur. D) The description of the mechanism of injury may be delayed due to word finding difficulties. Answer: C Explanation: A) Older adults have a narrowed tolerance for alterations in blood volume and will demonstrate very different signs of hypovolemic shock from those of younger adults. The effects of blood loss are not delayed in an older adult client. Age-related changes to cognition and difficulties with word finding are not special considerations that typically must be taken when assessing an older adult for trauma after a motor vehicle accident. B) Older adults have a narrowed tolerance for alterations in blood volume and will demonstrate very different signs of hypovolemic shock from those of younger adults. The effects of blood loss are not delayed in an older adult client. Age-related changes to cognition and difficulties with word finding are not special considerations that typically must be taken when assessing an older adult for trauma after a motor vehicle accident. C) Older adults have a narrowed tolerance for alterations in blood volume and will demonstrate very different signs of hypovolemic shock from those of younger adults. The effects of blood loss are not delayed in an older adult client. Age-related changes to cognition and difficulties with word finding are not special considerations that typically must be taken when assessing an older adult for trauma after a motor vehicle accident. D) Older adults have a narrowed tolerance for alterations in blood volume and will demonstrate very different signs of hypovolemic shock from those of younger adults. The effects of blood loss are not delayed in an older adult client. Age-related changes to cognition and difficulties with word finding are not special considerations that typically must be taken when assessing an older adult for trauma after a motor vehicle accident. Page Ref: 1247 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 51.1 Describe the primary survey and application to traumatic injuries in the context of the A (Airway), B (Breathing), C (Circulation), D (Disability), E (Exposure) approach to trauma | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Relate the pathogenesis of traumatic injuries to clinical manifestations.

7) The intensive care nurse is assessing a group of clients. Which clients does the nurse identify as likely requiring intubation? Select all that apply. A) A client with a closed head injury. B) A client with severe laryngeal edema. C) A client with projectile vomiting. D) A client with cervical stenosis. E) A client with multiple rib fractures. Answer: A, B Explanation: A) The client with a closed head injury is in danger of a reduced level of consciousness and consequent airway collapse. The client with severe laryngeal edema is in danger of the swelling obstructing the airway. Since both are at increased risk for airway compromise, this makes intubation more likely to be included in the plans of care for these clients. B) The client with a closed head injury and the client with severe laryngeal edema are at increased risk for airway compromise, which make intubation more likely to be included in the plans of care for these clients. C) While projectile vomiting, cervical stenosis, and multiple rib fractures are factors that may require consideration when performing an airway assessment or intubation, these conditions are not common reasons for intubation on their own. D) While projectile vomiting, cervical stenosis, and multiple rib fractures are factors that may require consideration when performing an airway assessment or intubation, these conditions are not common reasons for intubation on their own. E) While projectile vomiting, cervical stenosis, and multiple rib fractures are factors that may require consideration when performing an airway assessment or intubation, these conditions are not common reasons for intubation on their own. Page Ref: 1249 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 51.2 Describe the primary survey and differentiate the underlying pathogenesis of traumatic injuries. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Relate the pathogenesis of traumatic injuries to clinical manifestations.

8) The nurse is assisting with the intubation of a client who has sustained a traumatic injury. What is the priority intervention for the nurse? A) Inspecting the client's airway B) Assessing the client's breathing C) Obtaining the client's oxygen saturation D) Stabilizing the client's cervical spine Answer: D Explanation: A) When assisting with the intubation of a client, the nurse's priority intervention is stabilization of the client's cervical spine. Although assessing the client's airway, breathing, and oxygen saturation is important, when the decision to intubate has been made by the healthcare provider, preventing cervical spine injury is the nurse's first priority. B) When assisting with the intubation of a client, the nurse's priority intervention is stabilization of the client's cervical spine. Although assessing the client's airway, breathing, and oxygen saturation is important, when the decision to intubate has been made by the healthcare provider, preventing cervical spine injury is the nurse's first priority. C) When assisting with the intubation of a client, the nurse's priority intervention is stabilization of the client's cervical spine. Although assessing the client's airway, breathing, and oxygen saturation is important, when the decision to intubate has been made by the healthcare provider, preventing cervical spine injury is the nurse's first priority. D) When assisting with the intubation of a client, the nurse's priority intervention is stabilization of the client's cervical spine. Although assessing the client's airway, breathing, and oxygen saturation is important, when the decision to intubate has been made by the healthcare provider, preventing cervical spine injury is the nurse's first priority. Page Ref: 1249 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 51.2 Describe the primary survey and differentiate the underlying pathogenesis of traumatic injuries. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Relate the pathogenesis of traumatic injuries to clinical manifestations.

9) The nurse is assessing a client with a spinal cord injury who is exhibiting loss of motor function, pain, and temperature sensation distal to the injury. Which complication does the nurse suspect? A) Anterior cord syndrome B) Spinal shock C) Brown-Séquard syndrome D) Central cord syndrome Answer: A Explanation: A) Loss of motor function, pain, and temperature sensation distal to the injury are consistent with anterior cord syndrome. B) These symptoms are not consistent with spinal shock, Brown-Séquard syndrome, or central cord syndrome. C) These symptoms are not consistent with spinal shock, Brown-Séquard syndrome, or central cord syndrome. D) These symptoms are not consistent with spinal shock, Brown-Séquard syndrome, or central cord syndrome. Page Ref: 1252 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 51.2 Describe the primary survey and differentiate the underlying pathogenesis of traumatic injuries. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Relate the pathogenesis of traumatic injuries to clinical manifestations.

10) The nurse is assessing a neonate for a suspected spinal cord injury. What age-related considerations does the nurse take during the assessment? Select all that apply. A) Because of the client's body structure, there is an increased risk for lumbar injuries. B) The client's spine has increased ligamentous laxity, increasing the risk for spinal cord injury. C) Since this client is below the age of four, there is an increased risk of lumbar injury. D) The client's vertebral column is vulnerable to deformity without fracture. E) The most reliable way to determine the mechanism and anatomy of injury in this client is by imaging. Answer: B, D Explanation: A) The body structure of children below the age of eight, not four, places them at greater risk for cervical spine injury, not lumbar spine injury. Because of ligamentous laxity, the client is at increased risk for spinal cord injury without any radiographic evidence of injury such as fracture. B) Because of ligamentous laxity, the client is at increased risk for spinal cord injury without any radiographic evidence of injury such as fracture. C) The body structure of children below the age of eight places them at greater risk for cervical spine injury, not lumbar spine injury. D) Because of ligamentous laxity, the client is at increased risk for spinal cord injury without any radiographic evidence of injury such as fracture. E) Because of ligamentous laxity, the client is at increased risk for spinal cord injury without any radiographic evidence of injury such as fracture, therefore, radiographic tests are not an effectivediagnostic to evaluate for spinal cord injury in clients of this age group. Page Ref: 1252 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 51.2 Describe the primary survey and differentiate the underlying pathogenesis of traumatic injuries. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Relate the pathogenesis of traumatic injuries to clinical manifestations.

11) The nurse is caring for a client diagnosed with a pneumothorax. Which statement about this condition does the nurse know to be true? A) The client's diaphragm will be displaced by up to 4 cm. B) The client has a pleural effusion. C) The client has a collapsed lung with air leakage into the chest. D) The client will require surgical intervention. Answer: C Explanation: A) A pneumothorax does not displace the diaphragm by up to 4 cm, nor does the client have a pleural effusion in which blood accumulates in the pleural cavity. B) A pneumothorax does not displace the diaphragm by up to 4 cm, nor does the client have a pleural effusion in which blood accumulates in the pleural cavity. C) A pneumothorax refers to a collapsed lung occurring due to air leakage into the space between the lung and chest wall. D) Most cases of pneumothorax can be resolved without requiring surgery. Page Ref: 1253 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 51.2 Describe the primary survey and differentiate the underlying pathogenesis of traumatic injuries. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Relate the pathogenesis of traumatic injuries to clinical manifestations.

12) The nurse cares for a client who has sustained a trauma. While assessing the client, the client begins to exhibit dyspnea, distended neck veins, and tracheal deviation to the left side. What condition does the nurse expect? A) A right tension pneumothorax B) A left open pneumothorax C) A bilateral hemothorax D) A flail chest Answer: A Explanation: A) The client's symptoms are consistent with a right tension pneumothorax, as the trachea is deviating to the unaffected side. Dyspnea, distended neck veins, and tracheal deviation to the left side are not characteristic of a left open pneumothorax, a bilateral hemothorax, or a flail chest. B) Dyspnea, distended neck veins, and tracheal deviation to the left side are not characteristic of a left open pneumothorax since the trachea deviates to the unaffected side. C) Dyspnea, distended neck veins, and tracheal deviation to the left side are not characteristic of a bilateral hemothorax, or a flail chest due to the laterality and presence of the deviated trachea. D) Dyspnea, distended neck veins, and tracheal deviation to the left side are not characteristic of a left open pneumothorax, a bilateral hemothorax, or a flail chest due to the laterality and presence of the deviated trachea. Page Ref: 1254 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 51.2 Describe the primary survey and differentiate the underlying pathogenesis of traumatic injuries. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Relate the pathogenesis of traumatic injuries to clinical manifestations.

13) The nurse is caring for a client with pericardial tamponade. Which statements about the mechanism of this condition does the nurse know to be true? Select all that apply. A) This condition involves increased cardiac pressure leading to increased cardiac expansion. B) This condition is due to blood accumulating in the pericardial sac. C) This condition causes cardiac output to be dramatically reduced. D) This condition can ultimately result in cardiac arrest. E) This condition can be caused by any type of trauma to the mediastinum. Answer: B, C, D Explanation: A) Pericardial tamponade occurs due to the accumulation of blood in the pericardial sac. This causes cardiac output to be dramatically reduced due to decreased contractility and expansion, not increased contractility and expansion. The condition can ultimately lead to cardiac arrest. Pericardial tamponade can occur as a result of any type of trauma to the pericardium. While injury to the mediastinum may also be present, pericardial tamponade is not characteristically associated with this type of injury. The increased cardiac pressure associated with pericardial tamponade results in decreased cardiac expansion, not increased. B) Pericardial tamponade occurs due to the accumulation of blood in the pericardial sac. C) Pericardial tamponade occurs due to the accumulation of blood in the pericardial sac. This causes cardiac output to be dramatically reduced due to decreased contractility and expansion, not increased contractility and expansion. D) Pericardial tamponade occurs due to the accumulation of blood in the pericardial sac. This causes cardiac output to be dramatically reduced due to decreased contractility and expansion, not increased contractility and expansion. The condition can ultimately lead to cardiac arrest. E) Pericardial tamponade can occur as a result of any type of trauma to the pericardium. While injury to the mediastinum may also be present, pericardial tamponade is not characteristically associated with this type of injury. Page Ref: 1255 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 51.2 Describe the primary survey and differentiate the underlying pathogenesis of traumatic injuries. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Relate the pathogenesis of traumatic injuries to clinical manifestations.

14) The nurse is caring for a client with a diffuse axonal injury. Which statement about the client's condition does the nurse know to be true? A) Falls are a common cause of this type of injury. B) Radiographic findings do not demonstrate evidence of this injury. C) The immediate result of this injury is diffuse intracranial hemorrhage and loss of consciousness. D) It is common for spontaneous recovery to occur within 1-2 months of the initial insult. Answer: B Explanation: A) Motor vehicle accidents, not falls, are a common cause of this type of injury. B) In clients who have suffered a diffuse axonal injury, radiographic findings appear to be normal. C) The immediate result of a diffuse axonal injury is intracranial hemorrhage and increased intracranial pressure, which then leads to loss of consciousness. Spontaneous recovery is not common with this type of injury, and clients often remain in a vegetative state until death. D) Spontaneous recovery is not common with this type of injury, and clients often remain in a vegetative state until death. Page Ref: 1261 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 51.3 Describe the secondary survey and application to pathogenesis of traumatic injuries. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Relate the pathogenesis of traumatic injuries to clinical manifestations.

15) The nurse is caring for a client diagnosed with a myocardial contusion. The nurse understands that which complication can result from this condition? Select all that apply. A) Myocardial rupture B) Endocarditis C) Thromboembolism D) Cardiac tamponade E) Atrial fibrillation Answer: A, C, D Explanation: A) A myocardial contusion can result in complications such as myocardial rupture, thromboembolism, and cardiac tamponade. B) Endocarditis and atrial fibrillation are not common complications of this condition. C) A myocardial contusion can result in complications such as myocardial rupture, thromboembolism, and cardiac tamponade. D) A myocardial contusion can result in complications such as myocardial rupture, thromboembolism, and cardiac tamponade. E) Endocarditis and atrial fibrillation are not common complications of this condition. Page Ref: 1261 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 51.3 Describe the secondary survey and application to pathogenesis of traumatic injuries. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Relate the pathogenesis of traumatic injuries to clinical manifestations.

16) The nurse is providing education to a client with postconcussive syndrome about the symptoms associated with traumatic brain injuries. Which symptoms will the nurse review with the client? Select all that apply. A) Fatigue B) Vomiting C) Diarrhea D) Vertigo E) Photophobia Answer: A, B, D, E Explanation: A) Symptoms such as fatigue, vomiting, vertigo, and photophobia are associated with traumatic brain injuries and may be present in the client with postconcussive syndrome. B) Symptoms such as fatigue, vomiting, vertigo, and photophobia are associated with traumatic brain injuries and may be present in the client with postconcussive syndrome. C) Diarrhea is not a symptom typically associated with traumatic brain injury. D) Symptoms such as fatigue, vomiting, vertigo, and photophobia are associated with traumatic brain injuries and may be present in the client with postconcussive syndrome. E) Symptoms such as fatigue, vomiting, vertigo, and photophobia are associated with traumatic brain injuries and may be present in the client with postconcussive syndrome. Page Ref: 1261 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 51.3 Describe the secondary survey and application to pathogenesis of traumatic injuries. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and wellbeing, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Relate the pathogenesis of traumatic injuries to clinical manifestations.

17) The nurse is performing an assessment on zone III of the neck on a client with a cervical spine injury. The nurse understands that zone III is comprised of which structures? Select all that apply. A) Esophagus B) Distal carotid and vertebral arteries C) Jugular veins D) Pharynx E) Spinal cord Answer: B, D, E Explanation: A) The esophagus and jugular veins are structures included in zone II of the neck. B) Zone III of the neck is comprised of the distal carotid and vertebral arteries, pharynx, and spinal cord. C) The esophagus and jugular veins are structures included in zone II of the neck. D) Zone III of the neck is comprised of the distal carotid and vertebral arteries, pharynx, and spinal cord. E) Zone III of the neck is comprised of the distal carotid and vertebral arteries, pharynx, and spinal cord. Page Ref: 1261 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 51.3 Describe the secondary survey and application to pathogenesis of traumatic injuries. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Relate the pathogenesis of traumatic injuries to clinical manifestations.

18) The nurse is caring for a client with penetrating abdominal trauma. Which organ does the nurse identify as most commonly affected by this type of injury? A) Large intestine B) Stomach C) Spleen D) Liver Answer: D Explanation: A) The stomach, spleen, and large intestine are not as likely to be affected by this type of trauma. B) The stomach, spleen, and large intestine are not as likely to be affected by this type of trauma. C) The stomach, spleen, and large intestine are not as likely to be affected by this type of trauma. D) The liver is most commonly affected by penetrating abdominal trauma due to its size and location. Page Ref: 1262 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 51.3 Describe the secondary survey and application to pathogenesis of traumatic injuries. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Relate the pathogenesis of traumatic injuries to clinical manifestations.

19) The trauma nurse has arrived at the site of a major accident and is assessing several clients with extremity injuries. Which injury requires immediate intervention by the nurse? A) An open displacement fracture of the femur B) A dislocated hip with associated tibial fracture C) A penetrating injury of the right hand D) A contusion of the left arm with diffuse ecchymosis Answer: A Explanation: A) An open displacement fracture of the femur is located next to a major artery. Therefore, this injury requires immediate intervention by the nurse. B) While the other injuries require intervention, these conditions are not potentially lifethreatening. C) While the other injuries require intervention, these conditions are not potentially lifethreatening. D) While the other injuries require intervention, these conditions are not potentially lifethreatening. Page Ref: 1265 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 51.3 Describe the secondary survey and application to pathogenesis of traumatic injuries. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essential Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 2: Relate the pathogenesis of traumatic injuries to clinical manifestations.

20) The emergency department nurse has received a call from an incoming ambulance about a client who sustained a pelvic fracture. Which concomitant findings does the nurse understand to significantly increase the mortality rate in this client? Select all that apply. A) Abdominal injury requiring laparoscopic surgery B) Hypotension at the time of admission C) Airway injury requiring intubation D) Head injury requiring neurosurgery E) Pleural injury requiring chest tube placement Answer: A, B, D Explanation: A) In client's who have sustained a pelvic fracture, those with abdominal injuries requiring laparoscopic surgery, hypotension at the time of admission, and head injuries requiring neurosurgery have a significantly increased rate of mortality than clients without these concomitant findings. B) In client's who have sustained a pelvic fracture, those with abdominal injuries requiring laparoscopic surgery, hypotension at the time of admission, and head injuries requiring neurosurgery have a significantly increased rate of mortality than clients without these concomitant findings. C) Airway injuries requiring intubation and pleural injuries requiring chest tube placement are not findings that significantly influence the mortality rate of clients with pelvic fractures. D) In client's who have sustained a pelvic fracture, those with abdominal injuries requiring laparoscopic surgery, hypotension at the time of admission, and head injuries requiring neurosurgery have a significantly increased rate of mortality than clients without these concomitant findings. E) Airway injuries requiring intubation and pleural injuries requiring chest tube placement are not findings that significantly influence the mortality rate of clients with pelvic fractures. Page Ref: 1264 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 51.3 Describe the secondary survey and application to pathogenesis of traumatic injuries. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Relate the pathogenesis of traumatic injuries to clinical manifestations.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 52 Biologic, Chemical, and Radiologic Agents of Disease 1) The nurse is caring for several clients who sustained chemical injuries. Which statement related to chemical injuries does the nurse understand to be true? Select all that apply. A) The potential for unintentional exposure should be assumed, even if not apparent. B) A priority intervention is the removal of clothing. C) Protection of caregivers from exposure is important while caring for clients with these injuries. D) The injury-inducing agent may be difficult to identify without specialized equipment. E) Decontamination should occur with copious of amounts of soap-free water. Answer: B, C Explanation: A) The protection of caregivers from exposure to dangerous materials is important in this setting. The potential for intentional, not unintentional, exposure should be assumed, even if it not apparent. B) During the care of clients who have sustained chemical injuries, the removal of clothing is a priority intervention to remove residual contaminant. C) The protection of caregivers from exposure to dangerous materials is also important in this setting. D) The injury-inducing agent can be determined through clinical and laboratory findings in the case of chemical injuries. E) Soap may be used during decontamination if it is available. Page Ref: 1272 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: Nursing Process: Planning | Learning Outcome: 52.1 Describe dissemination of, current threats from, and concepts related to disorders caused by biologic, chemical, and radiologic agents. | QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the pathophysiology of disorders caused by biological, chemical, and radiologic agents.

2) The nurse is caring for a client with known exposure to a biologic agent. The nurse understands that which bacterial agents are most commonly weaponized? Select all that apply. A) Anthrax B) Smallpox C) Plague D) Q fever E) Venezuelan equine encephalitis Answer: A, C, D Explanation: A) Anthrax, plague, and Q fever are all common examples of weaponized bacterial agents. B) Smallpox and Venezuelan equine encephalitis are viral, not bacterial, agents. C) Anthrax, plague, and Q fever are all common examples of weaponized bacterial agents. D) Anthrax, plague, and Q fever are all common examples of weaponized bacterial agents. E) Smallpox and Venezuelan equine encephalitis are viral, not bacterial, agents. Page Ref: 1272 Cognitive Level: Understanding Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Assessment | Learning Outcome: 52.1 Describe dissemination of, current threats from, and concepts related to disorders caused by biologic, chemical, and radiologic agents. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the pathophysiology of disorders caused by biological, chemical, and radiologic agents.

3) An occupational health nurse is teaching employees about chemical agents. Which statement does the nurse include in the material? A) "The most common cause of injury occurs by these substances is through acts of terrorism." B) "Common side effects of exposure to these agents include flulike syndrome and hemorrhage." C) "These agents include viruses and biologic toxins that can result in severe infection and injury." D) "These agents are classified into several groups based on their nature or clinical effect." Answer: D Explanation: A) While acts of terrorism using chemical agents have occurred, unintentional injury by occupational exposure is far more likely. B) Flulike syndrome and hemorrhage are side effects resulting from exposure to biologic agents, not chemical agents. C) Chemical agents do not include viruses and biologic toxins that result in severe infection and injury. D) Chemical agents are classified into several groups based on their nature or clinical effect. Page Ref: 1272 Cognitive Level: Understanding Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Planning | Learning Outcome: 52.1 Describe dissemination of, current threats from, and concepts related to disorders caused by biologic, chemical, and radiologic agents. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and populationfocused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the pathophysiology of disorders caused by biological, chemical, and radiologic agents.

4) The nurse is caring for a client with exposure to an unknown chemical agent. The client asks, "Why can't a lab test be done to determine which agent I was exposed to?" What is the nurse's best response? A) "There is no way to determine exactly which test to run." B) "Obtaining results from a lab test would take longer than treatment would." C) "There are no lab tests available to identify the chemical." D) "It is more important to understand the type of injury you have." Answer: D Explanation: A) When caring for a client with a chemical injury by an unknown agent, the injury-inducing agent is often determined by the clinical presentation of the client. There are few tests available to identify what type of an exposure to a chemical agent has occurred, and these results require a significant amount of time to obtain. While the availability of testing and the timeline to obtain results may make the other statements accurate, the most accurate response is linked to the immediate needs of the client to provide information about the anticipated plan of care. B) When caring for a client with a chemical injury by an unknown agent, the injury-inducing agent is often determined by the clinical presentation of the client. There are few tests available to identify when an exposure to a chemical agent has occurred, and these results require a significant amount of time to obtain. While the availability of testing and the timeline to obtain results may make the other statements accurate, the most accurate response is linked to the immediate needs of the client to provide information about the anticipated plan of care. C) When caring for a client with a chemical injury by an unknown agent, the injury-inducing agent is often determined by the clinical presentation of the client. There are few tests available to identify when an exposure to a chemical agent has occurred, and these results require a significant amount of time to obtain. While the availability of testing and the timeline to obtain results may make the other statements accurate, the most accurate response is linked to the immediate needs of the client to provide information about the anticipated plan of care. D) When caring for a client with a chemical injury by an unknown agent, the injury-inducing agent is often determined by the clinical presentation of the client. There are few tests available to identify when an exposure to a chemical agent has occurred, and these results require a significant amount of time to obtain. While the availability of testing and the timeline to obtain results may make the other statements accurate, the most accurate response is linked to the immediate needs of the client to provide information about the anticipated plan of care. Page Ref: 1272 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 52.1 Describe dissemination of, current threats from, and concepts related to disorders caused by biologic, chemical, and radiologic agents. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the pathophysiology of disorders caused by biological, chemical, and radiologic agents. 4

5) The nurse is preparing to assess a client injured during a large-scale disaster for signs of exposure to hazardous agents and resulting injury. Which common manifestations of injuries due to biological, chemical, and radiologic agents does the nurse identify? Select all that apply. A) Flulike syndrome B) Hypoxia C) Skin ulceration D) Esophageal trauma E) Tracheal edema Answer: B, C, D, E Explanation: A) Common manifestations of injuries due to biological, chemical, and radiologic agents include hypoxia, skin ulceration, tracheal edema, and esophageal trauma. Flulike syndrome is a symptom that can be attributed specifically to a biologic agent. B) Common manifestations of injuries due to biological, chemical, and radiologic agents include hypoxia, skin ulceration, tracheal edema, and esophageal trauma. Flulike syndrome is a symptom that can be attributed specifically to a biologic agent. C) Common manifestations of injuries due to biological, chemical, and radiologic agents include hypoxia, skin ulceration, tracheal edema, and esophageal trauma. Flulike syndrome is a symptom that can be attributed specifically to a biologic agent. D) Common manifestations of injuries due to biological, chemical, and radiologic agents include hypoxia, skin ulceration, tracheal edema, and esophageal trauma. Flulike syndrome is a symptom that can be attributed specifically to a biologic agent. E) Common symptoms of injuries due to biological, chemical, and radiologic agents include hypoxia, skin ulceration, tracheal edema, and esophageal trauma. Flulike syndrome is a symptom that can be attributed specifically to a biologic agent. Page Ref: 1272-1273 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 52.1 Describe dissemination of, current threats from, and concepts related to disorders caused by biologic, chemical, and radiologic agents. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the pathophysiology of disorders caused by biological, chemical, and radiologic agents.

6) The nurse is caring for a client with confirmed anthrax exposure. Which statements about the mechanism of injury occurring with anthrax exposure does the nurse know to be true? Select all that apply. A) Active bacteria produce three proteins that ultimately produce the associated symptoms. B) After exposure to spores, the body's macrophages consume the foreign material. C) When the spores are activated, the macrophages are destroyed and the bacteria spreads. D) The symptom-producing compounds include the edema factor, the lethal factor, and the reactive factor. E) The cutaneous form of the agent cannot be transmitted to another person. Answer: A, B, C Explanation: A) When the body is exposed to anthrax spores, the spores are attacked by the body's macrophages. The spores are consumed and carried throughout the body until the spores become active, at which point the affected macrophages are destroyed and the active bacteria spreads. Active bacteria produce three proteins: the edema factor, the lethal factor, and the proactive (not reactive) factor. B) When the body is exposed to anthrax spores, the spores are attacked by the body's macrophages. The spores are consumed and carried throughout the body until the spores become active, at which point the affected macrophages are destroyed and the active bacteria spreads. Active bacteria produce three proteins: the edema factor, the lethal factor, and the proactive (not reactive) factor. C) When the body is exposed to anthrax spores, the spores are attacked by the body's macrophages. The spores are consumed and carried throughout the body until the spores become active, at which point the affected macrophages are destroyed and the active bacteria spreads. Active bacteria produce three proteins: the edema factor, the lethal factor, and the proactive (not reactive) factor. D) Active bacteria produce three proteins: the edema factor, the lethal factor, and the proactive (not reactive) factor. E) Anthrax cannot be transmitted from person to person with the exception of cutaneous anthrax. Page Ref: 1275 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 52.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders caused by biologic agents and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the pathophysiology of disorders caused by biological, chemical, and radiologic agents.

7) The nurse is assessing a client exposed to an unknown biologic agent. Which symptoms would cause the nurse to suspect gastrointestinal anthrax exposure? Select all that apply. A) Abdominal pain B) Vomiting C) Fever and chills D) Constipation E) Confusion Answer: A, B, C Explanation: A) Abdominal pain, vomiting, and fever and chills are symptoms associated with gastrointestinal anthrax infection. B) Abdominal pain, vomiting, and fever and chills are symptoms associated with gastrointestinal anthrax infection. C) Abdominal pain, vomiting, and fever and chills are symptoms associated with gastrointestinal anthrax infection. D) Constipation and confusion are not symptoms associated with this type of infection. E) Constipation and confusion are not symptoms associated with this type of infection. Page Ref: 1275 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 52.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders caused by biologic agents and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the pathophysiology of disorders caused by biological, chemical, and radiologic agents.

8) The nurse is teaching a community health class about anthrax exposure and prevention. Which statement will the nurse include in the material? A) "Vaccination includes the initial dose, as well as six-month and one-year follow up injections." B) "Vaccination is recommended for all individuals to ensure immunity." C) "Treatment for known exposure to anthrax includes vaccination and treatment with antibiotics." D) "Current recommendations for treatment for anthrax includes oral amoxicillin and levofloxacin." Answer: C Explanation: A) Vaccination includes the initial dose, as well as follow up doses at one month, six months, and yearly boosters. B) Vaccination is recommended for members of the military and lab and industrial workers at risk for exposure. C) Treatment for known exposure to anthrax includes vaccination and treatment with antibiotics. Vaccination includes the initial dose, as well as follow up doses at one month, six months, and yearly boosters. D) Current antibiotic recommendations for anthrax treatment include ciprofloxacin and levofloxacin, not amoxicillin. Page Ref: 1276-1277 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 52.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders caused by biologic agents and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the pathophysiology of disorders caused by biological, chemical, and radiologic agents.

9) A nurse performing medical outreach in a developing country is assessing a client for signs and symptoms of bubonic plague. Which finding does the nurse know is characteristic of this condition? A) Pulmonary congestion B) Swollen lymph nodes C) Evidence of an insect bite D) Hypotension Answer: B Explanation: A) Pulmonary congestion is characteristic of pneumonic plague. B) Bubonic plague is characterized by the presence of buboes, or swollen lymph nodes. C) Bubonic plague is characterized by the presence of buboes, or swollen lymph nodes. Although plague can be transmitted through insect bites, the presence of an insect bite is not considered a symptom of bubonic plague. D) Hypotension is characteristic of septicemic plague. Page Ref: 1277 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 52.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders caused by biologic agents and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the pathophysiology of disorders caused by biological, chemical, and radiologic agents.

10) The nurse is teaching a community health class about the history of smallpox. Which statements does the nurse include in the material? Select all that apply. A) "Smallpox was first identified in the eighteenth century." B) "Smallpox was declared eradicated in 1977." C) "Due to its eradication, weaponized smallpox is not considered a risk." D) "Before being eradicated, the death rate of smallpox was 30-50%." E) "The primary form of smallpox transmission is as a surface contaminant." Answer: B, D Explanation: A) Smallpox has been known to exist for over 3000 years. B) Due to extensive vaccination efforts, the disease was declared to be eradicated in 1977. However, at least two samples of the smallpox virus still exist in laboratories. One is located at the Centers for Disease Control and Prevention (CDC) in the United States, and the other is in Russia. C) The former Soviet Union was suspected of weaponizing smallpox in 1980, and there is concern that this virus may have changed hands when the Soviet Union came apart. D) Before being eradicated, smallpox had a mortality rate of approximately 30-50%. E) The disease is highly contagious and can be transmitted by becoming airborne from coughing or sneezing patients or as a surface contaminant spread by clothing and linens. Page Ref: 1279 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Planning | Learning Outcome: 52.2 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders caused by biologic agents and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the pathophysiology of disorders caused by biological, chemical, and radiologic agents.

11) The nurse is educating a group of industrial workers about the mechanism of injury by nerve agents. Which statement will the nurse include in the teaching? A) "Nerve agents block the action of muscarine." B) "Nerve agents block the action of cholinergic receptors." C) "Nerve agents block the action of acetylcholinesterase." D) "Nerve agents block the action of butyrylcholinesterase." Answer: C Explanation: A) Nerve agents result in overstimulation of receptor organs by blocking the action of the enzyme Nerve agents do not block the action of muscarine, cholinergic receptors, or butyrylcholinesterase. B) Nerve agents do not block the action of muscarine, cholinergic receptors, or butyrylcholinesterase. C) Nerve agents result in overstimulation of receptor organs by blocking the action of the enzyme acetylcholinesterase. D) Nerve agents do not block the action of muscarine, cholinergic receptors, or butyrylcholinesterase. Page Ref: 1281 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Planning | Learning Outcome: 52.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders caused by chemical agents and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the pathophysiology of disorders caused by biological, chemical, and radiologic agents.

12) The nurse is caring for a client exhibiting diarrhea, bradycardia, emesis, and salivation. The nurse understands that these findings are consistent with what mechanism? A) Overstimulation of acetylcholinesterase receptors B) Overstimulation of muscarinic receptors C) Overstimulation of nicotinic receptors D) Overstimulation of histone deacetylase Answer: B Explanation: A) These symptoms do not characterize overstimulation of acetylcholinesterase, nicotinic, or histone deacetylase receptors. B) Diarrhea, bradycardia, emesis, and salivation are characteristic symptoms of the overstimulation of muscarinic receptors. C) These symptoms do not characterize overstimulation of acetylcholinesterase, nicotinic, or histone deacetylase receptors. D) These symptoms do not characterize overstimulation of acetylcholinesterase, nicotinic, or histone deacetylase receptors. Page Ref: 1281 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 52.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders caused by chemical agents and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the pathophysiology of disorders caused by biological, chemical, and radiologic agents.

13) The nurse is collecting the medical history of a client with exposure to a nerve agent. Which assessment findings does the nurse understand are associated with inhalation of a nerve agent? Select all that apply. A) Rapid onset of symptoms B) Irritation of the eyes, nose, and airways C) Diaphoresis D) Gastrointestinal symptoms E) Seizures Answer: A, B, E Explanation: A) Rapid onset of symptoms, irritation of the eyes, nose, and airways, and seizures are assessment findings associated with inhalation of a nerve agent. B) Rapid onset of symptoms, irritation of the eyes, nose, and airways, and seizures are assessment findings associated with inhalation of a nerve agent. C) Diaphoresis and gastrointestinal symptoms may be present, but are not associated with this condition. D) Diaphoresis and gastrointestinal symptoms may be present, but are not associated with this condition. E) Rapid onset of symptoms, irritation of the eyes, nose, and airways, and seizures are assessment findings associated with inhalation of a nerve agent. Page Ref: 1282 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 52.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders caused by chemical agents and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the pathophysiology of disorders caused by biological, chemical, and radiologic agents.

14) The nurse is educating a group of industrial employees on the importance of decontamination following exposure to a vesicant. Which statement will the nurse include in the material? A) Cellular damage is limited to cutaneous and subcutaneous tissues. B) The onset of symptoms occur as soon as cellular damage ensues. C) Cellular damage occurs immediately on contact with the agent. D) Victims may not be aware when exposure and injury has occurred. Answer: D Explanation: A) Cellular damage is not limited to cutaneous and subcutaneous tissues. B) Onset of symptoms may be delayed as much as 1-12 hours after exposure, so victims may not be aware of when exposure and subsequent injury has occurred. C) It is important for clients to undergo decontamination as soon as possible following exposure to a vesicant, as cellular damage begins within 3-5 minutes after exposure. D) It is important for clients to undergo decontamination as soon as possible following exposure to a vesicant, as cellular damage begins within 3-5 minutes after exposure. Onset of symptoms may be delayed as much as 1-12 hours after exposure, so victims may not be aware of when exposure and subsequent injury has occurred. Page Ref: 1282 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: Nursing Process: Planning | Learning Outcome: 52.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders caused by chemical agents and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: VII. 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the pathophysiology of disorders caused by biological, chemical, and radiologic agents.

15) The nurse is caring for a client with cyanide poisoning. Which statement about the mechanism of injury in this client does the nurse know to be true? Select all that apply. A) Cyanide binds with cytochrome a3. B) Cyanide prevents the use of oxygen by cellular mitochondria. C) Cyanide halts ATP production in affected mitochondria. D) Cyanide causes oxygen to continue to be extracted from hemoglobin, resulting in hypoxia. E) Cyanide poisoning ultimately results in respiratory acidosis. Answer: A, B, C Explanation: A) Cyanide binds with cytochrome a3, preventing the use of oxygen in cellular mitochondria and halting ATP production. Oxygen is then no longer extracted from hemoglobin, which results in metabolic acidosis. B) Cyanide binds with cytochrome a3, preventing the use of oxygen in cellular mitochondria and halting ATP production. Oxygen is then no longer extracted from hemoglobin, which results in metabolic acidosis. C) Cyanide binds with cytochrome a3, preventing the use of oxygen in cellular mitochondria and halting ATP production. Oxygen is then no longer extracted from hemoglobin, which results in metabolic acidosis. D) Cyanide binds with cytochrome a3, preventing the use of oxygen in cellular mitochondria and halting ATP production. Oxygen is then no longer extracted from hemoglobin, which results in metabolic acidosis. E) Cyanide binds with cytochrome a3, preventing the use of oxygen in cellular mitochondria and halting ATP production. Oxygen is then no longer extracted from hemoglobin, which results in metabolic acidosis. Page Ref: 1285 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 52.3 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders caused by chemical agents and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the pathophysiology of disorders caused by biological, chemical, and radiologic agents.

16) The nurse is caring for a client with radiation poisoning. Which forms of energy does the nurse understand to be common causes of radiation poisoning? Select all that apply. A) Alpha rays B) Beta rays C) Protons D) Neutrons E) Gamma rays Answer: A, B, D, E Explanation: A) Alpha rays, beta rays, neutrons, and gamma rays are the most common causes of radiation poisoning. B) Alpha rays, beta rays, neutrons, and gamma rays are the most common causes of radiation poisoning. C) Protons are not considered to be a common form of energy associated with radiation poisoning. D) Alpha rays, beta rays, neutrons, and gamma rays are the most common causes of radiation poisoning. E) Alpha rays, beta rays, neutrons, and gamma rays are the most common causes of radiation poisoning. Page Ref: 1285 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 52.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders caused by radiologic and nuclear devices and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the pathophysiology of disorders caused by biological, chemical, and radiologic agents.

17) The nurse is assessing a client in the prodromal phase of radiation sickness. Which assessment findings does the nurse anticipate? Select all that apply. A) Diarrhea B) Vomiting C) Nausea D) Anorexia E) Fever Answer: B, C, D, E Explanation: A) Diarrhea is associated with the illness phase of radiation sickness. B) Vomiting, nausea, anorexia, and fever are symptoms associated with the prodromal phase of radiation sickness. C) Vomiting, nausea, anorexia, and fever are symptoms associated with the prodromal phase of radiation sickness. D) Vomiting, nausea, anorexia, and fever are symptoms associated with the prodromal phase of radiation sickness. E) Vomiting, nausea, anorexia, and fever are symptoms associated with the prodromal phase of radiation sickness. Page Ref: 1286 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 52.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders caused by radiologic and nuclear devices and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health MNL Learning Outcome: LO 1: Examine the pathophysiology of disorders caused by biological, chemical, and radiologic agents.

18) The nurse is caring for a client recovering from radiation sickness. Which factors does the nurse know will affect the ultimate outcome for this client? Select all that apply. A) Time to onset of symptoms B) Severity of cutaneous effects C) Total dose of radiation D) Organ damage E) Availability of medical services Answer: C, D, E Explanation: A) Time to onset of symptoms and the severity of cutaneous effects are important elements of the client's recovery, but do not affect the ultimate outcome for clients with radiation sickness. B) Time to onset of symptoms and the severity of cutaneous effects are important elements of the client's recovery, but do not affect the ultimate outcome for clients with radiation sickness. C) The total dose of radiation, associated organ damage, and the availability of appropriate medical services are all factors that will affect the ultimate outcome for a client with radiation sickness. D) The total dose of radiation, associated organ damage, and the availability of appropriate medical services are all factors that will affect the ultimate outcome for a client with radiation sickness. E) The total dose of radiation, associated organ damage, and the availability of appropriate medical services are all factors that will affect the ultimate outcome for a client with radiation sickness. Page Ref: 1287 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 52.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders caused by radiologic and nuclear devices and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the pathophysiology of disorders caused by biological, chemical, and radiologic agents.

19) The nurse is educating a client who has experienced radiation exposure. The client asks, "What type of exposure is most likely to lead to cancer?" What is the nurse's response? A) "All types of exposure will eventually lead to cancer." B) "When irradiation occurs, and the energy passes through the body, cancer may develop." C) "When contamination occurs, and radioactive material is deposited on the body, cancer may develop." D) "When incorporation occurs, and radioactive material is taken up by the body's organs, cancer may develop." Answer: D Explanation: A) Incorporation is when radioactive material is taken up by the body's organs. Not all types or instances of radiation exposure lead to incorporation and subsequent cancer. B) Contamination and irradiation may be factors contributing to cancer, but are not as likely to result in cancer as incorporation. C) Contamination and irradiation may be factors contributing to cancer, but are not as likely to result in cancer as incorporation. D) Incorporation is when radioactive material is taken up by the body's organs. Radiation exposure can result in the development of cancer when incorporation occurs, and radioactive material is taken up by the body's organs. Page Ref: 1286 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 52.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders caused by radiologic and nuclear devices and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the pathophysiology of disorders caused by biological, chemical, and radiologic agents.

20) The nurse is reviewing prescriptions for a client with acute radiation syndrome. Which prescription will the nurse verify with the healthcare provider before proceeding? A) IV normal saline solution for hydration B) Oral prochlorperazine for nausea C) Oral magnesium hydroxide for gastrointestinal prophylaxis D) Subcutaneous filgrastim for bone marrow stimulation Answer: C Explanation: A) Fluid replacement, antiemetics, and growth factor support are all prescriptions that are consistent with the client's diagnosis of acute radiation syndrome. B) Fluid replacement, antiemetics, and growth factor support are all prescriptions that are consistent with the client's diagnosis of acute radiation syndrome. C) The nurse will review the prescription for oral magnesium hydroxide, a prescription given for constipation prevention, with the healthcare provider before proceeding. This is because expected symptoms of acute radiation syndrome include diarrhea and electrolyte imbalance, which may be exacerbated by this prescription D) Fluid replacement, antiemetics, and growth factor support are all prescriptions that are consistent with the client's diagnosis of acute radiation syndrome. Page Ref: 1287 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Planning | Learning Outcome: 52.4 Differentiate the causes, classification, underlying pathogenesis, and clinical manifestations of disorders caused by radiologic and nuclear devices and approaches to diagnosis and treatment of these conditions across the lifespan. | QSEN Competencies: III B. Base individualized care plan on patient values, clinical expertise and evidence | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 1: Examine the pathophysiology of disorders caused by biological, chemical, and radiologic agents.

Pathophysiology: Concepts of Human Disease (Sorenson) Chapter 53 Pathophysiology at the End of Life 1) The plan of care for a client in hospice care should include: A) curative treatments. B) control of symptoms. C) postponing death. D) laboratory tests. Answer: B Explanation: A) Hospice is a formal program that delivers palliative care, rather than curative treatment, to patients who are near the end of life. Hospice care exists under the umbrella of palliative care services. Palliative care is care provided to patients experiencing life-threatening, progressive illness that focuses on providing effective relief of symptoms rather than on curing the illness. B) Hospice is a formal program that delivers palliative care, rather than curative treatment, to patients who are near the end of life. Hospice care exists under the umbrella of palliative care services. Palliative care is care provided to patients experiencing life-threatening, progressive illness that focuses on providing effective relief of symptoms rather than on curing the illness. C) While research shows that patients with lung cancer who received palliative care integrated with standard cancer care lived 3 months longer than patients who received standard cancer care alone, the goals of hospice and palliative care are not to prolong life. D) Laboratory, radiologic, and other diagnostic tests are not typically performed in the care of the terminally ill patient unless the results of such testing will change the management plan and benefit the patient. Page Ref: 1292-1293 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Planning | Learning Outcome: 53.1 Differentiate palliative care from curative care and describe the settings in which palliative care is delivered, and explain how the concept of oxygenation is related to symptoms experienced near the end of life that require palliative care. | QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Recognize how common symptoms for patients receiving palliative care affect quality of life.

2) The nurse is using the Karnofsky Performance Scale to determine the performance status of a client in palliative care with end-stage lung cancer. With a score of 50, what activity level should the nurse anticipate? A) Performs activities of daily living independently B) Requires occasional assistance with activities of daily living C) Requires considerable assistance with activities of daily living D) Needs total assistance Answer: C Explanation: A) The client with a score of 50 on the Karnofsky Performance Status Scale requires considerable assistance and frequent medical care. B) The client with a score of 50 on the Karnofsky Performance Status Scale requires considerable assistance and frequent medical care. C) The client with a score of 50 on the Karnofsky Performance Status Scale requires considerable assistance and frequent medical care. D) The client with a score of 50 on the Karnofsky Performance Status Scale requires considerable assistance and frequent medical care. Page Ref: 1293 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Assessment | Learning Outcome: 53.1 Differentiate palliative care from curative care and describe the settings in which palliative care is delivered, and explain how the concept of oxygenation is related to symptoms experienced near the end of life that require palliative care. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.6 Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Recognize how common symptoms for patients receiving palliative care affect quality of life.

3) Which of the following pain medication orders for a client with ovarian cancer would be most appropriate for the nurse to use to control a client's chronic pain? A) Administer short-acting pain medication as needed. B) Administer short-acting pain medication around the clock. C) Administer long-acting pain medication when the client reports severe pain. D) Administer long-acting pain medication around the clock. Answer: D Explanation: A) For patients experiencing chronic pain, long-acting medications are provided around the clock; short-acting medications are also made available for breakthrough pain. B) For patients experiencing chronic pain, long-acting medications are provided around the clock; short-acting medications are also made available for breakthrough pain. C) For patients experiencing chronic pain, long-acting medications are provided around the clock; short-acting medications are also made available for breakthrough pain. D) For patients experiencing chronic pain, long-acting medications are provided around the clock; short-acting medications are also made available for breakthrough pain. Page Ref: 1295 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Implementation | Learning Outcome: 53.2 Recognize the importance of pain assessment and management for individuals with terminal illness. | QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Recognize how common symptoms for patients receiving palliative care affect quality of life.

4) The nurse is caring for a client in palliative care who is alert and oriented to person, place, and time. Which assessment data would be most appropriate in determining the client's need for pain medication? A) Ask the client to rate his pain. B) Observe the client's face for signs of pain. C) Evaluate the client's heart rate, blood pressure, and pulse rate. D) Ask the client's spouse if the client is in pain. Answer: A Explanation: A) Comprehensive pain assessment is essential, with particular attention given to the patient's self-report of pain, including location, intensity, quality, pattern, and effects on function. Because this client is alert and oriented, the client's self-report of pain should be used to determine whether the client is in pain. B) Comprehensive pain assessment is essential, with particular attention given to the patient's self-report of pain, including location, intensity, quality, pattern, and effects on function. Because this client is alert and oriented, the client's self-report of pain should be used to determine whether the client is in pain. C) Comprehensive pain assessment is essential, with particular attention given to the patient's self-report of pain, including location, intensity, quality, pattern, and effects on function. Because this client is alert and oriented, the client's self-report of pain should be used to determine whether the client is in pain. D) Comprehensive pain assessment is essential, with particular attention given to the patient's self-report of pain, including location, intensity, quality, pattern, and effects on function. Because this client is alert and oriented, the client's self-report of pain should be used to determine whether the client is in pain. Page Ref: 1295 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 53.2 Recognize the importance of pain assessment and management for individuals with terminal illness. | QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of common symptoms for patients receiving palliative care.

5) What is the best way for the nurse to determine if a client is experiencing dyspnea? A) Observe the client's breathing without the client's knowledge B) Evaluate pulmonary function test results C) Send an arterial blood gas sample to the laboratory D) Obtain subjective data from the client Answer: D Explanation: A) Patients can experience acute or chronic dyspnea. In both types, a patient's selfreport of difficult breathing provides the most reliable data. B) Patients can experience acute or chronic dyspnea. In both types, a patient's self-report of difficult breathing provides the most reliable data C) Patients can experience acute or chronic dyspnea. In both types, a patient's self-report of difficult breathing provides the most reliable data D) Patients can experience acute or chronic dyspnea. In both types, a patient's self-report of difficult breathing provides the most reliable data Page Ref: 1296 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 53.3 Analyze the pathophysiologic mechanisms that are responsible for a patient's dyspnea on the basis of the disease processes that are present and the patient's description of the difficulty in breathing, and relate the pathophysiology to treatment. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of common symptoms for patients receiving palliative care.

6) Which nursing intervention would be a priority in managing dyspnea in the hospice client? A) Providing an inhaled bronchodilator B) Administering opioid medication C) Raising the head of the bed D) Administering supplemental oxygen Answer: B Explanation: A) Opioid medications, such as morphine, are highly effective in treating dyspnea. Opioid medications cause venous dilation, reducing blood return to the heart and therefore cardiac preload (volume load), oxygen consumption, demand for ventilation, and central perception of breathlessness. Opioid medications are therefore the cornerstone of treatment for end-stage dyspnea. The other interventions may also be useful in reducing dyspnea, but administration of an opioid is the priority. B) Opioid medications, such as morphine, are highly effective in treating dyspnea. Opioid medications cause venous dilation, reducing blood return to the heart and therefore cardiac preload (volume load), oxygen consumption, demand for ventilation, and central perception of breathlessness. Opioid medications are therefore the cornerstone of treatment for end-stage dyspnea. The other interventions may also be useful in reducing dyspnea, but administration of an opioid is the priority. C) Opioid medications, such as morphine, are highly effective in treating dyspnea. Opioid medications cause venous dilation, reducing blood return to the heart and therefore cardiac preload (volume load), oxygen consumption, demand for ventilation, and central perception of breathlessness. Opioid medications are therefore the cornerstone of treatment for end-stage dyspnea. The other interventions may also be useful in reducing dyspnea, but administration of an opioid is the priority. D) Opioid medications, such as morphine, are highly effective in treating dyspnea. Opioid medications cause venous dilation, reducing blood return to the heart and therefore cardiac preload (volume load), oxygen consumption, demand for ventilation, and central perception of breathlessness. Opioid medications are therefore the cornerstone of treatment for end-stage dyspnea. The other interventions may also be useful in reducing dyspnea, but administration of an opioid is the priority. Page Ref: 1297 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Implementation | Learning Outcome: 53.3 Analyze the pathophysiologic mechanisms that are responsible for a patient's dyspnea on the basis of the disease processes that are present and the patient's description of the difficulty in breathing, and relate the pathophysiology to treatment. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of common symptoms for patients receiving palliative care.

7) Which action by the spouse of a hospice client indicates understanding of the nurse's teaching plan for reducing dyspnea? A) Closing a window near the client B) Keeping the room warm C) Using a fan near the client's face D) Reducing the humidity level of the room Answer: C Explanation: A) Air movement across the face produced by an open window or fan can help to relieve dyspnea. B) Keeping the temperature cool may help relieve dyspnea. C) Air movement across the face produced by a fan can help to relieve dyspnea. D) When thick secretions are contributing to dyspnea, increasing the humidity level of the environment and increasing oral intake of liquids as tolerated may help. Page Ref: 1297 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Evaluation | Learning Outcome: 53.3 Analyze the pathophysiologic mechanisms that are responsible for a patient's dyspnea on the basis of the disease processes that are present and the patient's description of the difficulty in breathing, and relate the pathophysiology to treatment. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 2: Recognize how common symptoms for patients receiving palliative care affect quality of life.

8) At the time of death, which finding is the nurse most likely to assess? A) Lack of heartbeat B) Body temperature same as room temperature C) Rigor mortis D) Livor mortis Answer: A Explanation: A) Signs of somatic death include fixed and dilated pupils; cessation of heartbeat, respiration, movement, and reflexes; and relaxation of muscles and sphincters. B) Algor mortis is the drop in body temperature that begins immediately after death and is due to cessation of heat producing metabolic reactions and regulation of body temperature. Body temperature continues to decline until it reaches that of the environment within about 24 hours after death. C) Rigor mortis is the stiffening of body muscles that begins within 2-3 hours after death. D) When the heart is no longer pumping blood throughout the body, blood settles in the dependent parts of the body, resulting in a purple-red discoloration of those areas called livor mortis. While livor mortis occurs soon after death, it is not present at the time of death. Page Ref: 1309-1310 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 53.12 Attribute the underlying pathophysiologic mechanisms to the clinical manifestations that occur in the active phase of dying and the indicators of somatic death. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of common symptoms for patients receiving palliative care to diagnosis and treatment.

9) The nursing care plan for a client in hospice who is experiencing daytime coughing due to excessive accumulated secretions should include: A) chest physiotherapy. B) antitussive medication. C) bronchodilators. D) reducing fluid intake. Answer: A Explanation: A) The client who is coughing due to excessive secretions will benefit from chest physiotherapy to help mobilize accumulated secretions. B) Antitussive medications suppress a cough and are particularly effective at bedtime to help the patient achieve rest. They will not reduce the amount of secretions or help the client expel the secretions. C) If bronchospasm is a causative factor, inhaled bronchodilators are used to relax the smooth muscles of the airway. D) Nonpharmacologic interventions for cough include increasing the humidity in the environment and keeping the patient well hydrated, if possible, to decrease the viscosity of respiratory secretions. Page Ref: 1299 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Planning | Learning Outcome: 53.4 Explain the factors that trigger the cough reflex in terminal illness, the potential complications of coughing, characteristics of coughing that should be assessed, and pharmacologic and nonpharmacologic treatment strategies. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of common symptoms for patients receiving palliative care to diagnosis and treatment.

10) The daughter of a client, who is at the end of life, is concerned that the gurgling sound she hears is her father drowning in his own secretions. What is the best initial response by the nurse? A) "This must be very upsetting to watch, but he isn't suffering." B) "It might be best if you leave the room." C) "You may not be giving him enough fluid." D) "I'll suction him now." Answer: A Explanation: A) This response acknowledges that this is upsetting to family members and provides reassurance that the patient is not suffering. B) Asking the daughter to leave the room does not acknowledge the daughter's feelings and fears or provide family education. C) This gurgling sound is an end-of-life phenomenon, and although dehydration may be a factor, it is not due to any lack of care by the family or nursing staff. D) Oropharyngeal suctioning is usually not recommended because this procedure causes discomfort, is ineffective if secretions are beyond the reach of the catheter, and does not correct the underlying problem. Page Ref: 1299-1300 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity Standards: Nursing Process: Implementation | Learning Outcome: 53.5 Attribute the production and signs of excessive airway secretions in terminal illness and treatment strategies to the underlying pathophysiology. | QSEN Competencies: I.A.9 Discuss principles of effective communication | AACN Essential Competencies: IX.21. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship NLN Competencies: Relationship Centered Care: Effective Communication MNL Learning Outcome: LO 4: Consider the pathophysiology of common symptoms for patients receiving palliative care to diagnosis and treatment.

11) A client at the end of life has an antimuscarinic medication ordered for secretion management. When is the ideal time for the nurse administer this medication? A) At the first sign of the death rattle B) When the death rattle can be heard from several feet away C) Before the death rattle occurs D) If the death rattle upsets the family Answer: A Explanation: A) Because of the involvement of muscarinic receptors in the production of secretions, antimuscarinic medications are the drugs of choice for patients with the death rattle. These medications do not eliminate existing accumulated secretions, so they must be initiated at the first sign of the death rattle. B) Because of the involvement of muscarinic receptors in the production of secretions, antimuscarinic medications are the drugs of choice for patients with the death rattle. These medications do not eliminate existing accumulated secretions, so they must be initiated at the first sign of the death rattle. C) Because of the involvement of muscarinic receptors in the production of secretions, antimuscarinic medications are the drugs of choice for patients with the death rattle. These medications do not eliminate existing accumulated secretions, so they must be initiated at the first sign of the death rattle. D) Because of the involvement of muscarinic receptors in the production of secretions, antimuscarinic medications are the drugs of choice for patients with the death rattle. These medications do not eliminate existing accumulated secretions, so they must be initiated at the first sign of the death rattle. Page Ref: 1300 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Implementation | Learning Outcome: 53.5 Attribute the production and signs of excessive airway secretions in terminal illness and treatment strategies to the underlying pathophysiology. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of common symptoms for patients receiving palliative care to diagnosis and treatment.

12) The nurse would expect to assess which metabolic condition in the client at the end of life who is vomiting? A) Metabolic alkalosis B) Metabolic acidosis C) Respiratory alkalosis D) Respiratory acidosis Answer: A Explanation: A) Vomiting can lead to metabolic alkalosis from loss of gastric acid. B) Vomiting can lead to metabolic alkalosis from loss of gastric acid. C) Vomiting can lead to metabolic alkalosis from loss of gastric acid. D) Vomiting can lead to metabolic alkalosis from loss of gastric acid. Page Ref: 1300 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 53.6 Discriminate the characteristics of nausea and vomiting and the factors that trigger the emetic response, and relate the prevention and treatment of nausea and vomiting to the underlying cause. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of common symptoms for patients receiving palliative care to diagnosis and treatment.

13) What suggestions should the nurse give the family of a client with end-stage cancer who is experiencing nausea and vomiting? A) Do not feed the client. B) Encourage ingestion of foods that appeal to the client. C) Serve seasoned foods. D) Serve food very hot. Answer: B Explanation: A) Encourage the client to attempt to ingest foods that appeal to him and that he believes he may best tolerate. A general recommendation is to eat bland food at room temperature. The client does not need to be fasting if he feels he can tolerate food. B) Encourage the client to attempt to ingest foods that appeal to him and that he believes he may best tolerate. A general recommendation is to eat bland food at room temperature. The client does not need to be fasting if he feels he can tolerate food. C) Encourage the client to attempt to ingest foods that appeal to him and that he believes he may best tolerate. A general recommendation is to eat bland food at room temperature. The client does not need to be fasting if he feels he can tolerate food. D) Encourage the client to attempt to ingest foods that appeal to him and that he believes he may best tolerate. A general recommendation is to eat bland food at room temperature. The client does not need to be fasting if he feels he can tolerate food. Page Ref: 1302 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Implementation | Learning Outcome: 53.6 Discriminate the characteristics of nausea and vomiting and the factors that trigger the emetic response, and relate the prevention and treatment of nausea and vomiting to the underlying cause. | QSEN Competencies: I.B.10 Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of common symptoms for patients receiving palliative care to diagnosis and treatment.

14) How should the nurse respond when the son of an end-stage cancer patient tells the nurse that his "dad is refusing to eat" and he fears that his father has "given up hope"? A) Make suggestions of foods that his father might find palatable. B) Have the son complete a 24-hour food diary of what his father eats. C) Explain that this is normal and that his father is comfortable. D) Call the physician and request a nutrition consult. Answer: C Explanation: A) Family members may feel that they are failing or abandoning the patient by not feeding him. It is helpful to inform them that decreased intake of foods and fluids can lead to ketosis and subsequent release of endorphins that contribute to an enhanced sense of well-being and diminished discomfort. Family members can be assisted in redirecting their expression of care and concern away from food to other measures that provide comfort to the patient. B) Family members may feel that they are failing or abandoning the patient by not feeding him. It is helpful to inform them that decreased intake of foods and fluids can lead to ketosis and subsequent release of endorphins that contribute to an enhanced sense of well-being and diminished discomfort. Family members can be assisted in redirecting their expression of care and concern away from food to other measures that provide comfort to the patient. C) Family members may feel that they are failing or abandoning the patient by not feeding him. It is helpful to inform them that decreased intake of foods and fluids can lead to ketosis and subsequent release of endorphins that contribute to an enhanced sense of well-being and diminished discomfort. Family members can be assisted in redirecting their expression of care and concern away from food to other measures that provide comfort to the patient. D) Family members may feel that they are failing or abandoning the patient by not feeding him. It is helpful to inform them that decreased intake of foods and fluids can lead to ketosis and subsequent release of endorphins that contribute to an enhanced sense of well-being and diminished discomfort. Family members can be assisted in redirecting their expression of care and concern away from food to other measures that provide comfort to the patient. Page Ref: 1303 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity Standards: Nursing Process: Implementation | Learning Outcome: 53.7 Explain the pathophysiologic mechanisms involved in anorexia and cachexia and the clinical manifestations, treatment, and interrelationship of anorexia and cachexia occurring near the end of life. | QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX.6 Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of common symptoms for patients receiving palliative care.

15) A client in the terminal phase of dying reports feeling very tired and no longer wants to get out of bed and engage with family. What is the best response for the nurse to make to the family? A) "Assist your family member to get out of bed at least twice a day." B) "Encourage your family member to be a part of family events as much as possible." C) "Encourage your family member to be awake during the day." D) "Be present for your loved one and do not pressure him to be more involved." Answer: D Explanation: A) In the terminal phase of care, fatigue is an expected and generally uncontrollable consequence of progressive disease. Family members are encouraged to avoid pressuring the client to be more involved or more energetic than he or she can be. Family should be encouraged to be present for the family member and to take his or her lead in activity and rest. B) In the terminal phase of care, fatigue is an expected and generally uncontrollable consequence of progressive disease. Family members are encouraged to avoid pressuring the client to be more involved or more energetic than he or she can be. Family should be encouraged to be present for the family member and to take his or her lead in activity and rest. C) In the terminal phase of care, fatigue is an expected and generally uncontrollable consequence of progressive disease. Family members are encouraged to avoid pressuring the client to be more involved or more energetic than he or she can be. Family should be encouraged to be present for the family member and to take his or her lead in activity and rest. D) In the terminal phase of care, fatigue is an expected and generally uncontrollable consequence of progressive disease. Family members are encouraged to avoid pressuring the client to be more involved or more energetic than he or she can be. Family should be encouraged to be present for the family member and to take his or her lead in activity and rest. Page Ref: 1305 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Implementation | Learning Outcome: 53.8 Explain the pathophysiologic mechanisms involved in fatigue and the multifactorial causes of fatigue in terminal illness and its management. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings NLN Competencies: Relationship Centered Care: Effective Communication MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of common symptoms for patients receiving palliative care.

16) When starting a terminal client on an opioid for pain control, which action should be included in the plan of care? A) Administer a daily laxative B) Reduce fiber in the diet C) Limit fluid intake D) Administer a daily enema Answer: A Explanation: A) Patients who are taking opioid medications must also be provided with daily laxatives, and the dose of the laxative must be titrated upward when the dose of the opioid is increased. B) Nonpharmacologic approaches for constipation are also included in the plan of care. Increased fluid intake and the addition of high-fiber foods are encouraged for patients who can tolerate them. C) Nonpharmacologic approaches for constipation are also included in the plan of care. Increased fluid intake and the addition of high-fiber foods are encouraged for patients who can tolerate them. D) Enemas are used only for patients who develop impaction. Page Ref: 1306-1307 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: Nursing Process: Planning | Learning Outcome: 53.9 Describe the multifactorial causes of constipation associated with terminal illness, and explain prevention and treatment strategies to underlying causes. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.8. Implement evidencebased nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of common symptoms for patients receiving palliative care.

17) An alert and oriented female client in early hospice care is experiencing urinary incontinence. Which is the most appropriate initial intervention for this client? A) Teach pelvic floor muscle strengthening exercises B) Establish a voiding schedule C) Limit all fluid intake D) Place diapers on the client Answer: B Explanation: A) While pelvic floor muscle strengthening exercises have been demonstrated as effective for stress incontinence in other patient populations, hospice and palliative care patients may be unable to perform these exercises. B) Urinary incontinence in terminally ill patients can be treated with behavioral methods; one approach is to establish a voiding schedule for patients who can tolerate movement using a bedpan, bedside commode, or toilet. C) Patients may find that limiting intake of beverages with a diuretic effect, such as those containing caffeine, throughout the day and minimizing fluid intake before bedtime improve symptoms. However, reducing all fluid intake can result in dehydration. D) While the use of diapers may be used to keep skin clean and dry, it is not the initial intervention in a client who is alert and oriented. The use of a voiding schedule should be used first. Page Ref: 1308 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Planning | Learning Outcome: 53.10 Differentiate the causes, underlying pathogenesis, clinical manifestations, diagnosis and treatment approaches of transient urinary incontinence from those in chronic urinary incontinence (stress, urge, overflow, and functional types). | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of common symptoms for patients receiving palliative care.

18) The nurse is assessing a hospice client who has had changes in cognition due to delirium. Using the Confusion Assessment Method, what would the nurse expect to find? A) A gradual change in mental status B) Fluctuations in severity of mental status throughout the day C) Enhanced ability to focus D) Able to reorient to person and place Answer: B Explanation: A) The Confusion Assessment Method (CAM) is a delirium rating scale that detects delirium and differentiates it from dementia. The diagnosis of delirium using CAM is based on the presence of an acute onset of change in mental status with fluctuations in severity throughout the day plus impaired ability to focus attention. In addition to those two manifestations, either disorganized thinking or an altered level of consciousness must be present. B) The Confusion Assessment Method (CAM) is a delirium rating scale that detects delirium and differentiates it from dementia. The diagnosis of delirium using CAM is based on the presence of an acute onset of change in mental status with fluctuations in severity throughout the day plus impaired ability to focus attention. In addition to those two manifestations, either disorganized thinking or an altered level of consciousness must be present. C) The Confusion Assessment Method (CAM) is a delirium rating scale that detects delirium and differentiates it from dementia. The diagnosis of delirium using CAM is based on the presence of an acute onset of change in mental status with fluctuations in severity throughout the day plus impaired ability to focus attention. In addition to those two manifestations, either disorganized thinking or an altered level of consciousness must be present. D) The Confusion Assessment Method (CAM) is a delirium rating scale that detects delirium and differentiates it from dementia. The diagnosis of delirium using CAM is based on the presence of an acute onset of change in mental status with fluctuations in severity throughout the day plus impaired ability to focus attention. In addition to those two manifestations, either disorganized thinking or an altered level of consciousness must be present. Page Ref: 1309 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Assessment | Learning Outcome: 53.11 Explain factors that contribute to delirium at the end of life, its various manifestations, diagnosis, and treatment strategies. | QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX.6 Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of common symptoms for patients receiving palliative care.

19) What action should the nurse take when a home hospice client exhibits Cheyne-Stokes breathing? A) Tell the family that this type of breathing indicates improvement B) Ask the family to leave the room C) Prepare the family for imminent death D) Begin postmortem care Answer: C Explanation: A) Cheyne-Stokes breathing is a sign of imminent death. B) The family caring for a loved one should not be asked to leave the room at the time of death. Rather, they should be told that death is imminent. C) Clinical manifestations of the active phase of dying include Cheyne-Stokes breathing, which is characterized by a waxing and waning of the depth of breathing with regularly recurring intervals of apnea. Cheyne-Stokes breathing is a sign of imminent death. D) The client with Cheyne-Stokes breathing is in the final stages of dying. Postmortem care is given after the person has died. Page Ref: 1309 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: Nursing Process: Implementation | Learning Outcome: 53.12 Attribute the underlying pathophysiologic mechanisms to the clinical manifestations that occur in the active phase of dying and the indicators of somatic death. | QSEN Competencies: I.A.9 Discuss principles of effective communication | AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 4: Consider the pathophysiology of common symptoms for patients receiving palliative care to diagnosis and treatment.

20) Which is the best way for the nurse to assess pain in the neonate? A) Using the CRIES scale to assess for behavioral and physiologic indicators of pain B) Using the Oucher Scale with faces showing mild to severe pain C) Using the nurse's experience in caring for neonates as a guide D) Using the Children's Fatigue Scale Answer: A Explanation: A) The CRIES scale can be used for assessment of pain in full-term neonates. This scale uses behavioral indicators such as crying, sleeplessness, facial expressions, and physiologic indicators, such as heart rate and blood pressure, in the assessment of pain. B) For older children, there are scales such as the Oucher Scale, with faces depicting mild to severe levels of distress caused by pain that the child can point to in assisting nurses in assessment of the child's pain severity. C) While the nurse's experience is helpful in assessing pain, behavioral indicators provide a more reliable assessment of pain. D) The Children's Fatigue Scale assesses the impact of fatigue on factors such as the child's ability to engage in play or run, length of sleep, and feeling tired during the day. Page Ref: 1311 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: Nursing Process: Assessment | Learning Outcome: 53.13 Compare pediatric palliative care to adult palliative care with regard to causes of terminal illness, symptoms experienced near the end of life, and approaches to assessment of symptoms. | QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essential Competencies: IX. 1. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care MNL Learning Outcome: LO 3: Relate alterations in function to clinical manifestations of common symptoms for patients receiving palliative care.